Lung Cancer Treatment Options By Stage [I to IV]

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lung cancer treatment options

Once the lung cancer has been diagnosed through various investigations, TNM staging helps to determine the disease prognosis and to select an appropriate treatment strategy.

Lung Cancer Types

Lung cancer can be broadly divided into 2 types, Non Small Cell Lung Cancer and Small Cell Lung Cancer. Treatment approach for both is different. We will discuss it in detail below.

histological types of lung cancer

NSCLC (NON SMALL CELL LUNG CANCER)

The treatment of NSCLC mainly depends on the stage, type, location of the tumor, pulmonary function, performance status of the patient, presence of certain genetic abnormalities, along with other factors.

Following is the preferred treatment approach for different stages of NSCLC, but the final decision is taken after clinical assessment of the patient by an oncologist.

Lung Cancer Treatment Options according to stage

Stage 0 (Tis N0 M0)

Stage 0 NSCLC is limited to the superficial layer of the airway and can be treated by surgery alone as the standard treatment. Sometimes, endobronchial therapies like photodynamic therapy (PDT), laser therapy, or brachytherapy may be employed to treat Stage 0 NSCLC.

Stage I 

Surgery resection with mediastinal lymph node dissection is the standard treatment. Chemotherapy may be added in selected cases. In inoperable cases (poor lung reserve, poor performance status, etc), radiation therapy may be employed as the primary treatment.

Stage II 

Surgical resection with mediastinal lymph node dissection is done, while preoperative chemoradiation may be considered in selected cases. Chemotherapy should be considered after surgery. In inoperable cases, chemotherapy and/or radiotherapy may be given.

Stage III

Stage III NSCLC treatment generally includes a combination of surgery, radiation therapy, and chemotherapy. The overall treatment approach depends on the size and location of the tumor, the location of the lymph node involved, and overall health status of the patient.

Stage IV (Metastatic disease)

Chemotherapy, targeted therapy or immunotherapy is the mainstay of treatment. Other treatment options like surgery, radiation therapy or bone-directed therapy may be considered for palliation or relief of symptoms.

 

Lung Cancer Treatment Metastatic disease

Brief description of various treatment modalities employed for NSCLC:

Surgery

cancer surgery treatment

Surgery is the treatment of choice for early stage and some advanced stage lung cancers that have not spread to distant body parts and can be completely removed. For early-stage disease, a tumor can be removed with segmentectomy, wedge resection, or sleeve resection, where only a part of the affected lobe is removed. In case of advanced stage disease, lobectomy (surgical removal of the entire globe) or pneumonectomy (surgical resection of the entire lung) may be required depending on the size and location of the tumor. Surgery can also be employed as a palliative treatment for an advanced-stage disease to relieve airway obstruction by a growing tumor.

Radiation Therapy

radiation therapy

Radiation therapy (or radiotherapy) uses high-energy radiation directed to the affected area to kill cancerous cells. It can be employed either by using an external radiation source (external beam radiation therapy) or by directly placing the source of radiation near the cancer tissue (brachytherapy). Sometimes, it is used as palliative therapy to relieve pain, bleeding, and obstructive problems associated with the advanced-stage disease.

Chemotherapy

chemotherapy for cancer treatment

Chemotherapy means treatment with anti-cancer drugs that kill or decrease the growth of rapidly growing cancer cells. It is considered to be the mainstay of treatment for advanced stage disease that has spread to distant body parts. Depending on the physician’s preference and patient’s condition, it may also be combined with other treatment options to accelerate the benefit achievement. It may be used in the neoadjuvant (prior to surgery), adjuvant (after surgery) and palliative (metastatic disease) settings. It may be associated with side effects like  nausea/vomitinghair lossfatigue, cytopenias, etc due to its effect on normal body cells apart from cancerous cells. 

Targeted Therapy 

targeted-therapy

Targeted drugs are designed to target a specific gene or protein characteristic of the lung cancer cells. With the advancement in diagnostic techniques, a number of genetic abnormalities for NSCLC have been identified that can be targeted with the help of targeted drugs. Molecular testing to confirm the genetic abnormality is the pre-requisite for starting a targeted therapy. 
The following are various targeted drugs that have been approved for the treatment of NSCLC:

Bevacizumab

Bevacizumab

It is approved for the treatment of patients with unresectable, locally advanced, recurrent, or metastatic non-squamous NSCLC and without a recent history of hemoptysis. It can also be given along with chemotherapy for the treatment of patients with non-squamous NSCLC, and negative or unknown status of ALK/ROS1 rearrangements, sensitizing EGFR mutations, and PD-L1 expression <50%.

Ramucirumab

Ramucirumab

In combination with chemotherapy, it is approved for the treatment of patients with metastatic NSCLC whose disease has progressed on or after first-line platinum-based chemotherapy.

Gefitinib and Erlotinib

erlotinib

Both Gefitinib and erlotinib are approved as first-line therapy for patients with locally advanced, recurrent, or metastatic non-squamous NSCLC who have active sensitizing EGFR mutations.

Afatinib 

afatinib

It is an EGFR and HER2 inhibitor approved as the first-line therapy for patients with metastatic NSCLC who have active sensitizing EGFR mutations. The treatment with afatinib can be continued in patients who have progressed on first-line therapy and do not have multiple symptomatic lesions.

Osimertinib

osimertinib

It is an EGFR and T790M inhibitor approved as the first-line therapy for patients with locally advanced or metastatic NSCLC who have sensitizing EGFR mutations. The treatment with osimertinib can be continued in patients who have progressed on first-line therapy and do not have multiple symptomatic lesions (excluding symptomatic brain metastases). It is also approved as the subsequent therapy for patients with metastatic EGFR and T790M-positive NSCLC who have progressed on erlotinib, gefitinib, or afatinib.

Crizotinib

Crizotinib

It is an ALK and ROS1 inhibitor approved for the treatment of patients with locally advanced, metastatic (including brain metastases), ALK and/or ROS1 rearrangement-positive NSCLC. The treatment with crizotinib can be continued in patients with ALK rearrangements who have progressed on first-line therapy and do not have multiple symptomatic lesions.

Ceritinib 

Ceritinib

It is an ALK and ROS1 inhibitor approved for the treatment of patients with locally advanced, metastatic, ALK and/or ROS1 rearrangement-positive NSCLC who cannot tolerate crizotinib or have progressed on crizotinib treatment.

Alectinib

Alectinib

It is an ALK and MET inhibitor approved for the treatment of patients with locally advanced, metastatic, ALK rearrangement-positive NSCLC. It is also approved for the treatment of patients with metastatic, ALK-positive NSCLC who cannot tolerate crizotinib or have progressed on crizotinib treatment.

Brigatinib 

Brigatinib

It is an ALK inhibitor approved for the treatment of patients with metastatic, ALK-positive NSCLC who cannot tolerate crizotinib or have progressed on crizotinib treatment.

Dabrafenib+ Trametinib 

Dabrafenib + trametinib combination is approved for the treatment of patients with metastatic, BRAF V600E positive NSCLC. Single-agent therapy with dabrafenib can also be given to patients with metastatic, BRAF V600E positive NSCLC who cannot tolerate the combination therapy.

Immunotherapy 

immunotherapy

Cancer cells utilize certain mechanisms to escape from the immune system of the patient from attacking these cells. Immune checkpoint inhibitors have gained much attention in recent times. Immune checkpoints are cell surface protein on healthy cells and T cells that prevent healthy cells to be attacked by T cells, the soldiers of the immune system. Activated T cells express PD-1, a receptor that binds to different ligands including PD-L1, PD-L2, and similar ligands present on healthy cells.

Such binding prevents the T cells to attack the healthy cells. Cancer cells take advantage of this mechanism and express checkpoints like PD-L1, PDL2, and other on their surface to escape from the attack of the immune system. The immune checkpoint inhibitors block the surface proteins PD-1/L-1 and remove breaks from the T cells to identify and kill cancer cells.

Following immunotherapeutic agents are approved for the treatment of advanced-stage non-small cell lung cancer (NSCLC):

Nivolumab

Nivolumab

Treatment of patients with advanced-stage metastatic squamous NSCLC and non-squamous NSCLC who have experienced disease progression on or after standard platinum-based chemotherapy (regardless of tumor PD-L1 protein expression).

Pembrolizumab

Pembrolizumab

Single agent first-line treatment of patients with advanced-stage NSCLC without epidermal growth factor receptor (EGFR) activating mutation, anaplastic lymphoma kinase (ALK) rearrangement, BRAF V600E mutation, or ROS1 rearrangement and who express >/=50% PD-L1. For patients with PD-L1 expression <50% but >1%, it can be combined with chemotherapy for the first-line treatment. Subsequent treatment of patients with metastatic non-squamous or squamous NSCLC and PD-L1 expression levels of >/=1%.

Atezolizumab

Atezolizumab

Combined with chemotherapy and targeted therapy, atezolizumab can be given as first-line treatment of patients with metastatic non-squamous NSCLC and PD-L1 expression <50% or unknown. Subsequent treatment for patients with metastatic non-squamous or squamous NSCLC and PD-L1 expression levels of >/=1%.

Durvalumab

Durvalumab

It is recommended as consolidation treatment for patients who have not progressed after concurrent chemoradiation treatment for unresectable stage III NSCLC.

Palliative Treatment

These treatments help in improving the overall quality of life by providing relief from the symptoms and reducing the suffering caused by the disease.

These are generally given as supportive care and may include drugs to reduce pain and other symptoms such as vomitingfatigue, external-beam radiation therapy for bleeding or pain, surgery, photodynamic therapy, laser therapy, radiofrequency ablation, placing stents to ease airway obstruction, or using drugs to reduce pain and other symptoms.

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SCLC (SMALL CELL LUNG CANCER)

Similar to NSCLC, the treatment for SCLC depends on the stage assigned to the disease with the help of the investigational tests.

Very few patients are diagnosed with Stage I SCLC who can be considered the candidates for surgical resection. Thus, chemotherapy with or without radiotherapy remains the mainstay of the treatment.


Preferred treatment approaches for different stages of SCLC:

Limited stage

Chemotherapy with or without radiotherapy is the preferred treatment for the limited-stage SCLC. Surgery may be employed for an early-stage disease, but chemotherapy with or without radiotherapy is generally recommended after surgery due to a high recurrence rate of SCLC. Prophylactic cranial irradiation may also be employed to prevent the spread of disease to the brain as per physician’s discretion.

Extensive stage

Chemotherapy with or without radiotherapy is the preferred treatment for the extensive-stage SCLC. Radiation therapy is usually employed for the disease spread to distant organs not directly benefitted from chemotherapy.
Prophylactic cranial irradiation may also be employed to prevent the spread of disease to the brain as per physician’s discretion.

 

Brief description of various treatment modalities employed for SCLC:

Chemotherapy

Chemotherapy means treatment with anti-cancer drugs that kill or decrease the growth of rapidly growing cancer cells. Chemotherapy is the mainstay of treatment for SCLC. It may be associated with side effects like  nausea/vomitinghair lossfatigue, cytopenias, etc due to its effect on normal body cells apart from cancerous cells.

Radiation Therapy

Radiotherapy is commonly combined with chemotherapy for the treatment of SCLC. Radiotherapy is also employed for the treatment of cancer spread to distant body parts including the brain. Whole brain radiation treatment is generally given to patients with spread of disease to the brain or to patients who are at higher risk of disease spread to the brain. Radiotherapy can also be used for palliation of symptoms of the disease such as pain, bleeding, and obstructive problems.

Palliative Treatment

This may help in improving the overall quality of life by providing relief from the symptoms caused by the lung cancer. They are generally given as supportive care for advanced stage cancer. These include but are not limited to using drugs to reduce pain and other symptoms such as vomitingfatigue or external-beam radiation therapy for bleeding or pain, etc.

It is very important to assess the benefits of each lung cancer treatment option versus the possible risks and side effects before making a treatment decision. Sometimes the patient’s choice and health condition are also important to make a treatment choice.

Following are ultimate goals of treating stomach cancer:

  • Prolongation of life
  • Reduction of symptoms
  • Improvement in overall quality of life

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