Lung Cancer: Treatment Options

Reviewed by Bronwyn Long, DNP, MBA, RN, Jeffrey Kern, MD, Laurie L. Carr, MD
Lung cancer treatment is guided by the lung cancer’s location and size, and if it has spread anywhere.

Lung cancer treatment is guided by the lung cancer’s location and size, and if it has spread anywhere. Combining all this information provides what is called the lung cancer stage. Staging is different between non-small cell lung cancer and small cell lung cancer.

Non-Small Cell Lung Cancer Staging

Non-Small Cell Lung Cancer stages are numbered from 0 to IV. In general, the lower the number, the smaller the cancer and the less it has spread. The higher the number, the larger the cancer and the more it has spread. The table below describes the lung cancer stages for non-small cell cancer.

 Stages of Non-Small Cell Cancer (Simplified Version)

Stage 0 Cancer cells are identified, but do not invade the lung. These cells may invade the lung in the future.
Stage IA 1-3 A tumor is in the lung only and less than 1 ¼ inches in size
Stage IB A tumor is in the lung and is more than 1 ¼ inches but no more than 2 inches.
OR
The tumor is less than 2 inches, but affects the main airway, causes partial lung collapse or involves the lung lining.
Stage IIA The tumor is between 1 ¼ and 2 inches.
 OR
The tumor is any size up to 2 inches and affects the main airway, causes partial lung collapse or involves the lung lining.
Stage IIB Cancer has spread to the lymph nodes in the lung on the same side of the chest as the tumor, and the tumor is less than 2 inches in size.
OR
The tumor is greater than 2 inches but no more than 3 inches and invades the chest wall, heart, spine or diaphragm.
Stage IIIA The tumor is up to 2 inches in size and has spread to the lymph nodes between the lungs in the center of the chest.
OR
The tumor is up to 3 inches in size and invades the chest wall, heart, diaphragm, spine and lymph nodes in the lung.
OR
A metastasis has developed separately from the main cancer, in the same part of the lung, with or without lymph node involvement in the lung.
Stage IIIB The tumor up to 2 inches in size and has spread to the lymph nodes above the collarbone or is on the opposite side of the chest.
OR
The tumor is any size and invades the chest wall, heart, spine or diaphragm, and involves lymph nodes between the lungs.
OR
A metastasis has developed in the lung separately from the main cancer, and involves lymph nodes between the lungs.
Stage IIIC The tumor is over 2 inches in size and has spread to the lymph nodes above the collarbone or is on the opposite side of the chest.
OR
The tumor is any size and invades the chest wall, heart, spine or diaphragm, and has spread to the lymph nodes above the collarbone or is on the opposite side of the chest
OR
A metastasis has developed in the lung separately from the main cancer, and has spread to the lymph nodes above the collarbone or is on the opposite side of the chest
Stage IV Cancer has spread to the other lung or other organs.
 
 

Small Cell Lung Cancer Staging

Small cell lung cancer (SCLC) affects 15 percent of all lung cancer patients. Small cell lung cancer is the most aggressive type of lung cancer.

The stage of lung cancer also guides the best treatment option for small cell lung cancer. Small cell lung cancer staging is different from non-small cell lung cancer staging and is defined by:

  • Cancer is found in one lung and lymph nodes between the lungs: Limited Stage.

  • Cancer has spread outside of the lungs to other parts of the body: Extensive Stage.

  • The cancer has come back after treatment. The cancer may come back in the lungs or another part of the body: Recurrent.

 
 

Lung Cancer Treatment Options

Lung cancer treatment options may include surgery, radiation, chemotherapy, immunotherapy or combinations of these approaches. In treating lung cancer, three regions of cancer treatment or cancer control are considered: local (in one spot), regional (in a wider region defined by anatomy) and systemic (or whole body).
  • Local treatment is considered when the lung cancer is in the chest cavity and can be controlled with very localized therapy such, as surgery or radiation therapy.

  • Regional control is considered when the lung cancer has spread outside of the lung to lymph nodes or other places within the chest. The cancer can no longer be controlled with just local therapy, and regional treatment is used, which may include radiation therapy, chemotherapy and occasionally surgery.

  • Systemic control is considered when the lung cancer has spread to other parts of the body outside the chest, and therapy that goes throughout the entire body is needed. Chemotherapy and/or immunotherapy is often the treatment of choice for systemic control. Occasionally, radiation therapy is also used as treatment of selected areas such as the brain.

 

Surgery for Lung Cancer

There are different types of surgery used in the treatment of lung cancer. Your doctor may recommend one of the following procedures in the treatment of your lung cancer.
  • Segmentectomy is the removal of the tumor and a small part of the lung.

  • Lobectomy is the removal of the tumor and a larger part of the lung, called a lobe.

  • Pneumonectomy is removal of the tumor and an entire lung.

This surgery may be done by video-assisted thoracoscopic surgery (VATS). Using this procedure, several small incisions are made to remove a portion of a lung. Occasionally the operation cannot be done by VATS, and a larger incision has to be made in the chest to remove the tumor and lung. This is called a thoracotomy.

 

Radiation Therapy

Radiation therapy is used to kill lung cancer cells and keep lung cancer cells from growing where the radiation is provided. Radiation therapy is aimed from a machine outside the body at the tumor. This is performed by a radiation oncologist. The radiation therapy dose is calculated so you receive radiation aimed at the tumor while sparing normal tissue. Radiation therapy can also be provided internally with a radiation device placed inside the body next to the tumor. This is not used often for lung cancer.

Radiation therapy may also affect normal cells near the radiation area. This may lead to side effects.

Side effects of radiation for lung cancer may include:

  • Skin redness like a sunburn

  • Dryness and irritation of the skin where the radiation is given

  • General fatigue

  • Trouble swallowing (if the radiation is given near the esophagus)

  • Damage to normal lung tissue, resulting in scarring

Talk with your radiation oncologist about helpful techniques to treat the side effects.

 

Chemotherapy

Chemotherapy is the use of medications to kill the cancer cells.

Chemotherapy is typically given through a vein in an IV (intravenous) catheter, through a large catheter, called a port, which is implanted in the chest. This will prevents having a needle inserted in a vein each time medicine is needed. Chemotherapy is less irritating when it is placed in a large vein through a port. Some chemotherapy can be given in pill form. Chemotherapy moves throughout the body to kill cancer cells. This is systemic treatment.

Cycles of Chemotherapy

Lung cancer chemotherapy is often given in “cycles” that last approximately three weeks, although this may vary, depending on the type of chemotherapy used. Chemotherapy is often given several times during a cycle. Then your body is given a chance to rest before another cycle is started. The number of cycles may vary, but often four to six cycles of chemotherapy are given.

Chemotherapy medications may be given together to treat lung cancer. The best combination of medications is selected by your oncologist to treat your lung cancer.

Chemotherapy also can affect normal cells. Normal cells that duplicate quickly are most often affected, and this is often the cause of side effects.

Side effects of chemotherapy for lung cancer may include:

  • Hair loss (alopecia)
  • Sores in the mouth (mucositis)
  • Loss of appetite
  • Nausea and vomiting
  • Increased chance of infection
  • Bruising easily
  • Bleeding
  • Anemia/low blood count (cytopenia)
  • General fatigue
  • Shortness of breath (dyspnea)

Talk with your health care provider about helpful techniques to treat the side effects. Your lung cancer chemotherapy may need to be adjusted based on your side effects and your response to the chemotherapy.

 

Targeted Therapy

Advances in chemotherapy include targeted therapy. Mutations in certain genes have been found to cause certain lung cancers. Medication targeted toward theses mutations affect only the cancer cells that have the mutations, without harming normal cells that don’t have the mutated genes. This is an exciting new area of lung cancer treatment, but it cannot be used in everyone — only in particular types of lung cancer. Targeted therapy may be used alone. In order to determine if your cancer might respond to this targeted therapy, a specimen of your lung cancer may be sent for genetic analysis, or mutational profiling. The specimen will be analyzed to determine whether your cancer has any of the mutant genes that might respond to targeted therapy.

 

Immunotherapy

A new form of lung cancer treatment is called immunotherapy. These are drugs given intravenously every two to three weeks to stimulate your own white blood cells to attack the tumor.

The current immunotherapy drugs are called immune checkpoint inhibitors. Immune checkpoints are pathways in the immune system that help the immune system tell the difference between healthy and abnormal cells (such as cancer cells). Sometimes cancer cells can imitate healthy cells and avoid being recognized and killed by the immune system. Immune checkpoint inhibitors stimulate your immune system to kill cancer cells. These medications act very differently from chemotherapy. While chemotherapy attacks and kills cancer cells, immunotherapy activates your own white blood cells (lymphocytes) to find and kill the cancer.

These medicines are given IV (intravenously) over 30-60 minutes. During an immune checkpoint Inhibitor infusion, you will be monitored for any reaction to the medication that might cause wheezing, itching, rash, dizziness, increased shortness of breath, fever, chills or shaking.

Due to the increase in immune cell function, these drugs can cause side effects that are different from those seen with chemotherapy, and could be:

  • Fatigue

  • Diarrhea

  • Shortness of breath

  • Itching, rash

  • Nausea

 

Less common side effects could include:

  • Decreased appetite

  • Constipation

  • Increased serum creatinine

  • Increased liver enzymes

  • Electrolyte imbalances

  • Joint pain, muscle pain, pain in extremities, back pain

  • Vomiting

  • Weakness

  • Fever, chills

  • Swelling

 

When the immune system is stimulated to attack cancer cells, healthy cells of different organ systems can also be attacked. This is known as an immune mediated adverse reaction. You will be monitored by your oncologist for any such event. Symptoms related to the area of the body that can be affected will be assessed.

The following are symptoms of which you NEED to notify your oncologist:

  • Diarrhea

  • Nausea (interfering with the ability to eat and unrelieved by medication)

  • Vomiting (more than four to five times in a 24-hour period)

  • Inability to eat or drink for 24 hours or signs of dehydration (thirst, tiredness, dry mouth, dizziness, decrease in the amount of urine, dark urine)

  • Sudden changes in eyesight

  • Urine that turns dark or tea-colored or has blood in it

  • Blistering rash

  • Stools that are light colored, bloody, dark or tarry/sticky

  • Inability to pass urine or a change in the amount of urine passed

  • Sudden onset of shortness of breath, accompanied by cough and/or fever

  • Skin or the whites of your eyes turning yellow

  • Stomach pain or upset stomach

  • Very bad muscle pain, joint pain or weakness

  • Big weight gain or swelling in your arms or legs.

 

The following are symptoms of which you need to notify your oncologist at you next clinic visit:

  • Sores in the mouth

  • Decreased appetite

  • Itching, rash

  • Bleeding or bruising more easily than normal

  • Cough with or without fever

  • Signs of trouble with your thyroid or pituitary gland (change in mood, change in weight, constipation, dizziness, deeper voice, feeling cold, hair loss, fainting, headache or loss of sex drive).

 

Your oncologist will consider many factors to determine the best lung cancer treatment plan for you. These factors include your age, the specific type of cancer you have, the stage of cancer, perhaps a tumor genetic analysis, your general health and your history of any past treatments given for cancer. In addition to considering your lung cancer treatment options, supportive care of symptoms is also important.

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