Your Guide To Stage IV Lung Cancer

Among all cancers, lung cancer is the leading cause of cancer deaths worldwide. In the US, lung cancer is the second most common cancer in both men and women. According to the American Cancer Society, lung cancer makes up almost 25% of all cancer deaths¹.

There are two types of lung cancer: small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC).

Non-small cell lung cancer is the most common type of lung cancer, accounting for about 80-85%² of all lung cancers. They're less aggressive than small cell lung cancers, so they spread to other tissues and organs slower. This means patients have better chances of survival.

Small cell lung cancer accounts for about 15-20% of all lung cancers, and it’s more aggressive and tends to spread faster.

Learn more about the types of lung cancer here.

What is stage IV lung cancer?

Stages most often categorize lung cancers based on the tumor's size and whether it has spread (metastasized) beyond the lung.

Stage IV lung cancer is the most advanced and is metastatic, meaning cancer has spread from the originating lung to other parts of the body. This can include the lining surrounding the lung or the heart, distant lymph nodes, liver, adrenal glands, or brain. 

Doctors still consider any metastatic tumors that develop in another part of the body as lung cancer because lung cancer cells form them. 

Stage IV lung cancer has two substages:

• Stage IVA, where cancer has spread within the lungs, to the lining or fluid around the lungs or heart, or to one other location, such as the other lung (where cancer did not start), brain, liver, adrenal glands, or kidneys.

• Stage IVB, where cancer has spread to multiple places in one or more organs far away from the lungs, such as the brain, liver, or bones. Stage IVB is more common, and it's generally more difficult to treat.

Many people learn they have lung cancer in stage IV. According to the National Cancer Institute (NCI), 57% of lung cancer patients receive their diagnosis at stage IV³.

Multiple symptoms may be present depending on where the lung cancer has metastasized. For example, if lung cancer has spread to your brain, you're more likely to experience headaches and neurological problems. If it's spread to your bones, you may experience bone pain or fractures. Liver metastasis often results in jaundice, bloating, or nausea.

Common symptoms of stage IV lung cancer include:

• Chest pain that worsens with deep breathing, coughing, or laughing

• Back or abdominal pain

• A persistent cough

• Coughing up blood or rust-colored phlegm

• Feeling tired or weak

• Growth in the neck or collarbone area

• Unexplained weight loss

• Hoarseness or wheezing

• Issues with breathing

• Loss of appetite 

• Respiratory infections such as bronchitis and pneumonia that come back or never go away 

Find more information on lung cancer symptoms and early warning signs here.

Treatments for stage IV lung cancer

Treating stage IV lung cancer can be challenging. Lung cancer may continue to spread at this stage, and cancer cells may remain in the body and cause recurrence.

So, treatment will typically focus on extending and improving your quality of life by relieving symptoms and controlling cancer growth.

Factors that influence the treatment plan include the type of lung cancer, where cancer has spread, whether the cancer cells have a certain gene or protein changes, and your overall health.

While oncologists often recommend surgery at earlier stages of lung cancer, it doesn't work for most patients with stage IV lung cancer. That's because cancer has already spread to multiple organs in the body.

Your doctor will likely use a combination of treatments that attack cancer throughout the body when you're in stage IV. Your treatment plan may include:

Radiation therapy

Radiation therapy such as stereotactic body radiation therapy (SBRT) is a cancer treatment that delivers high doses of radiation to destroy cancer cells or prevent them from growing. In stage IV cancer, your doctor may use it to treat isolated metastases.

Chemotherapy

Although it's unlikely to cure you at this stage, chemotherapy can shrink the tumors you have or slow their growth. Chemotherapy uses drugs to kill cancer cells, and you will receive one or more chemotherapy drugs intravenously. Doctors often use this in combination with immunotherapy.

Immunotherapy

Immunotherapy works by releasing the ‘brakes’ on your immune system so it can fight cancer cells. You will receive immunotherapy alone or in combination with chemotherapy, depending on the level of immune expression in the tumor and the number of metastases.

Targeted therapy

Targeted therapy identifies and attacks specific cancer cells, and it’s an option for patients with certain genetic changes in their cancer. These therapies usually cause less harm to healthy cells than chemotherapy or radiation therapy. There is also the advantage of reduced treatment-related side effects and improved outcomes.

Clinical trials for stage IV lung cancer patients

For some patients, taking part in a clinical trial may be the best treatment choice. Clinical trials are part of the cancer research process where scientists, doctors, and researchers develop and test new treatments and therapies on enrolled patients.

Trials determine if new cancer treatments are safe and effective or better than standard treatments. Earlier clinical trials led to many of today's standard cancer treatments.

Why join a clinical trial?

Patients who take part in a clinical trial may receive standard treatments or be among the first to receive a new treatment. By participating in a clinical trial, you could access new and otherwise unavailable therapies not yet approved by the Food and Drug Administration (FDA).

How do cancer clinical trials work?

Some trials only include patients who have not yet received treatment. Other trials test treatments for patients whose cancer has not improved. Clinical trials also test novel ways to stop cancer from coming back or reduce the side effects of cancer treatment.

Clinical trials are taking place in many parts of the country. Search for lung cancer here to find available trials.

Prognosis and survival rates of stage IV lung cancer

When your oncologist makes a prognosis, they're predicting how they think the disease will develop and how your body will react.

Doctors often use five-year survival rates to express life expectancy for stage IV lung cancer, which estimates the percentage of people who will live for at least five years after the initial diagnosis³. A mean or median survival is another way to provide a prognosis.

Survival rate refers to the percentage of patients at a similar stage of the same disease still alive five years after their diagnosis. For example, a five-year survival rate of 18% means that 18 out of 100 people diagnosed with a specific type of cancer are likely to survive for at least five years.

According to the American Cancer Society, the five-year survival rate⁴ for stage IV non-small cell lung cancer is around 7%, and life expectancy is around 3% for stage IV small cell lung cancer.

Remember, survival rates are estimates. The current five-year survival rate is based on people diagnosed and treated at least five years ago. These estimates may not reflect the latest breakthroughs in treatments that may improve your outlook; researchers are constantly developing and improving treatments for lung cancer.

Survival rates can't predict what will happen in any particular case since no two people with lung cancer are alike, and you may respond differently to treatments. People can live for weeks, months, or even years after diagnosis.

Several factors can affect life expectancy with stage IV lung cancer:

Overall health

Generally, if you're healthy when diagnosed with stage IV lung cancer, you may tolerate lung cancer treatments better. People who are generally unwell may struggle to cope with treatment.

Age

Being older is linked⁵ to poorer outcomes in lung cancer patients irrespective of the stage. Older people are often in poorer general health, and their immune systems cannot control tumor growth.

Sex

Male sex is associated with poorer outcomes in people with lung cancer in general. Men are less likely to have "treatable" gene mutations⁶—those responsive to newer targeted therapies.

Essentially, men are more likely to get lung cancer than women, with poorer survival rates.

Genetic mutations

Mutations, such as in the epidermal growth factor receptor (EGFR) gene, may affect how stage IV lung cancer responds to treatment. EGFR contributes to the growth of several types of cancer, and drugs that block EGFR activity can slow cancer growth.

Targeted therapies can treat EGFR and other genetic mutations, increasing survival rates. Oral drugs such as Osimertinib target this pathway. There are other mutations/genetic changes such as ALK, ROS1, BRAF, HER2, etc.

Smoking

Cigarette smoking is the most established risk factor for lung cancer, but it's never too late to quit smoking. Carcinogens in tobacco smoke may act as genetic inducers and as promoters of disease progression. According to a 2018 study⁷, quitting cigarettes before starting chemotherapy can increase survival time by as much as six months.

Ability to perform daily activities

Though people with stage IV lung cancer tend to be symptomatic, not all will be equally ill or incapacitated. According to the Eastern Cooperative Oncology Group (ECOG) Performance Status, people with lung cancer who can perform everyday functions and have a higher performance score may survive longer than those who need more daily support.

Lung cancer location and type

There are many different types and subtypes of lung cancer. Some are more aggressive than others, such as large cell lung carcinoma. The tumor's location can make a big difference in how long a person survives. Metastases in critical organs such as the brain or liver may mean a worse prognosis.

Comorbidity

Most people with stage IV lung cancer have another chronic health condition, which is called “comorbidity.” The most common comorbid conditions are chronic pulmonary disease, diabetes, and congestive heart failure. Having one or more comorbidities complicates lung cancer treatment and significantly impacts⁸ life expectancy.

Response to treatment

If you respond well to cancer treatment, you'll likely live for longer.

What should you expect if you have stage IV lung cancer and are nearing the end of life?

At some point, your doctor may tell you that you've reached the final stages of lung cancer, and treatment will no longer help you. Common symptoms for people who have reached the final stages include:

• Pain

• Confusion and trouble focusing

• Cough

• Little interest in eating or drinking

• Shortness of breath

• Sleep changes: you may sleep more and more

• Fatigue

• Fast breathing or pauses in between breaths

• A rattle in the throat and upper part of the chest when breathing 

Having one or more of these symptoms doesn't always mean that you're nearing the end of life, but they can be signs. Your doctor or hospice staff can offer you treatments to relieve these symptoms and make you more comfortable.

Not all symptoms in the final stages of lung cancer are physical. It's also normal to feel anxious or depressed at this stage. You may experience a fear of dying, feel lonely as if no one truly understands what you're going through, and feel regret. It’s really important to communicate with the people who are caring for you.

Talk to your loved ones or healthcare team about these issues, and ask for support from a therapist or religious organization if you want guidance. It's also a good idea to talk to your doctors, friends, and family about end-of-life care options. This conversation will ensure you and your care team are on the same page.

When and how is palliative care used?

The final stage of lung cancer means there are no more treatment options, and a cure is not possible⁹. Your medical team may use palliative treatments to ease symptoms or improve comfort.

Palliative care is for when treatment is no longer an option. It focuses on relieving your symptoms and supporting you through the rest of your cancer journey. It involves only using medications that reduce the distressing symptoms of cancer, such as nausea and vomiting.

Palliative care should ideally begin after a cancer diagnosis, and you can start it anytime after. A study¹⁰ found that early and systematic integration of palliative care can improve the quality of life for patients with advanced lung cancer.

Palliative care is usually a team approach designed to address the physical and emotional concerns of people coping with late-stage lung cancer. You can receive palliative care in your home or at a hospice center.

What you should expect as family, friends, and caregivers

As someone nears the end of their life, it's difficult to know what to expect. Some people want to fight to the end, but others seem ready to accept death. Your loved one may withdraw in the last few months, and they may seem less open to visiting with family and friends. They may no longer be interested in activities that once excited them.

Your loved one might also experience spiritual changes, even if they aren't usually religious. They may be frustrated and irritable over fatigue and other limitations that mean they need more help. It's important to offer comfort and let them know they are not alone. Be calm and reassuring.

Caring for a dying loved one can be the hardest and most rewarding thing you will ever do. Be sure to take care of yourself during this time, even if it feels selfish. Taking care of a sick person often causes physical and emotional fatigue, stress, depression, and anxiety. A support system will help you maintain your well-being so you can support your loved ones as much as possible.

The lowdown

A stage IV lung cancer diagnosis means that cancer has spread from the lungs to distant parts of your body. While it usually can't be cured, various treatments can slow down cancer growth and manage your symptoms. It’s wise to integrate palliative care soon after diagnosis.