How Is Lung Cancer Treated?

The kind of treatment received for lung cancer depends on: 

• The type of lung cancer (either non-small cell or small cell)

• The size and position of the cancer

• How advanced the cancer is (stage)

• Overall health

There are two broad categories of lung cancer: small cell and non-small cell. The cancer cells of each type grow and spread in different ways. Each has its own set of standard treatment types, though there is some overlap. 

Small cell lung cancer

Small cell lung cancer is a disease in which malignant (cancer) cells form in the lung tissue. Under a microscope, the cells look small and round. Smoking (i.e., cigarettes, cigars, second-hand smoke, etc.) is the primary cause of small cell lung cancer, and the frequency and duration of exposure will increase the chance of having small cell lung cancer.

There are two types of small cell lung cancer: small cell carcinoma or combined small cell carcinoma. 

Small cell lung cancer has two stages, depending on how much it has spread to other areas of the body: limited-stage and extensive-stage.  

• With limited-stage small cell lung cancer, the cancer is in the lung and may have spread to the area between the lungs or the lymph nodes above the collarbone.

• With extensive-stage small cell lung cancer, the cancer has spread beyond the lung to areas between the lungs, or to the lymph nodes above the collarbone and to other parts of the body.

Non-small cell lung cancer

Like small cell lung cancer, non-small cell lung cancer also forms in the tissue of the lungs, but under a microscope, the cells are larger than those seen in small cell lung cancer.

Different types of non-small cell lung cancers have distinct cancer cells. The cancer cells of each type grow in different ways. The types of non-small cell lung cancer are named for the types of cells found in cancer and how the cells look under a microscope.

There are three main types of non-small cell lung cancer:

• Squamous cell carcinoma – cancer cells form in thin, flat cells that line the inside of the lungs

• Large cell carcinoma – cancer cells appear larger when viewed under a microscope 

• Adenocarcinoma – cancer cells begin in glandular cells found in the lining of certain internal organs. These cancer cells make and release fluids in the body, such as mucus and digestive juices. 

Other less common types include: 

• Adenosquamous carcinoma 

• Sarcomatoid carcinoma 

• Salivary gland carcinoma 

• Carcinoid tumor

• Unclassified carcinoma

Non-small cell lung cancer is diagnosed with one of six stages, according to the size of the tumor and how much the disease has spread:

• Occult (hidden) stage: Cancer cells can only be seen by examining the inside the airways that lead to the lungs. Cancer has not spread to nearby tissue.

• Stage 0: abnormal cells are present and are only found in the top layers of cells lining the air passages. Cancer has not spread to nearby tissue.

• Stage I: cancer is present; the size of the tumor in the lung (less than four centimeters) and the extent it has grown to nearby tissues determines its sub-stage. There are five sub-stages to stage I.

• Stage II: cancer is present; the size of the tumor in the lung (less than seven centimeters) and the extent it has grown to nearby tissues determines its sub-stage. There are two sub-stages to stage II. 

• Stage III: cancer is present; the size of the tumor in the lung (less or more than five centimeters) and the extent it has grown to nearby tissues determines its sub-stage. There are three sub-stages to stage III.

• Stage IV: cancer has spread to other parts of the body. There are two sub-stages to stage IV.

Standard treatments for non-small lung cancer include:

• Surgery

• Radiation therapy

• Chemotherapy

• Targeted therapy

• Immunotherapy

• Laser therapy

• Photodynamic therapy (PDT)

• Cryosurgery

• Electrocautery

Surgery

Lung cancer can be treated with three types of surgery: lobectomy, pneumonectomy, and wedge resection. 

Lobectomy

A lobectomy is a surgery that involves the removal of one or more significant parts of the lung, called lobes. There are three lobes in your right lung and two lobes in your left lung.

This procedure usually involves making a few small incisions or one long incision on the side of the chest. The long incision is called a thoracotomy and is based on your specific diagnosis.

Using either the short or long incisions, the affected lobe with the tumor, along with surrounding lymph nodes, are removed to prevent the possible spread of cancer cells.

Pneumonectomy

Pneumonectomy involves removing the entire lung. This surgery is performed when the cancer is either in the middle of the lung or has spread throughout the lung. Most people can survive with one lung providing enough oxygen intake and carbon dioxide removal. 

In rare cases, pneumonectomy may be performed with a special video camera (video-assisted thoracoscopic surgery, or VATS). This is considered a minimally invasive surgery and uses fewer incisions than the traditional open lung surgery.

Most pneumonectomy experts recommend only using this procedure for people with early-stage tumors close to the lung walls.

Wedge resection 

This type of surgery is similar to segmentectomy (removing a section of a lobe of the lung) in that it involves removing a portion of the lung. This is a limited procedure and is only used when the doctors are certain that the tumor is small and restricted to one lung area. 

The difference between this and segmentectomy is that wedge resection removes the cancerous tumor and a wedge-shaped section of the lung around the tumor. Segmentectomy removes a part of the lung larger than a wedge section and is less invasive than a complete lobectomy. Both wedge resection and segmentectomy are considered sub-lobar resection.

While the wedge resection and segmentectomy procedures are less invasive than most extensive lung cancer surgeries, such as lobectomy or pneumonectomy, they may also have a higher chance of cancer recurrence.

A doctor may recommend these procedures for microscopic tumors, like early-stage non-small cell lung cancers and limited-stage small cell lung cancer. 

Radiotherapy

Radiotherapy is a procedure that uses radiation to destroy cancer cells, and there are various ways it can be used to treat lung cancer. The two common types of radiotherapy are radical and stereotactic radiotherapy.

Radical radiotherapy, an intensive course of radiotherapy, is used to treat a highly localized tumor - such as non-small cell lung cancer - and is used when you are not healthy enough for surgery. For tiny tumors, stereotactic radiotherapy can be used instead of surgery.

Radiotherapy is also used to control symptoms like pain and coughing up blood. It also slows the spread of cancer when a cure is not possible. This scenario is commonly known as palliative radiotherapy. Palliative radiotherapy to the lung can improve not only the cancer symptoms but also the patient’s overall quality of life. 

A further type of radiotherapy referred to as prophylactic cranial irradiation (PCI) is often used to treat small cell lung cancer. PCI involves treating the entire brain with a low dose of radiation and is often used as a preventative measure to help mitigate the spread of small cell lung cancer to the brain. 

Radiotherapy can be administered through conventional external beam radiation therapy (EBRT) or stereotactic radiotherapy (SRS).

Conventional external beam radiation therapy (EBRT) 

EBRT is a non-invasive treatment method that delivers targeted beams of radiation to the tumor. The radiation beams are shaped as they leave the linear accelerator and as they reach the patient to ensure they are carefully and precisely directed at the cancer.

Stereotactic radiotherapy

SRS uses 3D imaging to target high doses of radiation to small tumors outside of the spine or brain. Stereotactic radiotherapy is less invasive than surgery, as there are no surgical incisions. However, it is critical to remain still during this procedure to ensure the accuracy of the treatment.

Stereotactic radiation therapy may also be used for tumors in the brain or spinal cord, using a few lower dose treatments rather than one larger one. 

Patients who undergo conventional radical radiotherapy are more likely to have between 20 and 32 treatment sessions. Radical radiotherapy is typically given to patients five days a week, with a break at weekends. Each session lasts from 10 to 15 minutes, and the course usually lasts from four to seven weeks.

Chemotherapy

Chemotherapy is a procedure that uses powerful cancer-killing medication to treat cancer. There are many ways that chemotherapy can be used to treat lung cancer, some of which include:

• Before surgery to shrink or reduce a tumor, which can increase the chances of a successful surgery. This is usually done as part of a clinical trial.

• After surgery to prevent cancer from returning. 

• To relieve symptoms and slow the spread of cancer when a cure is impossible.

• Combined with radiotherapy.

Usually, chemotherapy treatments are given in cycles. A cycle typically involves taking chemotherapy medicine for several days and then having a break for a few weeks. The purpose of the break is to let the therapy work and help your body recover from the effects of the treatment. The number of cycles needed often depends on the type and grade of lung cancer.  

On average, most patients need four to six cycles of treatment over three to six months to experience an improvement. However, if the cancer has not improved after these cycles, a different type of chemotherapy may be considered. Maintenance chemotherapy may also be prescribed to keep the cancer from advancing.

Chemotherapy for lung cancer consists of taking a combination of medication, usually administered through a drip into a vein or a tube connected to one of the blood vessels in your chest.

Some people prefer capsules to the intravenous method for convenience and comfort, but they have to be taken daily, while intravenous chemotherapy is given once every few weeks. 

Chemotherapy weakens the immune system, making you more vulnerable to infection and many undesirable side effects. Some of these side effects include fatigue, feeling sick, mouth ulcers, and hair loss. After the chemotherapy treatment, the side effects will pass, and you can begin taking other medication to assist in your recovery. 

Immunotherapy

Immunotherapy is a treatment plan involving taking a group of medicines to stimulate the immune system to target and kill cancer cells. This form of treatment can be used on its own or in combination with chemotherapy.

Different immunotherapy treatments work in different ways. Some help the immune system stop or slow down cancerous cells, while others help it destroy or prevent its spread. There are many types of immunotherapy, including:

Monoclonal antibodies (mAbs or MoAbs)

Monoclonal antibodies are man-made versions of immune system proteins. These can be very useful in treating cancer because they can be designed to attack a specific part of a cancer cell without affecting surrounding areas of the body.

Other monoclonal antibodies boost the immune system by inhibiting or stopping immune checkpoints. The body typically uses an immune checkpoint to naturally eliminate the immune system’s response and prevent it from destroying healthy cells. Cancer cells may find ways to hide from the immune system by enhancing these checkpoints.

The checkpoint inhibitors stop cancer cell’s ability to suppress the immune system from activating. This supports your body’s immune system in attacking the cancer cells.

The common checkpoints that these inhibitors affect are the PD-1/PD-L1 and CTLA-4 pathways. Some checkpoint inhibitors could treat tumors anywhere in the body by focusing on specific genetic changes. These are called “tumor-agnostic treatments.” 

Examples of immune checkpoint inhibitors are:

• Ipilimumab (Yervoy)

• Nivolumab (Opdivo)

• Pembrolizumab (Keytruda)

• Atezolizumab (Tecentriq)

• Avelumab (Bavencio)

• Durvalumab (Imfinzi)

The side effects of the monoclonal antibody treatment depend on the drug’s use. For example, the consequences of monoclonal antibodies used for targeted therapy are not like those used for immunotherapy.

Common immunotherapy side effects may be similar to flu-like symptoms or an allergic reaction, such as skin irritation.

Oncolytic virus therapy

Oncolytic virus therapy consists of using lab-modified viruses to eliminate cancer cells.

After the doctor injects the genetically enhanced virus into the cancer cells, the virus duplicates and kills the cancer cells. As the cells die off, proteins are released, instructing your immune system to target any similar cancer cells in your body. The virus does not enter the healthy cells.

T-cell therapy 

T cells are immune cells that fight infection. T-cell therapy is used to kill cancer cells.

T-cell therapy removes T cells from the blood, and specific proteins, called receptors, are added to the cells. These receptors allow those T cells to recognize cancer cells, and then they are returned to the body. Once there, they find and destroy cancer cells. This type of therapy is known as chimeric antigen receptor (CAR) T-cell therapy.

The typical side effects of T-cell therapy include fevers, confusion, low blood pressure, and, on rare occasions, seizures.

The type of drug, dosage and treatment schedule depends on various factors and considerations, including the type of cancer, location, size, and where it has spread to, in addition to your age, body weight, general health, and how well you can cope with side effects.

Alternative treatments 

In addition to the treatments mentioned above, there are also other treatments used to treat lung cancer, such as:

Radiofrequency ablation 

Radiofrequency ablation can be used to treat non-small cell lung cancer when it is at an early stage.

The doctor uses a scanner (CT) to guide a needle to the area of the tumor. The needle is pressed into the tumor, and radio waves are sent through the needle. These waves produce heat, killing the cancer cells.

While there may be some pain at the injection site for a few days following treatment, there are virtually no side effects or recovery period after the procedure.

Cryotherapy

Cryotherapy may be necessary if a tumor begins to obstruct the airway. This is referred to as endobronchial obstruction and can result in breathing problems, coughing, and coughing up blood.

Cryotherapy is performed similarly to internal radiotherapy, but instead of using a radioactive source, a device known as a cryoprobe is placed against the tumor. The cryoprobe can generate freezing temperatures, which help to shrink the tumor.

Photodynamic therapy 

Photodynamic therapy can treat early-stage lung cancer when surgery is not possible.

Photodynamic therapy can be used to remove a lung tumor that is blocking the airway and is performed in two stages. Stage one involves an injection to make cells sensitive to light. Stage two takes place over one to three days, during which a thin tube is directed to the tumor site, and a laser is beamed through it. The light beam created by the laser will specifically target and destroy cancer cells without harming any of the surrounding tissues. 

Possible side effects of photodynamic therapy can include inflammation of the airways and a build-up of fluid in the lungs, which can lead to breathlessness and lung pain. However, these symptoms gradually pass as the lungs recover from the impact of the treatment.

The lowdown

Lung cancer treatment is not managed by only one specialist. Instead, a comprehensive treatment is managed by a team of medical specialists from various disciplines and practices. These health professionals work together as a team to provide the best care and treatment for your needs.

Bear in mind that while your doctor may make educated recommendations, the final decision will be up to you.

While every cancer journey is unique, understanding average survival rates according to age, sex, and cancer stage, can help you make better-informed decisions.