Treatment options

Treatment and care of people with cancer is usually provided by a team of health professionals, both medical and allied health, called a multidisciplinary team.

Treatment for lung cancer depends on:

• the stage of the disease
• the location of the cancer
• the severity of symptoms
• your general health and wishes.

Treatment may involve the following.

Surgery

Early-stage non–small cell lung cancer (stages 0, I or II, and sometimes stage III) may be treated by surgery to remove the tumour.^[1],[2],[3] Some of the tests used for diagnosis and staging may be used to see whether the cancer has spread outside the lung. If it has spread, surgery might not be helpful. However, sometimes surgery is used to remove a metastasis in the brain if there is only one tumour, provided that the tumour in the lung can also be completely removed.

Pulmonary function tests are often done before surgery to measure how well the lungs are working, so that the doctor can assess whether surgery is a good option. If lung function is poor, removal of part or all of a lung might not be possible. If lung function is good, the surgeon might be able to remove more of the lung tissue, to increase the chance of curing the cancer.

Types of surgery that can be used include:^[4],[5],[6]

• pneumonectomy – removal of an entire lung
• lobectomy – removal of 1 of the lobes of the lung (the right lung is divided into 3 lobes; the left lung is divided into 2 lobes)
• segmentectomy or wedge resection – removal of part of a lobe
• sleeve resection (or sleeve lobectomy) – removal of a section of a large airway, followed by rejoining of the 2 parts of the airway.

Nearby lymph nodes will also be removed during the surgery to see if the cancer has spread.^[7]

These operations usually involving a surgical incision between the ribs in the side of the chest (thoracotomy). Recovery from surgery can take weeks to months. Increasingly, lung cancer surgery is done with a ‘keyhole’ approach, known as video-assisted thoracic surgery (VATS).^[8] This involves the use of tubes inserted through small cuts between the ribs. Robotically-assisted thoracic surgery (RATS) uses a robotic system. VATS and RATS are associated with faster recovery, and less pain and blood loss, but require a high degree of surgical skill.^[9]

Surgery is rarely used as the main treatment for small cell lung cancer because the cancer has usually spread to lymph nodes or other organs by the time it is found.^[10],[11]

Where small cell lung cancer is found as a single lung tumour, with no spread to lymph nodes or other organs, surgery may be an option, usually followed by additional treatment (chemotherapy often with radiation therapy).^[12]

Radiofrequency ablation

Radiofrequency ablation uses high-energy radio waves to heat the tumour and kill the cancer cells. This may be an option for treating small tumours, especially those that are not suitable for surgery.

Chemotherapy

Along with surgery, some people may receive chemotherapy.

Chemotherapy might be used as the main treatment for lung cancer, especially for stage III and IV non–small cell lung cancer. It may also be used after surgery to kill cancer cells that may remain but cannot be detected (adjuvant chemotherapy), or before surgery to shrink the tumour (neoadjuvant chemotherapy)^[13], to be able to remove the cancer with less extensive surgery.

Chemotherapy is usually given intravenously as an infusion. These drugs can have several side effects, which your doctor will explain to you in detail. Chemotherapy is usually given in multiple courses (cycles) for a set amount of time, or for as long as the treatment is effective. Having the treatment in cycles allows time for the healthy cells in your body to recover between treatments.

Chemotherapy is usually the main treatment for small cell lung cancer.^[14],[15]

Radiation therapy

Along with surgery, some people may receive radiation therapy.

Radiation therapy might be used either as the main treatment for lung cancer, after surgery to kill cancer cells that remain, before surgery to shrink the tumour, or to relieve symptoms of advanced lung cancer.^[16] The most common type of radiation therapy used is External beam radiation therapy (EBRT), which focuses radiation from outside the body. Radiation therapy can sometimes involve the use of new techniques that precisely target the cancer while reducing the amount of radiation exposure to surrounding tissues.^[17],[18] These include:

• Stereotactic body radiation therapy (SBRT)
• Intensity modulated radiation therapy (IMRT)
• Stereotactic radiosurgery (SRS)

Internal radiation therapy (brachytherapy), where a small source of radioactive material is placed into the cancer or near it, is sometimes used.^[19],[20]

Small cell lung cancer often spreads to the brain. For some patients who have responded to initial treatment, radiotherapy to the brain might be used to reduce the risk of the cancer spreading to the brain. This may increase the chance of cure.^[21],[22]

Targeted therapy

Targeted therapy refers to treatment with medicines that are designed to specifically attack cancer cells with less harm to normal cells. They often have different side effects to chemotherapy. They are usually given as single treatments, however, can be used in combination with chemotherapy sometimes.

Other medicines target cancer cells that have certain gene mutations that help them to grow and spread.^{[23],[24],[25]}

One type of  targeted therapy block the proteins that help tumours form new blood vessels. These are called angiogenesis inhibitors, such as bevacizumab. ^[26],[27]

Another type targets a protein (epidermal growth factor receptor) that helps cancer cells grow. EGFR inhibitors block the signal from EGFR that allows cell growth. EGFR inhibitors includes the medicines osimertinib, erlotinib, afatinib, and gefitinib.

Other targeted therapies include targets for ALK and ROS1 gene changes such as lorlatinib, alectinib, crizotinib, brigatinib and entrectinib.

More recent targeted therapies include targets for KRAS (e.g. sotorasib), MET alterations (e.g. tepotinib).

With further research and development in cancer treatment, there are more mutations being detected in lung cancer, and newer medicines being developed to target these mutations. .^{[28],[29],[30]}

Immunotherapy

Immunotherapy involves treatment with medicines that boost the ability of the immune system to attack cancer cells. Immunotherapy can be used to treat some forms of non–small cell lung cancer and small cell lung cancer.

For example, nivolumab, pembrolizumab, atezolizumab and cemiplimab are medicines that boost the immune response against cancer cells by targeting a protein on immune system cells (T cells) that normally stops these cells attacking the body’s normal tissues. This boosts the immune response against cancer cells.^[31],[32]

Other treatments

Other types of treatment that may be used for non–small cell lung cancer are:^[33]

• laser therapy – a laser beam is used to kill cancer cells
• photodynamic therapy – a laser light, combined with a medicine that becomes active when it is exposed to light, is used to kill cancer cells
• cryosurgery – an instrument is used to destroy abnormal tissue by freezing it
• electrocautery – a needle heated by an electric current is used to destroy abnormal tissue.

These treatments are mostly used for advanced disease.

Follow-up

After treatment for lung cancer, you will need regular follow-up examinations and tests to look for return of the cancer or side effects from treatment. These might include X-rays or CT scans.

Advanced disease

Stage IV lung cancer is considered incurable because tumours have spread to other parts of the body. Treatment to slow the growth of the cancer, provide improved quality of life and improve survival are the main goals of therapy. Surgery, chemotherapy, radiation therapy, immunotherapy and targeted treatments may relieve symptoms, slow the spread of the cancer and help you to live longer.^[34]

Specific treatments may also be used to:

• remove fluid buildup around the lungs, which can press on the lungs and make breathing difficult
• remove fluid buildup around the heart, which can press on the heart and affect its function
• relieve blockages in airways caused by the cancer.

Recurrent cancer

Lung cancer can recur (come back) after treatment. The cancer can recur in the lungs or somewhere else in the body, and is classified as local or distant (often called metastatic cancer).

Secondary cancer is when the cancer spreads to another part of the body.

Treatment of recurrent and secondary lung cancer will depend on where the cancer is, how large it is, what treatments have been used before and the person’s general health. It might involve surgery, chemotherapy, radiation therapy, immunotherapy or targeted treatments.^[35],[36]

Supportive care

Supportive care forms an important component of managing advanced lung cancer. The aim of supportive care is to improve the quality of life of patients, by either preventing or treating symptoms caused by the cancer or it’s treatment.  Supportive care includes physical, psychological, social, and spiritual support for patients and their families. Symptoms arising from lung cancer and its treatment including pain, shortness of breath, cough and weight loss, can be managed in conjunction with a pain specialist or palliative care specialist to provide improved quality of life.

You might feel overwhelmed, scared, anxious or upset if you have been diagnosed with cancer – these are all normal feelings. It’s very important to have support from family, friends, health professionals or other services to help you cope with cancer.

Getting the best advice and care: a guide for those affected by lung cancer contains guidance on what people with lung cancer can do to start conversations with their health professionals and be actively involved in the decisions about their care.

Living with cancer has information about physical, emotional and practical issues during and after diagnosis and treatment.