New treatment approaches and more effective medications offer greater benefits to people with lung cancer.
Each year, more than 224,000 Americans are diagnosed with lung cancer. Cigarette smoking is the main risk factor for lung cancer; it is the cause of 85 percent to 90 percent of lung cancers. Although it is much less common, nonsmokers can get lung cancer. There are a number of causes, including exposure to secondhand smoke, radon gas or cancer-causing chemicals at work.
In recent years, there have been some exciting developments in treating lung cancer. Researchers now understand more about the genetic makeup of lung cancer cells. By using genetic tests, doctors can identify specific types of lung tumors and prescribe treatments designed to target them. This advance has made lung cancer treatment safer and more effective with fewer side effects.
Diagnosing Lung Cancer
If a CT, MRI or PET scan shows an unusual spot on the lung, a doctor will sometimes perform a biopsy—taking a small piece of tissue from the lung. This tissue is then examined under a microscope to look for cancer cells. There are different types of biopsies. In a needle biopsy, the doctor passes a needle through the skin into the lung to remove the tissue. In some cases, a biopsy may be done during a procedure called a bronchoscopy. With the patient under sedation, the doctor inserts a small tube through the mouth or nose and into the lung. The tube, which has a light, small camera and a surgical instrument on the end, allows the doctor to see inside the lung and remove a small tissue sample.
If cancer cells are found in the tissue sample, a genetic test may be performed. The information obtained from the test can help doctors choose the best treatment.
Types of Lung Cancer
There are two major types of lung cancer: non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC). NSCLC accounts for about 85 percent of lung cancers and includes:
Adenocarcinoma, the most common form of lung cancer in the United States among both men and women;
Squamous cell carcinoma, which accounts for 25 percent to 30 percent of all lung cancers;
Large cell carcinoma, which accounts for about 10 percent of NSCLC tumors. SCLC tumors account for the remaining 15 percent of lung cancers in the United States. They tend to grow more quickly than NSCLC tumors. Usually, SCLC is more responsive to chemotherapy than NSCLC.
Tumors are classified in stages, which are based on whether the cancer is local (in the lung only), locally advanced (spread to nearby lymph nodes, which are small bean shaped organs that remove waste and fluids and help fight infection) or metastatic (spread to other parts of the body).
Surgery, radiation, chemotherapy and targeted treatments—alone or in combination—can all be used to treat lung cancer. To destroy cancer cells, targeted treatments focus on specific cell mechanisms thought to be important for the growth and survival of tumor cells. These medications tend to cause less severe side effects than chemotherapy.
Pathologists (doctors who identify diseases by studying cells and tissues under a microscope) and geneticists (scientists with special training in the study of genes) can give your doctor the information he or she needs to tailor a treatment that will be most effective for you. These specialists can determine the distinct characteristics of each lung cancer: the tumor type (NSCLC or SCLC, for example); how far it has advanced (its stage); and the mutations (gene changes) that cause or “drive” the cancer.
In this section we describe the treatments most often used. Your doctor will advise you about a treatment plan for your specific cancer.
Advances in surgical techniques now allow doctors to make much smaller incisions to remove tumors or even whole sections of a lung damaged by cancer. Using video-assisted thoracoscopic surgery (VATS), the surgeon inserts a tube called a thoracoscope. This device has a light and a tiny camera connected to a video monitor so that the surgeon can see inside the chest. In a similar type of procedure, surgeons in some medical centers use robot-assisted surgery to make small incisions and remove cancerous tissue. Both techniques result in a faster recovery with less discomfort and scarring than traditional open-chest surgery.
Increasing use of CT, MRI and PET scans has allowed radiation specialists to accurately target tumors in the lungs. They can shape the radiation beams to the size and dimensions of the tumor to help spare healthy tissues. As a result, radiation treatment has become much more focused and effective. In some cases where surgery is not possible, radiation may be used, either alone or in combination with chemotherapy. These treatments also may be used before surgery to shrink the tumor or after surgery to help prevent the cancer from coming back (recurring).
Chemotherapy and Targeted Treatments
A number of chemotherapy drugs have been approved by the U.S. Food and Drug Administration (FDA) for lung cancer treatment. These medications include:
• Pemetrexed (Alimta). For use in combination with cisplatin (another chemotherapy drug) for the initial treatment of advanced non-squamous NSCLC. Pemetrexed also is approved for use alone to treat this type of cancer after other chemotherapy has been given.
• Gemcitabine (Gemzar and others). For use in combination with cisplatin for the treatment of NSCLC.
When researchers discovered that a mutation in the gene EGFR was involved in the growth and spread of lung cancer, they began to study EGFR inhibitors—targeted treatments that could block the mutation. (Ten percent of people with lung cancer have EGFR mutations.) Today, two medications are effective treatment options for lung cancer patients with this gene mutation:
• Erlotinib (Tarceva and others). The FDA first approved the use of erlotinib for lung cancer in 2004. In 2013, it was approved as an initial treatment for patients with NSCLC that has spread to other parts of the body and has certain types of EGFR mutations or a piece missing (deletion) from this gene.
• Afatinib (Gilotrif). In 2013, the FDA approved afatinib for the initial treatment of metastatic NSCLC in patients with the same EGFR gene mutations or deletions as those who can be treated successfully with erlotinib.
Another gene mutation found in some lung cancers is referred to as ALK. Two targeted treatments are effective options for people whose cancer has this gene change:
• Crizotinib (Xalkori). This treatment was approved by the FDA in 2013 for treating metastatic NSCLC tumors with the ALK gene mutation. Crizotinib blocks the mutated ALK gene, stopping the growth of the tumor. In clinical trials, it was found to be more effective than chemotherapy.
• Ceritinib (Zykadia). This medication was approved in 2014 for people with metastatic ALK-positive lung cancer who cannot tolerate crizotinib or whose cancer continued to grow while being treated with crizotinib.
Because the genes of cancer cells can evolve, some tumors may become resistant to a targeted treatment. Medications to meet those challenges are being studied now in clinical trials, which often offer important treatment options for people with lung cancer.
Immunotherapy drugs. Researchers are studying another strategy that uses “immunotherapies”—medications that help the body’s own immune system destroy tumors. Clinical trials of a number of immunotherapies are ongoing as well.
Yet another approach to destroying cancer cells is cutting off the blood supply that tumors need to grow. Blood vessels grow in several ways. One way is through the presence of a substance produced by tumors called vascular endothelial growth factor (VEGF). This substance stimulates blood vessels to penetrate tumors and supply oxygen, minerals and other nutrients to feed them. When tumors spread throughout the body, they release VEGF to create new blood vessels.
Bevacizumab (Avastin) works by stopping VEGF from stimulating the growth of new blood vessels. (Because healthy tissues have an established blood supply, the drug does not affect them.) When combined with chemotherapy, bevacizumab has been shown to help patients—with certain types of NSCLC, such as adenocarcinoma and large cell carcinoma—to live longer.
Although cancer treatments can cause side effects, your health care team can help you manage these symptoms and improve your quality of life. Talk with your nurse or doctor if you experience pain, nausea and vomiting, fatigue or other symptoms after taking your medication.
There are also a number of things you can do to help ease treatment side effects:
To help your doctor prescribe the best medication, it’s useful to give an accurate report of your pain. Keep a journal that includes information on:
• When the pain occurs;
• How long it lasts;
• How strong it is on a scale of 1 to 10, with 1 being the least amount of pain and 10 the most intense;
• What makes the pain feel better and what makes it feel more intense.
Nausea and Vomiting
In addition to taking medication to control nausea and vomiting, there are things you can do to ease these symptoms. For example:
• Be sure that you fully understand your health care team’s instructions for taking anti-nausea medicines.
• Eat and drink slowly. Try having small meals throughout the day instead of a large breakfast, lunch and dinner.
• Avoid sweet, fried or fatty foods, as well as foods with strong odors. Eating foods cold or at room temperature can help you avoid strong smells.
• Wear loose-fitting clothing that doesn’t bind or add stress to your body.
• Rinse your mouth often to eliminate any bad taste. Use a solution made up of one quart of plain water, half a teaspoon of table salt and half a teaspoon of baking soda. It’s important to maintain good oral care, and rinsing the mouth is part of that.
• Try taking ginger to help relieve nausea. Sipping on ginger tea may be effective, as well as sucking on ginger lollipops or drops.
• Be sure that you are drinking enough fluids. Ask your nurse or doctor about proper nutrition, which is especially important during this time.
To reduce fatigue:
• Take several short naps or breaks in a comfortable chair rather than in bed.
• Take walks or do some other type of exercise, if possible.
• Try easier or shorter versions of the activities you enjoy.
• Ask your family or friends to help you with tasks you find difficult or tiring.
• Save your energy for things you find most important.
For more information on coping with these and other treatment side effects, visit www.cancercare.org.
There are many important reasons to stay active. Being active can help you tolerate treatments better, recover from surgery faster and reduce fatigue, pain and the need for pain medication. Other benefits of exercise include maintaining flexibility and strength, reducing anxiety or depression and boosting your self-esteem.
The American College of Sports Medicine and the American Cancer Society recommend that people with cancer do some type of activity for 30 minutes a day. It doesn’t have to be 30 minutes all at once: try doing 10 minutes three times a day or 15 minutes twice a day. Even five-minute activity breaks can benefit you. The key is to choose an activity program that works best for you, whether it involves bicycling, walking or weight training.
Q. My breathing has been affected by surgery and chemotherapy. What can I do about this?
A. When surgery reduces the size of the lungs, you cannot take in as much air. Some medications also change lung function and lead to shortness of breath. Any time you have difficulty breathing, you should report it to your doctor. He or she can prescribe pulmonary (lung) rehabilitation therapy. This therapy may include exercise training, energy-conserving techniques, breathing strategies and nutritional counseling to improve lung function.
Q. What is a spiral CT scan and how good is it at detecting tumors? Does it increase survival?
A. Spiral CT is a type of x-ray that scans the body in a spiral path. This allows more images to be made in a shorter time than with older CT methods. A spiral CT scan also creates more detailed pictures and may be better at finding small nodules (growths that may or may not be cancerous). The challenge is knowing which nodules are benign (not cancer)—and therefore can be left alone—and which ones may be early tumors that should be biopsied or removed. Finding lung tumors when they are small offers a better chance at effective treatment. The National Lung Cancer Screening Study did show that spiral CT scanning in people aged 55 to 74 who smoked a pack of cigarettes a day for 30 years benefited from this type of screening.
Q. My lung cancer has an RET gene mutation. Are any drugs being studied for this type of tumor?
A. The RET gene mutation was recognized about two years ago. For people with other types of cancer with this mutation, three medications have been approved by the U.S. Food and Drug Administration (FDA): cabozantinib (Cometriq) and vandetanib (Caprelsa) for people with thyroid cancer and sunitinib (Sutent) for those with kidney or pancreatic cancer, as well as gastrointestinal stromal tumors. Talk with your doctor about lung cancer clinical trials for people with the RET gene mutation and ask whether he or she recommends prescribing any of these medications to you “off label” (using a prescription drug legally to treat a cancer for which the drug has not been approved by the FDA).