Non-Small Cell Lung Cancer Treatment
General Information(Symptoms and Diagnosis)
Stages
Treatment
General Information About Non-Small Cell Lung Cancer
Key Points
- Non-small cell lung cancer is a disease in which malignant
(cancer) cells form in the tissues of the lung.
- There are several types of non-small cell lung cancer.
- Smoking is the major risk factor for non-small cell lung
cancer.
- Signs of non-small cell lung cancer include a cough that
doesn't go away and shortness of breath.
- Tests that examine the lungs are used to detect (find),
diagnose, and stage non-small cell lung cancer.
- Certain factors affect prognosis (chance of recovery) and
treatment options.
- For most patients with non-small cell lung cancer, current
treatments do not cure the cancer.
Non-small
cell lung cancer is a disease in which malignant (cancer) cells form in
the tissues of the lung.
The lungs
are a pair of cone-shaped breathing organs
in the chest. The lungs bring oxygen
into the body as you breathe in. They release carbon
dioxide, a waste product of the body's cells,
as you breathe out. Each lung has sections called lobes.
The left lung has two lobes. The right lung is slightly larger and has
three lobes. Two tubes called bronchi
lead from the trachea
(windpipe) to the right and left lungs. The bronchi are sometimes also
involved in lung
cancer. Tiny air sacs called alveoli
and small tubes called bronchioles
make up the inside of the lungs.
Anatomy of the respiratory
system, showing the trachea and both lungs and their lobes and airways.
Lymph nodes and the diaphragm are also shown. Oxygen is inhaled into
the lungs and passes through the thin membranes of the alveoli and into
the bloodstream (see inset).
A thin membrane
called the pleura
covers the outside of each lung and lines the inside wall of the chest cavity.
This creates a sac called the pleural
cavity. The pleural cavity normally contains a small
amount
of fluid
that helps the lungs move smoothly in the chest when you breathe.
There are two main types
of lung cancer: non-small
cell lung cancer and small
cell lung cancer.
See the following PDQ
summaries for more information about lung cancer:
- Small
Cell Lung Cancer Treatment
- Unusual
Cancers of Childhood Treatment
- Lung
Cancer Prevention
- Lung
Cancer Screening
There
are several types of non-small cell lung cancer.
Each type of non-small
cell lung cancer has different kinds of cancer
cells. The cancer cells of each type grow and spread in different ways.
The types of non-small cell lung cancer are named for the kinds of
cells found in the cancer and how the cells look under a microscope:
- Squamous
cell carcinoma: Cancer that begins in squamous
cells, which are thin, flat cells that look like fish
scales.
This is also called epidermoid carcinoma.
- Large
cell carcinoma: Cancer that may begin in several types of
large cells.
- Adenocarcinoma:
Cancer that begins in the cells that line the alveoli and make
substances such as mucus.
Other less common types
of non-small cell lung cancer are: pleomorphic,
carcinoid
tumor,
salivary
gland carcinoma, and unclassified carcinoma.
Smoking
is the major risk factor for non-small cell lung cancer.
Anything
that increases your chance of getting a disease is called a risk
factor. Having a risk factor does not mean that you will
get
cancer; not having risk factors doesn't mean that you will not get
cancer. Talk to your doctor if you think you may be at risk for lung
cancer.
Risk
factors for lung cancer include the following:
- Smoking cigarettes,
pipes,
or cigars,
now or in the past. This is the most important risk factor for lung
cancer. The earlier in life a person starts smoking, the more often a
person smokes, and the more years a person smokes, the greater the risk
of lung cancer.
- Being exposed to secondhand
smoke.
- Being exposed to radiation
from any of the following:
- Radiation
therapy to the breast
or chest.
- Radon
in the home or workplace.
- Imaging
tests such as CT
scans.
- Atomic bomb radiation.
- Being exposed to asbestos,
chromium, nickel, beryllium, arsenic,
soot, or tar in the workplace.
- Living where there is air pollution.
- Having a family
history of lung cancer.
- Being infected
with the human
immunodeficiency virus (HIV).
- Taking beta
carotene supplements
and being a heavy smoker.
Older age
is the main risk factor for most cancers. The chance of getting cancer
increases as you get older.
When smoking is combined
with other risk factors, the risk of lung cancer is increased.
Signs
of non-small cell lung cancer include a cough that doesn't go away and
shortness of breath.
Sometimes lung cancer
does not cause any signs
or symptoms.
It may be found during a chest
x-ray done for another condition.
Signs and symptoms may be caused by lung cancer or by other conditions.
Check with your doctor if you have any of the following:
- Chest discomfort or pain.
- A cough that doesn't go away or gets worse over time.
- Trouble breathing.
- Wheezing.
- Blood
in sputum
(mucus
coughed up from the lungs).
- Hoarseness.
- Loss of appetite.
- Weight loss for no known reason.
- Feeling very tired.
- Trouble swallowing.
- Swelling in the face and/or veins
in the neck.
Tests
that examine the lungs are used to detect (find), diagnose, and stage
non-small cell lung cancer.
Tests and procedures to
detect, diagnose,
and stage
non-small cell lung cancer are often done at the same time. Some of the
following tests and procedures may be used:
- Physical
exam and history
: An exam of the body to check general signs of
health, including checking for signs of disease, such as lumps or
anything else that seems unusual. A history of the patient's health
habits, including smoking, and past jobs, illnesses, and treatments
will also be taken.
- Laboratory
tests : Medical procedures that test
samples
of tissue,
blood,
urine,
or other substances in the body. These tests help to diagnose disease,
plan and check treatment, or monitor
the disease over time.
- Chest x-ray: An x-ray
of the organs and bones inside the chest. An x-ray is a type of energy
beam that can go through the body and onto film, making a picture of
areas inside the body.
X-ray of the chest.
X-rays are used to take pictures of organs and bones of the chest.
X-rays pass through the patient onto film.
- CT
scan (CAT scan): A procedure that makes a
series of detailed pictures of areas inside the body, such as the
chest, taken from different angles. The pictures are made by a computer
linked to an x-ray machine. A dye
may be injected
into a vein or swallowed to help the organs or tissues show up more
clearly. This procedure is also called computed tomography,
computerized tomography, or computerized axial tomography.
- Sputum
cytology : A procedure in which a pathologist
views a sample of sputum (mucus coughed up from the lungs) under a
microscope, to check for cancer cells.
- Fine-needle
aspiration (FNA) biopsy of the lung: The
removal of tissue or fluid from the lung using a thin needle. A CT
scan, ultrasound,
or other imaging
procedure is used to locate the abnormal
tissue or fluid in the lung. A small incision
may be made in the skin where the biopsy needle is inserted into the
abnormal tissue or fluid. A sample is removed with the needle and sent
to the laboratory. A pathologist then views the sample under a
microscope to look for cancer cells. A chest x-ray is done after the
procedure to make sure no air is leaking from the lung into the chest.
Fine-needle aspiration
biopsy of the lung. The patient lies on a table that slides through the
computed tomography (CT) machine, which takes x-ray pictures of the
inside of the body. The x-ray pictures help the doctor see where the
abnormal tissue is in the lung. A biopsy needle is inserted through the
chest wall and into the area of abnormal lung tissue. A small piece of
tissue is removed through the needle and checked under the microscope
for signs of cancer.
- Bronchoscopy
: A procedure to look inside the trachea and large
airways in the lung for abnormal areas. A bronchoscope
is inserted through the nose or mouth into the trachea and lungs. A
bronchoscope is a thin, tube-like instrument with a light and a lens
for viewing. It may also have a tool to remove tissue samples, which
are checked under a microscope for signs of cancer.
Bronchoscopy. A
bronchoscope is inserted through the mouth, trachea, and major bronchi
into the lung, to look for abnormal areas. A bronchoscope is a thin,
tube-like instrument with a light and a lens for viewing. It may also
have a cutting tool. Tissue samples may be taken to be checked under a
microscope for signs of disease.
- Thoracoscopy
: A surgical
procedure to look at the organs inside the chest to check for abnormal
areas. An incision (cut) is made between two ribs, and a thoracoscope
is inserted into the chest. A thoracoscope is a thin, tube-like
instrument with a light and a lens for viewing. It may also have a tool
to remove tissue or lymph
node samples, which are checked under a microscope for
signs
of cancer. In some cases, this procedure is used to remove part of the esophagus
or lung. If certain tissues, organs, or lymph nodes can't be reached, a
thoracotomy
may be done. In this procedure, a larger incision is made between the
ribs and the chest is opened.
- Thoracentesis
: The removal of fluid from the space between the
lining of the chest and the lung, using a needle. A pathologist views
the fluid under a microscope to look for cancer cells.
- Light
and electron
microscopy : A laboratory test in which
cells
in a sample of tissue are viewed under regular and high-powered
microscopes to look for certain changes in the cells.
- Immunohistochemistry
: A test that uses antibodies
to check for certain antigens
in a sample of tissue. The antibody is usually linked to a radioactive
substance or a dye that causes the tissue to light up under a
microscope. This type of test may be used to tell the difference
between different types of cancer.
Certain
factors affect prognosis (chance of recovery) and treatment options.
The prognosis
(chance of recovery)
and treatment options depend on the following:
- The stage
of the cancer (the size of the tumor and whether it is in the lung only
or has spread to other places in the body).
- The type of lung cancer.
- Whether the cancer has mutations
(changes) in certain genes,
such as the epidermal
growth factor receptor (EGFR) gene or the anaplastic
lymphoma kinase (ALK) gene.
- Whether there are signs and symptoms such as coughing or
trouble breathing.
- The patient's general health.
Stages of Non-Small Cell Lung Cancer
Key Points
- After lung cancer has been diagnosed, tests are done to
find out if cancer cells have spread within the lungs or to other parts
of the body.
- There are three ways that cancer spreads in the body.
- Cancer may spread from where it began to other parts of the
body.
- The following stages are used for non-small cell lung
cancer:
- Occult (hidden) stage
- Stage 0 (carcinoma in situ)
- Stage I
- Stage II
- Stage IIIA
- Stage IIIB
- Stage IV
After
lung cancer has been diagnosed, tests are done to find out if cancer
cells have spread within the lungs or to other parts of the body.
The process used to find
out if cancer
has spread within the lungs
or to other parts of the body is called staging.
The information gathered from the staging process determines the stage
of the disease. It is important to know the stage in order to plan
treatment. Some of the tests used to diagnose
non-small
cell lung cancer are also used to stage the disease. (See
the
General
Information section.)
Other tests and
procedures that may be used in the staging process include the
following:
- MRI
(magnetic resonance imaging): A procedure that uses a
magnet, radio
waves, and a computer to make a series of detailed
pictures
of areas inside the body, such as the brain. This procedure is also
called nuclear magnetic resonance imaging (NMRI).
- CT
scan (CAT scan): A procedure that makes a
series of detailed pictures of areas inside the body, such as the brain
and abdomen,
taken from different angles. The pictures are made by a computer linked
to an x-ray
machine. A dye
may be injected
into a vein
or swallowed to help the organs
or tissues
show up more clearly. This procedure is also called computed
tomography, computerized tomography, or computerized axial tomography.
- PET
scan (positron emission tomography scan): A
procedure to find malignant
tumor
cells in the body. A small amount of radioactive
glucose
(sugar) is injected into a vein. The PET scanner
rotates around the body and makes a picture of where glucose is being
used in the body. Malignant tumor cells show up brighter in the picture
because they are more active and take up more glucose than normal cells
do.
PET (positron emission
tomography) scan. The patient lies on a table that slides through the
PET machine. The head rest and white strap help the patient lie still.
A small amount of radioactive glucose (sugar) is injected into the
patient's vein, and a scanner makes a picture of where the glucose is
being used in the body. Cancer cells show up brighter in the picture
because they take up more glucose than normal cells do.
- Radionuclide
bone scan : A procedure to check if there
are
rapidly dividing cells,
such as cancer cells, in the bone. A very small amount of radioactive
material is injected
into a vein
and travels through the bloodstream. The radioactive material collects
in the bones and is detected by a scanner.
- Pulmonary
function test (PFT): A test to see how well
the lungs are working. It measures how much air the lungs can hold and
how quickly air moves into and out of the lungs. It also measures how
much oxygen
is used and how much carbon
dioxide is given off during breathing. This is also called
lung function test.
- Endoscopic
ultrasound (EUS): A procedure in which an endoscope
is inserted into the body. An endoscope is a thin, tube-like instrument
with a light and a lens
for viewing. A probe at the end of the endoscope is used to bounce
high-energy sound waves (ultrasound)
off internal tissues or organs and make echoes. The echoes form a
picture of body tissues called a sonogram.
This procedure is also called endosonography. EUS may be used to guide fine
needle aspiration (FNA) biopsy of the lung, lymph
nodes, or other areas.
Endoscopic
ultrasound-guided fine-needle aspiration biopsy. An endoscope that has
an ultrasound probe and a biopsy needle is inserted through the mouth
and into the esophagus. The probe bounces sound waves off body tissues
to make echoes that form a sonogram (computer picture) of the lymph
nodes near the esophagus. The sonogram helps the doctor see where to
place the biopsy needle to remove tissue from the lymph nodes. This
tissue is checked under a microscope for signs of cancer.
- Mediastinoscopy
: A surgical
procedure to look at the organs, tissues, and lymph nodes between the
lungs for abnormal
areas. An incision
(cut) is made at the top of the breastbone
and a mediastinoscope
is inserted into the chest. A mediastinoscope is a thin, tube-like
instrument with a light and a lens for viewing. It may also have a tool
to remove tissue or lymph node samples, which are checked under a microscope
for signs
of cancer.
Mediastinoscopy. A
mediastinoscope is inserted into the chest through an
incision above the breastbone to look for abnormal areas between the
lungs. A mediastinoscope is a thin, tube-like instrument with a light
and a lens for viewing. It may also have a cutting tool. Tissue samples
may be taken from lymph nodes on the right side of the chest and
checked
under a microscope for signs of cancer. In an anterior mediastinotomy
(Chamberlain procedure), the incision is made beside the breastbone to
remove tissue samples from the lymph nodes on the left side of the
chest.
- Anterior
mediastinotomy : A surgical procedure to
look
at the organs and tissues between the lungs and between the breastbone
and heart for abnormal areas. An incision (cut) is made next to the
breastbone and a mediastinoscope is inserted into the chest. A
mediastinoscope is a thin, tube-like instrument with a light and a lens
for viewing. It may also have a tool to remove tissue or lymph node
samples, which are checked under a microscope for signs of cancer. This
is also called the Chamberlain procedure.
- Lymph node biopsy
: The removal of all or part of a lymph node. A pathologist
views the tissue under a microscope to look for cancer cells.
- Bone
marrow aspiration and biopsy : The removal
of
bone
marrow, blood,
and a small piece of bone by inserting a hollow needle into the hipbone
or breastbone. A pathologist views the bone marrow, blood, and bone
under a microscope to look for signs of cancer.
There
are three ways that cancer spreads in the body.
Cancer can spread
through tissue,
the lymph
system, and the blood:
- Tissue. The cancer spreads from where it began by growing
into nearby areas.
- Lymph system. The cancer spreads from where it began by
getting into the lymph system. The cancer travels through the lymph
vessels to other parts of the body.
- Blood. The cancer spreads from where it began by getting
into the blood. The cancer travels through the blood
vessels to other parts of the body.
Cancer
may spread from where it began to other parts of the body.
When cancer spreads
to another part of the body, it is called metastasis.
Cancer cells
break away from where they began (the primary
tumor) and travel through the lymph system or blood.
- Lymph system. The cancer gets into the lymph system,
travels through the lymph vessels, and forms a tumor
(metastatic
tumor) in another part of the body.
- Blood. The cancer gets into the blood, travels through the
blood vessels, and forms a tumor (metastatic tumor) in another part of
the body.
The metastatic tumor is
the same type of cancer as the primary tumor. For example, if non-small
cell lung cancer spreads to the brain, the cancer cells in the brain
are actually lung
cancer cells. The disease is metastatic lung cancer, not
brain cancer.
The
following stages are used for non-small cell lung cancer:
Occult
(hidden) stage
In the occult
(hidden) stage, cancer
cannot be seen by imaging
or bronchoscopy.
Cancer cells
are found in sputum
(mucus
coughed up from the lungs)
or bronchial
washing (a sample of cells taken from inside the airways
that
lead to the lung). Cancer may have spread to other parts of the body.
Stage
0 (carcinoma in situ)
In stage
0, abnormal
cells
are found in the lining of the airways. These abnormal cells may become
cancer
and spread into nearby normal tissue.
Stage 0 is also called carcinoma
in situ.
Stage
I
Stage I non-small cell lung
cancer. In stage IA, cancer is in the lung only and is 3 cm or smaller.
In stage IB, the cancer is (a) larger than 3 cm but not larger than 5
cm, (b) has spread to the main bronchus, and/or (c) has spread to the
innermost layer of the lung lining. Part of the lung may have collapsed
or become inflamed (not shown).
In stage I, cancer
has formed. Stage I is divided into stages IA and IB:
- Stage
IA: The tumor
is in the lung
only and is 3 centimeters
or smaller.
- Stage
IB: Cancer has not spread to the lymph
nodes and one or more of the following is true:
- The tumor
is larger than 3 centimeters
but not larger than 5 centimeters.
- Cancer has spread to the main bronchus
and is at least 2 centimeters below where the trachea
joins the bronchus.
- Cancer has spread to the innermost layer of the membrane
that covers the lung.
- Part of the lung has collapsed or developed pneumonitis
(inflammation
of the lung) in the area where the trachea joins the bronchus.
Stage
II
Stage II is divided into
stages IIA and IIB. Stage IIA and IIB are each divided into two
sections depending on the size of the tumor,
where the tumor is found, and whether there is cancer
in the lymph
nodes.
- Stage
IIA:
Stage IIA non-small
cell lung cancer. Cancer has spread to certain lymph nodes on the same
side of the chest as the primary tumor; the cancer is (a) 5 cm or
smaller, (b) has spread to the main bronchus, and/or (c) has spread to
the innermost layer of the lung lining. OR, cancer has not spread to
lymph nodes; the cancer is (d) larger than 5 cm but not larger than 7
cm, (e) has spread to the main bronchus, and/or (f) has spread to the
innermost layer of the lung lining. Part of the lung may have collapsed
or become inflamed (not shown).
(1) Cancer
has spread to lymph
nodes on the same side of the chest as the tumor.
The lymph nodes with cancer are within the lung or near the bronchus.
Also, one or more of the following is true:
- The tumor is not larger than 5 centimeters.
- Cancer has spread to the main bronchus
and is at least 2 centimeters below where the trachea
joins the bronchus.
- Cancer has spread to the innermost layer of the membrane
that covers the lung.
- Part of the lung has collapsed or developed pneumonitis
(inflammation
of the lung) in the area where the trachea joins the bronchus.
or
(2) Cancer has not
spread to lymph nodes and one or more of the following is true:
- The tumor is larger than 5 centimeters but not larger
than 7 centimeters.
- Cancer has spread to the main bronchus and is at least
2 centimeters below where the trachea joins the bronchus.
- Cancer has spread to the innermost layer of the
membrane that covers the lung.
- Part of the lung has collapsed or developed pneumonitis
(inflammation of the lung) in the area where the trachea joins the
bronchus.
- Stage
IIB:
Stage IIB non-small
cell lung cancer. Cancer has spread to certain lymph nodes on the same
side of the chest as the primary tumor; the cancer is (a) larger than 5
cm but not larger than 7 cm, (b) has spread to the main bronchus,
and/or (c) has spread to the innermost layer of the lung lining. Part
of the lung may have collapsed or become inflamed (not shown). OR, (d)
the cancer is larger than 7 cm; (e) has spread to the main bronchus,
(f) the diaphragm, (g) the chest wall or the lining of the chest wall;
and/or (h) has spread to the membrane around the heart. There may be
one or more separate tumors in the same lobe of the lung; cancer may
have spread to the nerve that controls the diaphragm; the whole lung
may have collapsed or become inflamed (not shown).
(1) Cancer
has spread to nearby lymph
nodes on the same side of the chest as the tumor.
The lymph nodes with cancer are within the lung or near the bronchus.
Also, one or more of the following is true:
- The tumor is larger than 5 centimeters
but not larger than 7 centimeters.
- Cancer has spread to the main bronchus
and is at least 2 centimeters below where the trachea
joins the bronchus.
- Cancer has spread to the innermost layer of the membrane
that covers the lung.
- Part of the lung has collapsed or developed pneumonitis
(inflammation
of the lung) in the area where the trachea joins the bronchus.
or
(2) Cancer has not
spread to lymph nodes and one or more of the following is true:
- The tumor is larger than 7 centimeters.
- Cancer has spread to the main bronchus (and is less
than 2 centimeters below where the trachea joins the bronchus), the chest
wall, the diaphragm,
or the nerve
that controls the diaphragm.
- Cancer has spread to the membrane around the heart or
lining the chest wall.
- The whole lung has collapsed or developed pneumonitis
(inflammation of the lung).
- There are one or more separate tumors in the same lobe
of the lung.
Stage
IIIA
Stage
IIIA is divided into three sections depending on the size
of
the tumor,
where the tumor is found, and which lymph
nodes have cancer
(if any).
Stage IIIA non-small cell
lung cancer (1). Cancer has spread to certain lymph nodes on the same
side of the chest as the primary tumor. The cancer may have spread to
(a) the main bronchus; (b) lung lining, chest wall lining, or chest
wall; (c) diaphragm; and/or (d) membrane around the heart; and/or (e)
there may be one or more separate tumors in the same lobe of the lung.
Cancer may have spread to the nerve that controls the diaphragm, and
part or all of the lung may have collapsed or become inflamed (not
shown).
(1) Cancer has spread to
lymph nodes on the same side of the chest as the tumor. The lymph nodes
with cancer are near the sternum
(chest bone) or where the bronchus
enters the lung.
Also:
- The tumor may be any size.
- Part of the lung (where the trachea
joins the bronchus) or the whole lung may have collapsed or developed pneumonitis
(inflammation
of the lung).
- There may be one or more separate tumors in the same lobe
of the lung.
- Cancer may have spread to any of the following:
- Main bronchus, but not the area where the trachea joins
the bronchus.
- Chest
wall.
- Diaphragm
and the nerve
that controls it.
- Membrane
around the lung or lining the chest wall.
- Membrane around the heart.
or
Stage IIIA lung cancer (2).
Cancer has spread to certain lymph nodes on the same side of the chest
as the primary tumor. The cancer may have spread to (a) the main
bronchus; (b) the lung lining, chest wall lining, or chest wall; (c)
diaphragm; (d) heart and/or membrane around the it; (e) major blood
vessels that lead to or from the heart; (f) trachea; (g) esophagus; (h)
sternum; and/or (i) carina; and/or (j) there may be one or more
separate tumors in any lobe of the same lung. Cancer may have spread to
the nerves that control the diaphragm and larynx, and the whole lung
may have collapsed or become inflamed (not shown).
(2) Cancer has spread to
lymph nodes on the same side of the chest as the tumor. The lymph nodes
with cancer are within the lung or near the bronchus. Also:
- The tumor may be any size.
- The whole lung may have collapsed or developed pneumonitis
(inflammation of the lung).
- There may be one or more separate tumors in any of the
lobes of the lung with cancer.
- Cancer may have spread to any of the following:
- Main bronchus, but not the area where the trachea joins
the bronchus.
- Chest wall.
- Diaphragm and the nerve that controls it.
- Membrane around the lung or lining the chest wall.
- Heart or the membrane around it.
- Major blood
vessels that lead to or from the heart.
- Trachea.
- Esophagus.
- Nerve that controls the larynx
(voice box).
- Sternum
(chest bone) or backbone.
- Carina
(where the trachea joins the bronchi).
or
Stage IIIA non-small cell
lung cancer (3). Cancer has spread to (a) the heart; (b) major blood
vessels that lead to or from the heart; (c) trachea; (d) esophagus; (e)
sternum; and/or (f) carina. Cancer may have spread to the nerve that
controls the larynx (not shown).
(3) Cancer has not
spread to the lymph nodes and the tumor may be any size. Cancer has
spread to any of the following:
- Heart.
- Major blood vessels that lead to or from the heart.
- Trachea.
- Esophagus.
- Nerve that controls the larynx (voice box).
- Sternum (chest bone) or backbone.
- Carina (where the trachea joins the bronchi).
Stage
IIIB
Stage
IIIB is divided into two sections depending on the size of
the tumor,
where the tumor is found, and which lymph
nodes have cancer.
Stage IIIB non-small cell
lung cancer (1). Cancer has spread to lymph nodes above the collarbone
or on the opposite side of the chest as the primary tumor. The cancer
may have spread to (a) the main bronchus; (b) lung lining, chest wall
lining, or chest wall; (c) diaphragm; (d) heart or the membrane around
it; (e) major blood vessels that lead to or from the heart; (f)
trachea; (g) esophagus; (h) sternum; and/or (i) carina; and/or (j)
there may be one or more separate tumors in any of the lobes of the
lung. Part or all of the lung may have collapsed or become inflamed and
cancer may have spread to the backbone and/or the nerves that control
the diaphragm and larynx (not shown).
(1) Cancer has spread to
lymph nodes above the collarbone
or to lymph nodes on the opposite side of the chest as the tumor. Also:
- The tumor may be any size.
- Part of the lung
(where the trachea
joins the bronchus)
or the whole lung may have collapsed or developed pneumonitis
(inflammation
of the lung).
- There may be one or more separate tumors in any of the lobes
of the lung with cancer.
- Cancer may have spread to any of the following:
- Main bronchus.
- Chest
wall.
- Diaphragm
and the nerve
that controls it.
- Membrane
around the lung or lining the chest wall.
- Heart or the membrane around it.
- Major blood
vessels that lead to or from the heart.
- Trachea.
- Esophagus.
- Nerve that controls the larynx
(voice box).
- Sternum
(chest bone) or backbone.
- Carina
(where the trachea joins the bronchi).
or
Stage IIIB non-small cell
lung cancer (2). Cancer has spread to certain lymph nodes on the same
side of the chest as the primary tumor and to (a) the heart; (b) major
blood vessels that lead to or from the heart; (c) trachea; (d)
esophagus; (e) sternum; and/or (f) carina; and/or (g) there may be
separate tumors in different lobes of the same lung. Cancer may have
spread to the backbone and/or the nerve that controls the larynx (not
shown).
(2) Cancer has spread to
lymph nodes on the same side of the chest as the tumor. The lymph nodes
with cancer are near the sternum (chest bone) or where the bronchus
enters the lung. Also:
- The tumor may be any size.
- There may be separate tumors in different lobes of the same
lung.
- Cancer has spread to any of the following:
- Heart.
- Major blood vessels that lead to or from the heart.
- Trachea.
- Esophagus.
- Nerve that controls the larynx (voice box).
- Sternum (chest bone) or backbone.
- Carina (where the trachea joins the bronchi).
Stage
IV
Stage IV non-small cell
lung cancer. The cancer has spread to the other lung, and/or to lymph
nodes, fluid around the lungs or heart, and/or other parts of the body,
such as the brain, liver, adrenal gland, kidney, or bone.
In stage
IV, the tumor
may be any size and cancer
may have spread to lymph
nodes. One or more of the following is true:
- There are one or more tumors in both lungs.
- Cancer is found in fluid
around the lungs or the heart.
- Cancer has spread to other parts of the body, such as the
brain, liver,
adrenal
glands, kidneys,
or bone.
Recurrent Non-Small Cell Lung Cancer
Recurrent
non-small
cell lung cancer is cancer
that has recurred (come back) after it has been treated. The cancer may
come back in the brain, lung,
or other parts of the body.
Treatment Option Overview
Key Points
- There are different types of treatment for patients with
non-small cell lung cancer.
- Nine types of standard treatment are used:
- Surgery
- Radiation therapy
- Chemotherapy
- Targeted therapy
- Laser therapy
- Photodynamic therapy (PDT)
- Cryosurgery
- Electrocautery
- Watchful waiting
- New types of treatment are being tested in clinical trials.
- Chemoprevention
- Radiosensitizers
- New combinations
- Patients may want to think about taking part in a clinical
trial.
- Patients can enter clinical trials before, during, or after
starting their cancer treatment.
- Follow-up tests may be needed.
There
are different types of treatment for patients with non-small cell lung
cancer.
Different types of
treatments are available for patients with non-small
cell lung cancer. Some treatments are standard
(the currently used treatment), and some are being tested in clinical
trials. A treatment clinical trial is a research
study meant to help improve current treatments or obtain
information on new treatments for patients with cancer.
When clinical trials show that a new treatment is better than the
standard treatment, the new treatment may become the standard
treatment. Patients may want to think about taking part in a clinical
trial. Some clinical trials are open only to patients who have not
started treatment.
Nine
types of standard treatment are used:
Surgery
Four types of surgery
are used to treat lung
cancer:
- Wedge
resection: Surgery to remove a tumor
and some of the normal tissue
around it. When a slightly larger amount of tissue is taken, it is
called a segmental
resection.
Wedge resection of the
lung. Part of the lung lobe containing the cancer and a small amount of
healthy tissue around it is removed.
- Lobectomy:
Surgery to remove a whole lobe
(section) of the lung.
Lobectomy. A lobe of
the lung is removed.
- Pneumonectomy:
Surgery to remove one whole lung.
Pneumonectomy. The
whole lung is removed.
- Sleeve
resection: Surgery to remove part of the bronchus.
Even if the doctor
removes all the cancer that can be seen at the time of the surgery,
some patients may be given chemotherapy
or radiation
therapy after surgery to kill any cancer cells
that are left. Treatment given after the surgery, to lower the risk
that the cancer will come back, is called adjuvant
therapy.
Radiation
therapy
Radiation therapy is a
cancer treatment that uses high-energy x-rays
or other types of radiation
to kill cancer cells or keep them from growing. There are two types of
radiation therapy:
- External
radiation therapy uses a machine outside the body to send
radiation toward the cancer.
- Internal
radiation therapy uses a radioactive
substance sealed in needles, seeds,
wires, or catheters
that are placed directly into or near the cancer.
Stereotactic
body radiation therapy is a type of external radiation
therapy. Special equipment is used to place the patient in the same
position for each radiation treatment. Once a day for several days, a
radiation machine aims a larger than usual dose
of radiation directly at the tumor. By having the patient in the same
position for each treatment, there is less damage to nearby healthy
tissue. This procedure is also called stereotactic external-beam
radiation therapy and stereotaxic radiation therapy.
Stereotactic
radiosurgery is a type of external radiation therapy used
to
treat lung cancer that has spread to the brain. A rigid head frame is
attached to the skull
to keep the head still during the radiation treatment. A machine aims a
single large dose of radiation directly at the tumor in the brain. This
procedure does not involve surgery. It is also called stereotaxic
radiosurgery, radiosurgery, and radiation surgery.
For tumors in the
airways, radiation is given directly to the tumor through an endoscope.
The way the radiation
therapy is given depends on the type and stage
of the cancer being treated.
It also depends on where the cancer is found. External and internal
radiation therapy are used to treat non-small cell lung cancer.
Chemotherapy
Chemotherapy is a cancer
treatment that uses drugs
to stop the growth of cancer cells, either by killing the cells or by
stopping them from dividing. When chemotherapy is taken by mouth or injected
into a vein
or muscle, the drugs enter the bloodstream and can reach cancer cells
throughout the body (systemic
chemotherapy). When chemotherapy is placed directly into
the cerebrospinal
fluid, an organ,
or a body cavity
such as the abdomen,
the drugs mainly affect cancer cells in those areas (regional
chemotherapy).
The way the chemotherapy
is given depends on the type and stage of the cancer being treated.
See Drugs
Approved for Non-Small Cell Lung Cancer for more information.
Targeted
therapy
Targeted
therapy is a type of treatment that uses drugs or other
substances to attack specific cancer cells. Targeted therapies usually
cause less harm to normal cells than chemotherapy or radiation therapy
do. Monoclonal
antibodies and tyrosine
kinase inhibitors are the two main types of targeted
therapy
being used to treat advanced,
metastatic,
or recurrent
non-small cell lung cancer.
Monoclonal
antibodies
Monoclonal antibody therapy
is a cancer treatment that uses antibodies
made in the laboratory from a single type of immune
system cell. These antibodies can identify substances on
cancer cells or normal substances in the blood
or tissues that may help cancer cells grow. The antibodies attach to
the substances and kill the cancer cells, block their growth, or keep
them from spreading. Monoclonal antibodies are given by infusion.
They may be used alone or to carry drugs, toxins,
or radioactive material directly to cancer cells.
There are different
types of monoclonal antibody therapy:
- Vascular
endothelial growth factor (VEGF) inhibitor therapy: Cancer
cells make a substance called VEGF,
which causes new blood
vessels to form (angiogenesis)
and helps the cancer grow. VEGF inhibitors block VEGF and stop new
blood vessels from forming. This may kill cancer cells because they
need new blood vessels to grow. Bevacizumab
and ramucirumab
are VEGF inhibitors and angiogenesis
inhibitors.
- Epidermal
growth factor receptor (EGFR) inhibitor therapy: EGFRs
are proteins
found on the surface of certain cells, including cancer cells. Epidermal
growth factor attaches to the EGFR on the surface of the
cell
and causes the cells to grow and divide. EGFR inhibitors block the receptor
and stop the epidermal growth factor from attaching to the cancer cell.
This stops the cancer cell from growing and dividing. Cetuximab
and necitumumab
are EGFR inhibitors.
- Immune
checkpoint inhibitor therapy: PD-1
is a protein on the surface of T
cells that helps keep the body's immune
responses in check. When PD-1 attaches to another protein
called PDL-1 on a cancer cell, it stops the T cell from killing the
cancer cell. PD-1 inhibitors attach to PDL-1 and allow the T cells to
kill cancer cells. Nivolumab
and pembrolizumab
are types of immune checkpoint inhibitors.
Immune checkpoint
inhibitor. Checkpoint proteins, such as PD-L1 on tumor cells and PD-1
on T cells, help keep immune responses in check. The binding of PD-L1
to PD-1 keeps T cells from killing tumor cells in the body (left
panel). Blocking the binding of PD-L1 to PD-1 with an immune checkpoint
inhibitor (anti-PD-L1 or anti-PD-1) allows the T cells to kill tumor
cells (right panel).
Tyrosine
kinase inhibitors
Tyrosine kinase
inhibitors are small-molecule
drugs that go through the cell membrane
and work inside cancer cells to block signals that cancer cells need to
grow and divide. Some tyrosine kinase inhibitors also have angiogenesis
inhibitor effects.
There are different
types of tyrosine kinase inhibitors:
- Epidermal
growth factor receptor (EGFR) tyrosine kinase inhibitors:
EGFRs are proteins found on the surface and inside certain cells,
including cancer cells. Epidermal growth factor attaches to the EGFR
inside the cell and sends signals to the tyrosine kinase area of the
cell, which tells the cell to grow and divide. EGFR tyrosine kinase
inhibitors stop these signals and stop the cancer cell from growing and
dividing. Erlotinib,
gefitinib,
and afatinib
are types of EGFR tyrosine kinase inhibitors. Some of these drugs work
better when there is also a mutation
(change) in the EGFR gene.
- Kinase
inhibitors that affect cells with certain gene changes:
Certain changes in the ALK and ROS1
genes cause too much protein to be made. Blocking these proteins may
stop the cancer from growing and spreading. Crizotinib
is used to stop proteins from being made by the ALK
and ROS1 gene. Ceritinib
is used to stop proteins from being made by the ALK
gene.
See Drugs
Approved for Non-Small Cell Lung Cancer for more information.
Laser
therapy
Laser
therapy is a cancer treatment that uses a laser
beam (a narrow beam of intense light) to kill cancer cells.
Photodynamic
therapy (PDT)
Photodynamic
therapy (PDT) is a cancer treatment that uses a drug and a
certain type of laser light to kill cancer cells. A drug that is not
active until it is exposed to light is injected into a vein. The drug
collects more in cancer cells than in normal cells. Fiberoptic
tubes are then used to carry the laser light to the cancer cells, where
the drug becomes active and kills the cells. Photodynamic therapy
causes little damage to healthy tissue. It is used mainly to treat
tumors on or just under the skin or in the lining of internal organs.
When the tumor is in the airways, PDT is given directly to the tumor
through an endoscope.
Cryosurgery
Cryosurgery
is a treatment that uses an instrument to freeze and destroy abnormal
tissue,
such as carcinoma
in situ. This type of treatment is also called
cryotherapy.
For tumors in the airways, cryosurgery is done through an endoscope.
Electrocautery
Electrocautery is a
treatment that uses a probe or needle heated by an electric current to
destroy abnormal tissue. For tumors in the airways, electrocautery is
done through an endoscope.
Watchful
waiting
Watchful
waiting is closely monitoring
a patient's condition
without giving any treatment until signs
or symptoms
appear or change. This may be done in certain rare cases of non-small
cell lung cancer.
New
types of treatment are being tested in clinical trials.
This summary section
describes treatments that are being studied in clinical trials. It may
not mention every new treatment being studied. Information about
clinical trials is available from the NCI
website.
Chemoprevention
Chemoprevention
is the use of drugs, vitamins,
or other substances to reduce the risk of cancer or to reduce the risk
cancer will recur
(come back). For lung cancer, chemoprevention is used to lessen the
chance that a new tumor will form in the lung.
Radiosensitizers
Radiosensitizers
are substances that make tumor cells easier to kill with radiation
therapy. The combination of chemotherapy and radiation therapy given
with a radiosensitizer is being studied in the treatment of non-small
cell lung cancer.
New
combinations
New combinations of
treatments are being studied in clinical
trials.
Patients
may want to think about taking part in a clinical trial.
For some patients,
taking part in a clinical
trial may be the best treatment choice. Clinical trials
are
part of the cancer research process. Clinical trials are done to find
out if new cancer treatments are safe and effective or better than the standard
treatment.
Many of today's
standard treatments for cancer are based on earlier clinical trials.
Patients who take part in a clinical trial may receive the standard
treatment or be among the first to receive a new treatment.
Patients who take
part in clinical trials also help improve the way cancer will be
treated in the future. Even when clinical trials do not lead to
effective new treatments, they often answer important questions and
help move research forward.
Patients
can enter clinical trials before, during, or after starting their
cancer treatment.
Some clinical trials
only include patients who have not yet received treatment. Other trials
test treatments for patients whose cancer has not gotten better. There
are also clinical trials that test new ways to stop cancer from recurring
(coming back) or reduce the side
effects of cancer treatment.
Clinical trials are taking place in many parts of the country.
See the Treatment Options section that follows for links to current
treatment clinical trials. These have been retrieved from NCI's
listing of clinical trials.
Follow-up
tests may be needed.
Some of the tests
that were done to diagnose
the cancer or to find out the stage
of the cancer may be repeated. Some tests will be repeated in order to
see how well the treatment is working. Decisions about whether to
continue, change, or stop treatment may be based on the results of
these tests.
Some of the tests
will continue to be done from time to time after treatment has ended.
The results of these tests can show if your condition
has changed or if the cancer has recurred
(come back). These tests are sometimes called follow-up
tests or check-ups.
Treatment Options by Stage
Occult Non-Small Cell Lung Cancer
Treatment of occult
non-small cell lung cancer depends on the stage
of the disease. Occult tumors
are often found at an early stage (the tumor is in the lung
only) and sometimes can be cured
by surgery.
Check the
list of NCI-supported cancer clinical trials that are now accepting
patients with occult
non-small cell lung cancer. For more specific results, refine
the search by using other search features, such as the location of the
trial, the type of treatment, or the name of the drug. Talk with your
doctor about clinical trials that may be right for you. General
information about clinical trials is available from the NCI
website.
Stage 0 (Carcinoma in Situ)
Treatment of stage
0 may include the following:
- Surgery
(wedge
resection or segmental
resection).
- Photodynamic
therapy for tumors
in or near the bronchus.
- Electrocautery, cryosurgery,
or laser
surgery for tumors in or near the bronchus.
Check the
list of NCI-supported cancer clinical trials that are now accepting
patients with stage
0 non-small cell lung cancer. For more specific results,
refine the search by using other search features, such as the location
of the trial, the type of treatment, or the name of the drug. Talk with
your doctor about clinical trials that may be right for you. General
information about clinical trials is available from the NCI
website.
Stage I Non-Small Cell Lung Cancer
Treatment of stage I non-small
cell lung cancer may include the following:
- Surgery
(wedge
resection, segmental
resection, sleeve
resection, or lobectomy).
- External
radiation therapy, including stereotactic
body radiation therapy for patients who cannot have
surgery
or choose not to have surgery.
- A clinical
trial of chemotherapy
or radiation
therapy following surgery.
- A clinical trial of treatment given through an endoscope,
such as photodynamic
therapy (PDT).
- A clinical trial of surgery followed by chemoprevention.
Check the
list of NCI-supported cancer clinical trials that are now accepting
patients with stage
I non-small cell lung cancer. For more specific results,
refine the search by using other search features, such as the location
of the trial, the type of treatment, or the name of the drug. Talk with
your doctor about clinical trials that may be right for you. General
information about clinical trials is available from the NCI
website.
Stage II Non-Small Cell Lung Cancer
Treatment of stage II non-small
cell lung cancer may include the following:
- Surgery
(wedge
resection, segmental
resection, sleeve
resection, lobectomy,
or pneumonectomy).
- Chemotherapy
followed by surgery.
- Surgery followed by chemotherapy.
- External
radiation therapy for patients who cannot have surgery.
- A clinical
trial of radiation
therapy following surgery.
Check the
list of NCI-supported cancer clinical trials that are now accepting
patients with stage
II non-small cell lung cancer. For more specific results,
refine the search by using other search features, such as the location
of the trial, the type of treatment, or the name of the drug. Talk with
your doctor about clinical trials that may be right for you. General
information about clinical trials is available from the NCI
website.
Stage IIIA Non-Small Cell Lung Cancer
Treatment of stage
IIIA non-small cell lung cancer that can be removed with surgery
may include the following:
- Surgery followed by chemotherapy.
- Surgery followed by radiation
therapy.
- Chemotherapy followed by surgery.
- Surgery followed by chemotherapy combined with radiation
therapy.
- Chemotherapy and radiation therapy followed by surgery.
- A clinical
trial of new combinations of treatments.
Treatment of stage IIIA
non-small cell lung cancer that cannot be removed with surgery may
include the following:
- Chemotherapy and radiation therapy given over the same
period of time or one followed by the other.
- External
radiation therapy alone for patients who cannot be treated
with combined
therapy, or as palliative
treatment to relieve symptoms
and improve the quality
of life.
- Internal
radiation therapy or laser
surgery, as palliative treatment to relieve symptoms and
improve the quality of life.
- A clinical trial of new combinations of treatments.
For more information
about supportive
care for signs
and symptoms including cough, shortness of breath, and chest pain, see
the PDQ
summary on Cardiopulmonary
Syndromes.
Non-small
cell lung cancer of the superior sulcus, often called Pancoast
tumor, begins in the upper part of the lung
and spreads to nearby tissues
such as the chest
wall, large blood
vessels, and spine.
Treatment of Pancoast tumors may include the following:
- Radiation therapy alone.
- Radiation therapy followed by surgery.
- Chemotherapy and radiation therapy given as separate
treatments over the same period of time. Surgery may also be done after
chemotherapy and radiation therapy.
- Surgery alone.
- A clinical trial of new combinations of treatments.
Some stage IIIA
non-small cell lung tumors that have grown into the chest
wall may be completely removed. Treatment of chest wall tumors
may include the following:
- Surgery.
- Surgery and radiation therapy.
- Radiation therapy alone.
- Chemotherapy combined with radiation therapy and/or surgery.
- A clinical trial of new combinations of treatments.
Check the
list of NCI-supported cancer clinical trials that are now accepting
patients with stage
III non-small cell lung cancer. For more specific results,
refine the search by using other search features, such as the location
of the trial, the type of treatment, or the name of the drug. Talk with
your doctor about clinical trials that may be right for you. General
information about clinical trials is available from the NCI
website.
Stage IIIB Non-Small Cell Lung Cancer
Treatment of stage
IIIB non-small cell lung cancer may include the following:
- Chemotherapy
followed by external
radiation therapy.
- Chemotherapy and radiation
therapy given as separate treatments over the same period
of
time.
- Chemotherapy followed by surgery.
- External radiation therapy alone for patients who cannot be
treated with chemotherapy.
- External radiation therapy as palliative
therapy, to relieve symptoms
and improve the quality
of life.
- Laser
therapy and/or internal
radiation therapy to relieve symptoms
and improve the quality
of life.
- Clinical
trials of new external radiation therapy schedules
and new types of treatment.
- A clinical trial of chemotherapy and radiation therapy
combined with a radiosensitizer.
- Clinical trials of targeted
therapy combined with chemotherapy and radiation therapy.
For more information
about supportive
care for signs
and symptoms such as cough, shortness of breath, and chest pain, see
the following PDQ
summaries:
- Cardiopulmonary
Syndromes
- Cancer
Pain
Check the
list of NCI-supported cancer clinical trials that are now accepting
patients with stage
III non-small cell lung cancer. For more specific results,
refine the search by using other search features, such as the location
of the trial, the type of treatment, or the name of the drug. Talk with
your doctor about clinical trials that may be right for you. General
information about clinical trials is available from the NCI
website.
Stage IV Non-Small Cell Lung Cancer
Treatment of stage
IV non-small cell lung cancer may include the following:
- Chemotherapy.
- Chemotherapy followed by more chemotherapy as maintenance
therapy to help keep cancer from progressing.
- Combination chemotherapy and targeted
therapy with a monoclonal
antibody, such as bevacizumab,
cetuximab,
or necitumumab.
- Targeted therapy with a monoclonal antibody, such as nivolumab
or pembrolizumab.
- Targeted therapy with a tyrosine
kinase inhibitor, such as erlotinib,
gefitinib,
afatinib,
crizotinib,
or ceritinib.
- External
radiation therapy as palliative
therapy, to relieve symptoms
and improve the quality
of life.
- Laser
therapy and/or internal
radiation therapy for tumors
that are blocking the airways.
- A clinical
trial of new drugs
and combinations of treatments.
For more information
about supportive
care for signs
and symptoms including cough, shortness of breath, and chest pain, see
the following PDQ
summaries:
- Cardiopulmonary
Syndromes
- Cancer
Pain
- Last
Days of Life
Treatment Options for Recurrent Non-Small Cell Lung Cancer
Treatment of recurrent
non-small
cell lung cancer may include the following:
- External
radiation therapy as palliative
therapy, to relieve pain and other symptoms
and improve the quality
of life.
- Chemotherapy
with or without targeted
therapy with a monoclonal
antibody, such as ramucirumab.
- Targeted therapy with a monoclonal antibody, such as nivolumab
or pembrolizumab.
- Targeted therapy with a tyrosine
kinase inhibitor, such as erlotinib,
gefitinib,
or crizotinib,
for tumors
with certain gene
changes.
- Laser
therapy or internal
radiation therapy for tumors
that are blocking the airways.
- Surgery
to remove cancer
that has spread to the brain, followed by radiation
therapy to the whole brain.
- Stereotactic
radiosurgery for tumors that have spread to the brain and
cannot be treated with surgery.
-NIH