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Cancer Medicine :: Lung Cancer(Non-small cell)Treatment

Lung Cancer - Non-small cell

Making treatment decisions for non-small cell lung cancer

After the cancer is found and staged, your cancer care team will discuss your treatment options with you. Depending on the stage of the disease and other factors, the main treatment options for people with non-small cell lung cancer (NSCLC) may include:

Surgery

Radiation therapy

Other local treatments

Chemotherapy

Targeted therapies

In many cases, more than one of these treatments may be used.

It is important to take time and think about your options. In choosing a treatment plan, one of the most important factors is the stage of the cancer. For this reason, it is very important that your doctor order all the tests needed to determine the cancer's stage. Other factors to consider include your overall health, the likely side effects of the treatment, and the probability of curing the disease, extending life, or relieving symptoms. Age alone should not be a barrier to treatment. Older people can benefit from treatment as much as younger people, as long as their general health is good.

 

When considering your treatment options it is often a good idea to get a second opinion, if possible. This may provide you with more information and help you feel more confident about the treatment plan you have chosen. Your doctor should not mind that you want to get a second opinion. If your doctor has done tests, the results can be sent to the second doctor so that you will not have to have them done again.

You may have different types of doctors on your treatment team, depending on the stage of your cancer and your treatment options. These doctors may include:

A thoracic surgeon: a doctor who treats diseases of the lungs and chest with surgery.

A radiation oncologist: a doctor who treats cancer with radiation therapy.

A medical oncologist: a doctor who treats cancer with medicines such as chemotherapy.

A pulmonologist: a doctor who specializes in medical treatment of diseases of the lungs.

You may have different types of doctors on your treatment team, depending on the stage of your cancer and your treatment options. These doctors may include:

A thoracic surgeon: a doctor who treats diseases of the lungs and chest with surgery.

A radiation oncologist: a doctor who treats cancer with radiation therapy.

A medical oncologist: a doctor who treats cancer with medicines such as chemotherapy.

A pulmonologist: a doctor who specializes in medical treatment of diseases of the lungs.

Many other specialists may be involved in your care as well, including nurse practitioners, nurses, respiratory therapists, social workers, and other health professionals.

Surgery for non-small cell lung cancer

Surgery to remove the cancer (often along with other treatments) may be an option for early stage non-small cell lung cancers. If surgery can be done, it provides the best chance to cure NSCLC. Lung cancer surgery is a complex operation that can have serious consequences, so it should be done by a surgeon who has a lot of experience operating on lung cancers.

If your doctor thinks the lung cancer can be treated with surgery, pulmonary function tests will be done beforehand to determine if you will have enough healthy lung tissue left after surgery. Other tests will check the function of your heart and other organs to be sure you're healthy enough for surgery.

Types of lung surgery

Several different operations can be used to treat (and possibly cure) non-small cell lung cancer. These operations require general anesthesia (where you are in a deep sleep) and a surgical incision between the ribs in the side of the chest (called a thoracotomy).

Pneumonectomy: an entire lung is removed in this surgery.

Lobectomy: a section (lobe) of the lung is removed in this surgery.

Segmentectomy or wedge resection: part of a lobe is removed in this surgery.

Another type of operation, known as a sleeve resection, may be used to treat some cancers in large airways in the lungs. If you think of the large airway with a tumor as similar to the sleeve of a shirt with a stain an inch or 2 above the wrist, the sleeve resection would be like cutting across the sleeve above and below the stain and sewing the cuff back onto the shortened sleeve. A surgeon may be able to do this operation instead of a pneumonectomy to preserve more lung function.

With any of these operations, nearby lymph nodes are also removed to look for possible spread of the cancer.

The type of operation your doctor recommends depends on the size and location of the tumor and on how well your lungs are functioning. In some cases, doctors may prefer to do a more extensive operation (for example, a lobectomy instead of a segmentectomy) if a person's lungs are healthy enough, as it may provide a better chance to cure the cancer.

When you wake up from surgery, you will have a tube (or tubes) coming out of your chest and attached to a special canister to allow excess fluid and air to drain out. The tube(s) will be removed once the fluid drainage and air leak subside. Generally, you will need to spend 5 to 7 days in the hospital after the surgery.

Video-assisted thoracic surgery: Some doctors now treat some early stage lung cancers near the outside of the lung with a procedure called video-assisted thoracic surgery (VATS), which is less invasive than a thoracotomy.

During this operation, a thin rigid tube with a tiny video camera on the end is placed through a small hole in the side of the chest to help the surgeon see the chest cavity on a TV monitor. One or two other small holes are created in the skin, and long instruments passed through these holes are used to do the same operation that would be done using an open approach (thoracotomy). One of the incisions is enlarged if a lobectomy or pneumonectomy is done to allow the specimen to be removed. Because usually only small incisions are needed, there is less pain after the surgery and a shorter hospital stay – usually 4 to 5 days.

Most experts recommend that only early stage tumors smaller than 3 to 4 centimeters (about 1½ inches) near the outside of the lung be treated this way. The cure rate after this surgery seems to be the same as with older techniques. But it is important that the surgeon doing this procedure is experienced since it requires a great deal of technical skill.

Possible risks and side effects of lung surgery

Possible complications during and soon after surgery depend on the extent of the surgery and a person's health beforehand. Serious complications can include excessive bleeding, wound infections, and pneumonia. While it is rare, in some cases people may not survive the surgery, which is why it is very important that surgeons select patients carefully.

Surgery for lung cancer is a major operation, and recovering from the operation typically takes weeks to months. Because the surgeon must spread ribs to get to the lung when doing a thoracotomy, the incision will hurt for some time after surgery. Your activity will be limited for at least a month or two.

If your lungs are in good condition (other than the presence of the cancer) you can usually return to normal activities after some time if a lobe or even an entire lung has been removed. If you also have non-cancerous lung diseases such as emphysema or chronic bronchitis (which are common among heavy smokers), you may become short of breath with activities after surgery.

Surgery for lung cancers with limited spread to other organs

If the lung cancer has spread to the brain or adrenal gland and there is only one tumor, you may benefit from having the metastasis removed. This surgery should be considered only if the tumor in the lung can also be completely removed. Even then, not all lung cancer experts agree with this approach, especially if the tumor is in the adrenal gland.

For tumors in the brain, this is done by surgery through a hole in the skull (craniotomy). It should only be done if the tumor can be removed without damaging vital areas of the brain that control movement, sensation, and speech.

Surgery to relieve symptoms of NSCLC

If you can't have major surgery because of reduced lung function or other serious medical problems, or if the cancer is widespread, other types of surgery may still be used to relieve some symptoms.

For example, sometimes fluid can build up in the chest cavity outside of the lungs. It can press on the lungs and cause trouble breathing. To remove the fluid and keep it from coming back, doctors sometimes perform a procedure called pleurodesis. A small cut is made in the skin of the chest wall, and a hollow tube is placed into the chest to remove the fluid. Either talc or a drug such as doxycycline or a chemotherapy drug is then instilled into the chest cavity. This causes the linings of the lung (visceral pleura) and chest wall (parietal pleura) to stick together, sealing the space and limiting further fluid buildup. The tube is generally left in for a couple of days to drain any new fluid that might accumulate.

Other, non-surgical techniques can also be used to relieve symptoms. For example, tumors can sometimes grow into airways, blocking them and causing problems such as pneumonia or shortness of breath. Treatments such as laser therapy or photodynamic therapy can be used to relieve the blockage in the airway. In some cases, a bronchoscope may be used to place a stent (a stiff tube) made of metal or silicone in the airway after treatment to help keep it open. These procedures are described in more detail in the section "Other local treatments for non-small cell lung cancer.

Radiation therapy for non-small cell lung cancer

Radiation therapy uses high-energy rays (such as x-rays) or particles to kill cancer cells. There are 2 main types of radiation therapy – external beam radiation therapy and brachytherapy (internal radiation therapy).

External beam radiation therapy

External beam radiation therapy (EBRT) focuses radiation delivered from outside the body on the cancer. This is the type of radiation therapy most often used to treat a primary lung cancer or its metastases to other organs.

Before your treatments start, the radiation team will take careful measurements to determine the correct angles for aiming the radiation beams and the proper dose of radiation. Radiation therapy is much like getting an x-ray, but the radiation is stronger. The procedure itself is painless. Each treatment lasts only a few minutes, although the setup time – getting you into place for treatment – usually takes longer. Most often, radiation treatments to the lungs are given 5 days a week for 4 to 7 weeks.

Standard (conventional) EBRT is used much less often than in the past. Newer techniques help doctors treat lung cancers more accurately while lowering the radiation exposure to nearby healthy tissues. These techniques may offer better chances of increasing the success rate and reducing side effects. Most doctors now recommend using these newer techniques when they are available.

Three-dimensional conformal radiation therapy (3D-CRT): 3D-CRT uses special computers to precisely map the location of the tumor(s). Radiation beams are shaped and aimed at the tumor(s) from several directions, which makes it less likely to damage normal tissues.

Intensity modulated radiation therapy (IMRT): IMRT is an advanced form of 3D therapy. It uses a computer-driven machine that moves around the patient as it delivers radiation. Along with shaping the beams and aiming them at the tumor from several angles, the intensity (strength) of the beams can be adjusted to minimize the dose reaching the most sensitive normal tissues. This technique is used most often if tumors are near important structures such as the spinal cord. Many major hospitals and cancer centers are now able to provide IMRT.

Stereotactic radiation therapy: A newer form of treatment, known as stereotactic body radiation therapy (SBRT) or stereotactic ablative radiotherapy (SABR), is sometimes used to treat very early stage lung cancers when surgery isn't an option due to issues with the patient’s health. Instead of giving small doses of radiation each day for several weeks, SBRT uses very focused beams of high-dose radiation given on one or a few days. Several beams are aimed at the tumor from different angles. To target the radiation precisely, the person is put in a specially designed body frame for each treatment. This reduces the movement of the lung tumor during breathing. Like other forms of external radiation, the treatment itself is painless.

Early results with SBRT have been very promising, and it seems to have a low risk of complications. But because it is still a fairly new technique, there isn't much long-term data on its use.

Another type of stereotactic radiation therapy can sometimes be used instead of surgery for single tumors that have spread to the brain. This is sometimes called stereotactic radiosurgery or SRS. In one version of stereotactic radiation therapy, a machine called a Gamma Knife® focuses about 200 beams of radiation on the tumor from different angles over a few minutes to hours. The head is kept in the same position by placing it in a rigid frame. In another version, a linear accelerator (a machine that creates radiation) that is controlled by a computer moves around the head to deliver radiation to the tumor from many different angles.

Brachytherapy (internal radiation therapy)

Brachytherapy is used most often to shrink tumors to relieve symptoms caused by lung cancer in an airway, although in some cases it may be part of a larger treatment regimen trying to cure the cancer. For this type of treatment, the doctor places a small source of radioactive material (often in the form of pellets) directly into the cancer or into the airway next to the cancer. This is usually done through a bronchoscope, but it may also be done during surgery. The radiation travels only a short distance from the source, limiting the effects on surrounding healthy tissues. The radiation source is usually removed after a short time. Less often, small radioactive "seeds" are left in place permanently, and the radiation gets weaker over several weeks.

When is radiation therapy used?

External beam radiation therapy is sometimes used as the main treatment of lung cancer (sometimes along with chemotherapy), especially if the lung tumor cannot be removed by surgery because of its size or location, or if a person's health is too poor for surgery.

After surgery, radiation therapy can be used (alone or along with chemotherapy) to try to kill very small deposits of cancer that surgery may have missed. In some cases, radiation therapy may be used before surgery (usually along with chemotherapy) to try to shrink a lung tumor to make it easier to operate on.

Radiation therapy can also be used to relieve (palliate) symptoms of advanced lung cancer such as pain, bleeding, trouble swallowing, cough, and problems caused by brain metastases. For example, brachytherapy is most often used to help relieve blockage of large airways by cancer.

In some cases, doctors may recommend giving lower doses of radiation to the whole brain, even if there are no visible signs the cancer has spread there. The goal of this treatment, known as prophylactic cranial irradiation, is to try to prevent tumors from forming in the brain. Many doctors don't agree that the potential benefits of this treatment outweigh the possible side effects, however. If it is used, it is usually given 5 days a week over 2 weeks.

Possible side effects of radiation therapy

Common side effects of external radiation therapy include

Sunburn-like skin problems

Hair loss where the radiation enters the body

Fatigue

Nausea and vomiting

Loss of appetite and weight loss

Often these go away after treatment. When radiation is given with chemotherapy, the side effects are often worse.

Chest radiation therapy may damage your lungs and cause a cough, problems breathing, and shortness of breath. These usually improve after treatment is over, although in some cases the symptoms may not go away completely.

Your esophagus, which is in the middle of your chest, may be exposed to radiation, which could cause a sore throat and trouble swallowing during treatment. This may make it hard to eat anything other than soft foods or liquids for a while.

Radiation therapy to large areas of the brain can sometimes cause memory loss, headache, trouble thinking, or reduced sexual desire. Usually these symptoms are minor compared with those caused by a brain tumor, but they can reduce your quality of life. Side effects of radiation therapy to the brain usually become most serious 1 or 2 years after treatment.

Other local treatments for non-small cell lung cancer

At times, treatments other than surgery or radiation therapy may be used to treat lung tumors at a specific location.

Radiofrequency ablation (RFA)

This technique is being studied for small lung tumors that are near the outer edge of the lungs, especially in people who can't have or don't want surgery. It uses high-energy radio waves to heat the tumor. A thin, needle-like probe is placed through the skin and moved along until the end is in the tumor. Placement of the probe is guided by CT scans. Once it is in place, an electric current is passed through the probe, which heats the tumor and destroys the cancer cells. RFA is usually done as an outpatient procedure, using local anesthesia (numbing medicine) where the probe is inserted. You may be given medicine to help you relax as well.

Major complications are uncommon, but they can include the partial collapse of a lung (which often resolves on its own) or bleeding into the lung.

Photodynamic therapy (PDT)

Photodynamic therapy is sometimes used to treat very early stage lung cancers that are still confined to the outer layers of the lung airways when other treatments aren't appropriate. It can also be used to help open up airways blocked by tumors to help people breathe better.

For this technique, a light-activated drug called porfimer sodium (Photofrin®) is injected into a vein. This drug is more likely to collect in cancer cells than in normal cells. After a couple of days (to give the drug time to build up in the cancer cells), a bronchoscope is passed down the throat and into the lung. This may be done with either local anesthesia (where the throat is numbed) or general anesthesia (where you are in a deep sleep). A special laser light on the end of the bronchoscope is aimed at the tumor, which activates the drug and causes the cells to die. The dead cells are then removed a few days later during a bronchoscopy. This process can be repeated if needed.

PDT may cause swelling in the airway for a few days, which may lead to some shortness of breath, as well as coughing up blood or thick mucus. Some of this drug also collects in normal cells in the body, such as skin and eye cells. This can make you very sensitive to sunlight or strong indoor lights. Too much exposure can cause serious skin reactions, which is why doctors recommend staying out of any strong light for 4 to 6 weeks after the injection.

Laser therapy

Lasers can sometimes be used to treat very small lung cancers in the linings of airways. They can also be used to help open up airways blocked by larger tumors to help people breathe better.

You are usually asleep (under general anesthesia) for this type of treatment. The laser is on the end of a bronchoscope, which is passed down the throat and next to the tumor. The doctor then aims the laser beam at the tumor to burn it away. This treatment can usually be repeated, if needed.

Stent placement

Lung tumors that have grown into an airway can sometimes cause trouble breathing or other problems. To help keep the airway open (often after other treatments such as photodynamic therapy or laser therapy), a stent may be placed in the airway. Stents are hard silicone or metal tubes that can be put in place in the airway with a bronchoscope.

Chemotherapy for non-small cell lung cancer

Chemotherapy (chemo) is treatment with anti-cancer drugs injected into a vein or taken by mouth. These drugs enter the bloodstream and go throughout the body, making this treatment useful for cancer that has spread (metastasized) to distant organs. Depending on the stage of lung cancer, chemo may be used in different situations:

Chemo (sometimes along with radiation therapy) may be used to try to shrink a tumor before surgery. This is known as neoadjuvant therapy.

Chemo (sometimes along with radiation therapy) may be given after surgery to try to kill any cancer cells that may have been left behind. This is known as adjuvant therapy.

Chemo may be given as the main treatment (sometimes along with radiation therapy) for more advanced cancers or for some people who aren't healthy enough for surgery.

Doctors give chemo in cycles, with a period of treatment (usually 1 to 3 days) followed by a rest period to allow the body time to recover. Some chemo drugs, though, are given every day. Chemo cycles generally last about 3 to 4 weeks, and treatment typically involves 4 to 6 cycles. Chemo is often not recommended for patients in poor health, but advanced age by itself is not a barrier to getting chemo.

Most often, treatment for lung cancer uses a combination of 2 chemo drugs. Studies have shown that adding a third chemo drug doesn't add much benefit and is likely to cause more side effects. Single-drug chemo is sometimes used for people who might not tolerate combination chemotherapy well, such as those in poor overall health or who are elderly.

The chemo drugs most frequently used for non-small cell lung cancer are:

Cisplatin

Carboplatin

Paclitaxel (Taxol®)

Albumin-bound paclitaxel (nab-paclitaxel, Abraxane®)

Docetaxel (Taxotere®)

Gemcitabine (Gemzar®)

Vinorelbine (Navelbine®)

Irinotecan (Camptosar®, CPT-11)

Etoposide (VP-16®)

Vinblastine

Pemetrexed (Alimta®)

Often a combination that includes either cisplatin or carboplatin plus one other drug is used. Sometimes combinations with less severe side effects, such as gemcitabine with vinorelbine or paclitaxel, may be used.

For people with advanced lung cancers who meet certain criteria, targeted therapy drugs such as bevacizumab (Avastin®) or cetuximab (Erbitux®) may be added to initial treatment as well (see the "Targeted therapies for non-small cell lung cancer" section).

If the initial chemo treatment for advanced lung cancer is no longer working, the doctor may recommend second-line treatment with a single drug such as docetaxel or pemetrexed. Another option may be the targeted therapy erlotinib (Tarceva®) (see the "Targeted therapies for non-small cell lung cancer" section). Again, advanced age is no barrier to receiving these drugs as long as the person is in good general health.

Some doctors may recommend second-line treatment with a single chemo or targeted drug, even in people who have had a good response to their initial chemotherapy. The intent is to try to keep the lung cancer from growing or coming back for as long as possible and hopefully help patients live longer. This concept, known as maintenance therapy, is still being studied, as it's not yet clear if the possible benefits outweigh the risks and side effects. 

Possible side effects

Chemo drugs work by attacking cells that are dividing quickly, which is why they work against cancer cells. But other cells in the body, such as those in the bone marrow (where new blood cells are made), the lining of the mouth and intestines, and the hair follicles, also divide quickly. These cells are also likely to be affected by chemo, which can lead to certain side effects.

The side effects of chemo depend on the type and dose of drugs given and the length of time they are taken. Some common side effects include:

Hair loss

Mouth sores

Loss of appetite

Nausea and vomiting

Diarrhea or constipation

Low blood counts

Chemo can affect the blood-forming cells of the bone marrow, leading to low blood counts. This can cause:

Increased chance of infections (from low white blood cell counts)

Easy bruising or bleeding (from low blood platelet counts)

Fatigue (from low red blood cell counts)

These side effects are usually short-term and go away after treatment is finished. There are often ways to lessen these side effects. For example, there are drugs that can be given to help prevent or reduce nausea and vomiting.

Some drugs such as cisplatin, vinorelbine, docetaxel, or paclitaxel can damage nerves. This can sometimes lead to symptoms (mainly in the hands and feet) such as pain, burning or tingling sensations, sensitivity to cold or heat, or weakness. This is called peripheral neuropathy. In most cases this goes away once treatment is stopped, but it may be long lasting in some people. 

You should report this or any other side effects you notice while getting chemotherapy to your medical team so that they can be treated promptly. In some cases, the doses of the chemotherapy drugs may need to be reduced or treatment may need to be delayed or stopped to prevent the effects from getting worse.

Targeted therapies for non-small cell lung cancer

As researchers have learned more about the changes in lung cancer cells that help them grow, they have been able to develop newer drugs that specifically target these changes. These targeted drugs work differently from standard chemotherapy (chemo) drugs. They often have different (and less severe) side effects. At this time, they are most often used for advanced lung cancers, either along with chemo or by themselves.

Drugs that target tumor blood vessel growth (angiogenesis)

For tumors to grow, they must form new blood vessels to keep them nourished. This process is called angiogenesis. Some targeted drugs block this new blood vessel growth.

Bevacizumab (Avastin®): Bevacizumab is a type of drug known as a monoclonal antibody (a man-made version of a specific immune system protein). It targets vascular endothelial growth factor (VEGF), a protein that helps new blood vessels to form.

This drug has been shown to prolong survival of patients with advanced lung cancer when it is added to standard chemotherapy regimens as part of first-line treatment. Bevacizumab is given by infusion into a vein every 2 to 3 weeks. While chemotherapy plus bevacizumab is usually given for 4 to 6 cycles, many doctors continue giving bevacizumab by itself until the cancer starts growing again.

The possible side effects of this drug are different from (and may add to) those of chemotherapy drugs. Some of these effects can be serious.

Bevacizumab can cause serious bleeding, which limits its use to some extent. It is typically not used in patients who are coughing up blood or who are on "blood thinners" such as aspirin or warfarin (Coumadin®). Most current guidelines do not recommend using bevacizumab in patients with the squamous cell type of lung cancer, because it may lead to serious bleeding in the lungs. However, studies are under way to see if bevacizumab is safe as long as the squamous cell cancer is not located near large blood vessels in the center of the chest.

Other rare but possibly serious side effects include blood clots, holes forming in the intestines, heart problems, and slow wound healing. More common side effects include high blood pressure, tiredness, low white blood cell counts, headaches, mouth sores, loss of appetite, and diarrhea.

Drugs that target EGFR

Epidermal growth factor receptor (EGFR) is a protein found on the surface of cells. It normally helps the cells to grow and divide. Some lung cancer cells have too much EGFR, which causes them to grow faster.

Erlotinib (Tarceva®): Erlotinib is a drug that blocks EGFR from signaling the cell to grow. It has been shown to help keep some lung tumors under control, especially in women and in people who never smoked. It is used by itself, mainly for advanced lung cancers if initial treatment with chemotherapy is no longer working. Erlotinib may also be used as the first treatment in patients whose cancers have a mutation (change) in the EGFR gene.

This drug is taken daily as a pill. The side effects of erlotinib tend to be milder than those of typical chemotherapy drugs. The most worrisome side effect for many people is an acne-like rash on the face and chest, which in some cases can lead to skin infections. Other side effects can include diarrhea, loss of appetite, and feeling tired.

Cetuximab (Erbitux®): Cetuximab is a monoclonal antibody that targets EGFR. For patients with advanced lung cancer, some doctors may add it to standard chemotherapy as part of first-line treatment.

Cetuximab is not FDA approved for use against lung cancer at this time, although it is approved for use against other cancers, and doctors can prescribe it for use in lung cancer. This drug is expensive, and not all insurance companies may cover the cost. If you are considering taking this drug, it is important to find out beforehand if your insurance will cover it.

Cetuximab is given by IV infusion, usually once a week. A rare but serious side effect of cetuximab is an allergic reaction during the first infusion, which could cause problems with breathing and low blood pressure. You may be given medicine before treatment to help prevent this. Many people develop skin problems such as an acne-like rash on the face and chest during treatment, which in some cases can lead to infections. Other side effects may include headache, tiredness, fever, and diarrhea.

Drugs that target the ALK gene

About 5% of non-small cell lung cancers have been found to have a rearrangement in a gene called ALK. This change is most often seen in non-smokers (or light smokers) who have the adenocarcinoma subtype of NSCLC. The ALK gene rearrangement produces an abnormal protein that causes the cells to grow and spread. The new drug crizotinib (Xalkori®) blocks the abnormal ALK protein. In studies of patients whose lung cancers had this gene change, this drug shrank tumors in about 50% to 60% of patients, even though most of them had already had chemotherapy.

The most common side effects are mild and included nausea and vomiting, diarrhea, constipation, swelling, fatigue, and eye problems. Some side effects can be severe, such as low white blood cell counts, lung inflammation, and heart rhythm problems. In August 2011, this drug was approved by the FDA to treat patients with lung cancers that have the ALK gene change. It is taken twice a day as a pill. This drug helps shrink tumors, but it still is not known if it helps patients live longer, so more studies are needed.

Complementary and alternative therapies for non-small cell lung cancer

When you have cancer you are likely to hear about ways to treat your cancer or relieve symptoms that your doctor hasn't mentioned. Everyone from friends and family to Internet groups and Web sites may offer ideas for what might help you. These methods can include vitamins, herbs, and special diets, or other methods such as acupuncture or massage, to name a few.

What exactly are complementary and alternative therapies?

Not everyone uses these terms the same way, and they are used to refer to many different methods, so it can be confusing. We use complementary to refer to treatments that are used along with your regular medical care.Alternative treatments are used instead of a doctor's medical treatment.

Complementary methods: Most complementary treatment methods are not offered as cures for cancer. Mainly, they are used to help you feel better. Some methods that are used along with regular treatment are meditation to reduce stress, acupuncture to help relieve pain, or peppermint tea to relieve nausea. Some complementary methods are known to help, while others have not been tested. Some have been proven not be helpful, and a few have even been found harmful.

Alternative treatments: Alternative treatments may be offered as cancer cures. These treatments have not been proven safe and effective in clinical trials. Some of these methods may pose danger, or have life-threatening side effects. But the biggest danger in most cases is that you may lose the chance to be helped by standard medical treatment. Delays or interruptions in your medical treatments may give the cancer more time to grow and make it less likely that treatment will help.

Treatment choices by stage for non-small cell lung cancer

The treatment options for non-small cell lung cancer (NSCLC) are based mainly on the stage (extent) of the cancer, but other factors, such as a person's overall health and lung function, as well as certain traits of the cancer itself, are also important.

If you smoke, one of the most important things you can do to be ready for treatment is to try to quit. Studies have shown that patients who stop smoking after a diagnosis of lung cancer tend to have better outcomes than those who don't.

Occult cancer

For these cancers, malignant cells are seen on sputum cytology but no obvious tumor can be found with bronchoscopy or imaging tests. They are usually early stage cancers. Bronchoscopy is usually repeated about every 3 months to look for a tumor. If a tumor is found, treatment will depend on the stage.

Stage 0

Because stage 0 NSCLC is limited to the lining layer of airways and has not invaded deeper into the lung tissue or other areas, it is usually curable by surgery alone. No chemotherapy or radiation therapy is needed.

If you are healthy enough for surgery, you can usually be treated by segmentectomy or wedge resection (removal of defined segments or small wedges of the lung). Cancers in some locations, such as where the windpipe divides into the left and right main bronchi, may be treated with a sleeve resection, but in some cases they may be hard to remove completely without removing a lobe or even an entire lung.

In some cases, photodynamic therapy, laser therapy, or brachytherapy may be useful alternatives to surgery for stage 0 cancers. If you are truly stage 0, these treatments will probably cure you.

Stage I

If you have stage I NSCLC, surgery may be the only treatment you need. The tumor may be removed either by taking out one lung lobe (lobectomy) or by taking out a smaller piece of a lung (sleeve resection, segmentectomy, or wedge resection). At least some lymph nodes within the lung and outside the lung in the mediastinum will be removed to check them for cancer cells.

Segmentectomy or wedge resection is recommended only for treating the smallest stage I cancers (those less than 2 cm across) and for patients with other medical conditions that make removing the entire lobe dangerous. This stage is most suited for video-assisted thoracic surgery (VATS). It is not yet clear that this type of surgery is as good as removing the whole lung, even for these small tumors. This is being studied right now in a clinical trial. Until the results of this study are known, most surgeons believe it is better to perform a lobectomy if the patient can tolerate it, as it offers the best chance for cure.

For some people with stage I NSCLC, adjuvant chemotherapy after surgery may lower the risk that cancer will return. But doctors aren't sure how best to determine in which people the benefits outweigh the downsides, so most don't recommend chemotherapy if it looks like all of the cancer was removed with surgery. New lab tests that look at the patterns of certain genes in the cancer cells appear promising and may help with this. Studies are now under way to see if these tests are accurate.

After surgery, chemotherapy and/or radiation therapy may also be recommended if the pathology report shows that there were cancer cells at the edge of the surgery specimen. This means that some cancer may have been left behind. Another approach would be to have a second surgery to try to ensure that all the cancer has been removed. (This might be followed by chemotherapy as well.)

If you have serious medical problems that would prevent you from having surgery, you may receive only radiation therapy as your main treatment. Radiofrequency ablation (RFA) may be another option if the tumor is small and in the outer part of the lung.

Stage II

People who have stage II NSCLC and are healthy enough for surgery usually have the cancer removed by lobectomy, sleeve resection, or, less often, segmentectomy. Sometimes removing the whole lung (pneumonectomy) is needed.

Any lymph nodes likely to have cancer in them are also removed. The extent of lymph node involvement and whether or not cancer cells are found at the edges of the removed tissues are important factors when planning the next step of treatment.

In some cases, chemotherapy (often along with radiation) may be recommend before surgery to try to shrink the tumor to make the operation easier.

After surgery, chemotherapy (with or without radiation therapy) is typically recommended to try to destroy any cancer cells left behind. As with stage I cancers, newer lab tests now being studied may allow doctors to tell which patients need this adjuvant treatment and which are less likely to benefit from it.

If cancer cells are found at the edge of the tissue removed by surgery, chemotherapy and radiation therapy are more likely to be used. Or your doctor may recommend a second, more extensive surgery, followed by chemotherapy.

If you have serious medical problems that would prevent you from having surgery, you may receive only radiation therapy as your main treatment.

Stage IIIA

Treatment for stage IIIA NSCLC may include radiation therapy, chemotherapy, surgery, or some combination of these. For this reason, planning treatment for stage IIIA NSCLC will often require input from a medical oncologist, radiation oncologist, and a thoracic surgeon. Treatment options will depend on the size of the tumor, where it is located in your lung, which lymph nodes it has spread to, your overall health, and how well you are tolerating treatment.

For patients who can tolerate it, treatment usually starts with chemotherapy, with or without radiation therapy. Surgery may be an option after this if the doctor thinks any remaining cancer can be removed and the patient is healthy enough. (In selected T3N1 cases, where the cancer has not reached the lymph nodes in the middle of the chest, surgery may be an option as the first treatment.) This is often followed by chemotherapy, and possibly radiation therapy if it hasn't been given before.

For people who can't tolerate chemotherapy or surgery, radiation therapy is usually the treatment of choice.

Stage IIIB

Stage IIIB NSCLC has usually spread too widely to be completely removed by surgery. If you are in fairly good health you may be helped by chemotherapy and radiation therapy.

Again, treatment depends on a person's overall health and how well they are tolerating it. For people who can't have chemotherapy, radiation therapy is usually the treatment of choice.

Because treatment is unlikely to cure these cancers, taking part in a clinical trial of newer treatments may be a good option. Several clinical trials are in progress to determine the best treatment for people with this stage of lung cancer.

Stage IV

Stage IV NSCLC is widespread when it is diagnosed. Because these cancers have spread to distant sites, they are very hard to cure. Treatment options depend on the site of the distant spread, the number of tumors, and your overall health. If you are in otherwise good health, treatments such as surgery, chemotherapy, and radiation therapy may help you live longer and make you feel better by relieving symptoms, even though they aren't likely to cure you. Other treatments, such as photodynamic therapy or laser therapy, may also be used to help relieve symptoms. In any case, if you are going to receive treatment for advanced NSCLC, be sure you understand the goals of treatment before you start.

Cancer that has spread widely throughout the body is usually treated with chemotherapy, as long as the person is healthy enough to tolerate it. The targeted therapy bevacizumab (Avastin) is FDA-approved for use with chemotherapy in people who are not at high risk for bleeding (that is, they do not have squamous cell NSCLC, have not coughed up blood, and are not taking "blood thinning" medicine). However, some doctors may use it for certain patients with squamous cell cancer as long as the tumor is not near large blood vessels in the center of the chest. If bevacizumab is used, it is often continued even after chemotherapy is finished.

Other targeted drugs may also be useful in some situations. For tumors that have the ALK gene change, crizotinib (Xalkori) is an option. For some other patients, the anti-EGFR drug cetuximab (Erbitux) may be added to chemotherapy. This is more often used for people who cannot use bevacizumab for medical reasons. For people whose cancers have certain changes in the EGFR gene, some doctors may recommend using the anti-EGFR drug erlotinib (Tarceva) by itself as the first treatment. In some patients with those gene changes, chemo may be given first for a time, followed by erlotinib. This is known as maintenance therapy.

For cancers that have caused a malignant pleural effusion (fluid in the space around the lungs), the fluid may be drained and pleurodesis may be done to help prevent it from coming back. Then chemotherapy and/or targeted drugs may be given.

Cancer that is limited in the lungs and has only spread to one other site (such as the brain) is not common but can sometimes be treated with surgery and/or radiation therapy. For example, a single tumor in the brain may be treated with surgery or stereotactic radiation (such as the Gamma Knife), followed by radiation to the whole brain. Treatment for the lung tumor is then based on its T and N stages, and may include surgery and/or chemotherapy.

As with other stages, treatment for stage IV lung cancer depends on a person's overall health and how well they are tolerating it. For example, some people not in good health might get only 1 chemotherapy drug instead of 2. For people who can't tolerate chemotherapy, radiation therapy is usually the treatment of choice. Local treatments such as laser therapy, photodynamic therapy, or stent placement may also be used to help relieve symptoms caused by lung tumors.

Because treatment is unlikely to cure these cancers, taking part in a clinical trial of newer treatments may be a good option.

Cancer that progresses or recurs after treatment

If cancer continues to grow during treatment (progresses) or comes back (recurs), further treatment will depend on the extent of the cancer, what treatments have been used, and a person's health and desire for further treatment. It is important to understand the goal of any further treatment – if it is to try to cure the cancer, to slow its growth, or to help relieve symptoms – as well as the likelihood of benefits and risks.

If cancer continues to grow during initial treatment such as radiation therapy, chemotherapy may be tried. If a cancer continues to grow during combination chemotherapy, second line treatment most often consists of a single chemotherapy drug such as docetaxel or pemetrexed, or the targeted therapy erlotinib (Tarceva).

Smaller cancers that recur locally in the lungs can sometimes be retreated with surgery or radiation therapy (if it hasn't been used before). Cancers that recur in the lymph nodes between the lungs are usually treated with chemotherapy, possibly along with radiation if it hasn't been used before. For cancers that return at distant sites, chemotherapy and/or targeted therapies are often the treatments of choice.

At some point, it may become clear that standard treatments are no longer controlling the cancer. If you want to continue anti-cancer treatment, you might think about taking part in a clinical trial of newer lung cancer treatments. While these are not always the best option for every person, they may benefit you as well as future patients.

Even if your cancer can't be cured, you should be as free of symptoms as possible. If curative treatment is not an option, treatment aimed at specific sites can often relieve symptoms and may even slow the spread of the disease. Symptoms such as shortness of breath or coughing up blood caused by cancer in the lung airways can often be treated effectively with radiation therapy, brachytherapy, laser therapy, photodynamic therapy, stent placement, or even surgery if needed. Radiation therapy can be used to help control cancer spread in the brain or relieve pain in a specific area if cancer has spread.

Many people with lung cancer are concerned about pain. If the cancer grows near certain nerves it can sometimes cause pain, but this can almost always be treated effectively with pain medicines. Sometimes radiation therapy or other treatments will help as well. It is important that you talk to your doctor and take advantage of these treatments.

What happens after treatment for non-small cell lung cancer?

For some people with lung cancer, treatment may remove or destroy the cancer. Completing treatment can be both stressful and exciting. You may be relieved to finish treatment, but find it hard not to worry about cancer growing or coming back. (When cancer comes back after treatment, it is called recurrence.) This is a very common concern in people who have had cancer.

It may take a while before your fears lessen. But it may help to know that many cancer survivors have learned to live with this uncertainty and are living full lives. 

For some other people, the lung cancer may never go away completely. These people may get regular treatments with chemotherapy, radiation therapy, or other therapies to help keep the cancer in check. Learning to live with cancer as a more of a chronic disease can be difficult and very stressful. It has its own type of uncertainty. 

Follow-up care

If you have completed treatment, your doctors will still want to watch you closely. It is very important to go to all of your follow-up appointments. During these visits, your doctors will ask questions about any problems you may have and may do exams and lab tests or imaging tests (such as x-rays or CT scans).

In people with no signs of cancer remaining, most doctors recommend follow-up visits and CT scans every 4 to 6 months for the first 2 years after treatment, and yearly visits and CT scans after this.

Follow-up is needed to check for cancer recurrence or spread, as well as possible side effects of certain treatments. This is the time for you to talk to your cancer care team about any changes or problems you notice and any questions or concerns you have.

Almost any cancer treatment can have side effects. Some may last for a few weeks to several months, but others can last the rest of your life. Don't hesitate to tell your cancer care team about any symptoms or side effects that bother you so they can help you manage them.

It is important to keep health insurance. Tests and doctor visits cost a lot, and even though no one wants to think of their cancer coming back, this could happen.

If cancer does recur, treatment will depend on the location of the cancer and what treatments you've had before. It may be surgery, radiation therapy, chemotherapy, targeted therapy, or some combination of these. 

Seeing a new doctor

At some point after your cancer diagnosis and treatment, you may find yourself seeing a new doctor who does not know anything about your medical history. It is important that you be able to give your new doctor the details of your diagnosis and treatment. Make sure you have this information handy:

A copy of your pathology report(s) from any biopsies or surgeries

If you had surgery, a copy of your operative report(s)

If you were in the hospital, a copy of the discharge summary that doctors prepare when patients are sent home

If you had radiation therapy, a copy of the treatment summary

If you had chemotherapy or targeted therapies, a list of the drugs, drug doses, and when you took them

Copies of your x-rays, CT scans, and other imaging tests (these can often be put on a DVD)

The doctor may want copies of this information for his records, but always keep copies for yourself

What`s new in non-small cell lung cancer research and treatment?

Lung cancer research is currently being done in medical centers throughout the world. Progress in prevention, early detection, and treatment based on current research is expected to save many thousands of lives each year.

Prevention

Tobacco

At this time, many researchers believe that prevention offers the greatest opportunity to fight lung cancer. Although decades have passed since the link between smoking and lung cancers was clearly identified, scientists estimate that smoking is still responsible for about 87% of lung cancer deaths. Research is continuing on:

Ways to help people quit smoking through counseling, nicotine replacement, and other medicines

Ways to convince young people to never start smoking

Inherited differences in genes that may make some people much more likely to get lung cancer if they smoke or are exposed to someone else's smoke

Diet, nutrition, and medicines

Although researchers are looking for ways to use vitamins or medicines to prevent lung cancer in people at high risk, so far none have been shown to conclusively reduce risk. Some studies have suggested that a diet high in fruits and vegetables may offer some protection, but more research is needed to confirm this. 

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