Lung Cancer

How is lung cancer treated?

Treatment for lung cancer depends on the type of lung cancer, stage of cancer and general health and fitness of the patient. An individual with cancer should be assessed by a specialist to determine which modality of treatment is best suited for them. 

Types of treatment 

• Surgery: Surgery for lung cancer involves the removal of part or all of a lung affected by cancer to stop the spread of the disease. It is usually recommended for early-stage lung cancer where the tumour is confined to one area and can be safely removed. 
• Chemotherapy: Refers to the use of drugs to destroy growing cancer cells, by preventing them from growing and dividing, and can be given either intravenously (through a vein) or by tablets. 
  
• Radiotherapy: Uses high-energy x-rays to kill cancer cells in a specific area, while minimising damage to normal cells nearby. Depending on the stage of the cancer, it may be used as the main treatment. In early-stage lung cancer, stereotactic body radiotherapy (SBRT) is used as an alternative to surgery. In locally advanced lung cancer, radiation is sometimes given along with chemotherapy. It may also be used after lung cancer surgery if there are any areas of cancer that could not be removed. Volumetric modulated arc therapy (VMAT) and intensity modulated radiotherapy (IMRT) can reduce radiation doses to normal organs. Radiosurgery and SBRT may also be used to treat cancers that have spread to other organs in some cases. 
• Targeted therapy: Refers to drugs which are designed to ‘target’ specific changes in the cancer cells that help them to grow, divide and spread. Targeted therapy is usually recommended based on the molecular profile of lung cancer. 
• Immunotherapy: Refers to a group of drugs called immune checkpoint inhibitors (ICI) which work by helping the body’s immune system recognise and destroy cancer cells. 

Treatment by type and stage of lung cancer 

SCLC 

Limited stage disease is usually treated with a combination of chemotherapy and radiotherapy to the lungs and mediastinal lymph nodes. After completion of chemoradiation, radiotherapy to the brain may be recommended to reduce the risk of cancer relapse in the brain. Extensive stage disease is usually treated with a combination of chemotherapy and immunotherapy. Some patients may also be treated with radiotherapy depending on their sites of spread and response to treatment. 

NSCLC

• Stage 1 and 2: Surgery to remove the cancer is the preferred treatment for stage 1 and stage 2 NSCLC. In some cases, the initial surgery may be preceded or followed by post-operative therapy. This may include chemotherapy, targeted therapy, or immunotherapy. The most common surgery for lung cancer is lobectomy, which involves the removal of the affected lobe of the lung. Other types of operations such as a sub lobar resection (removal of less than a lobe of the lung) or pneumonectomy (removal of the entire lung) are occasionally performed depending on the patient’s underlying health status as well as the size and location of the patient’s lung cancer. Whenever possible, these operations are performed by video-assisted thoracoscopic surgery (VATS) using small incisions on the chest to facilitate recovery after surgery. Radiation therapy may be recommended for people who are not suitable for surgery due to severe lung disease or other underlying medical problems. 
• Stage 3: Management of stage 3 lung cancer usually requires multidisciplinary care as it comprises a combination of surgery, radiotherapy, chemotherapy and immunotherapy. Some patients with stage 3 lung cancer may be unsuitable for surgery, such as those where the cancer has spread to multiple lymph nodes in the middle of both lungs (‘mediastinum’) or where the cancer is very close to vital organs such as the heart or big blood vessels. For these patients a combination of chemotherapy with radiotherapy to the lungs and lymph nodes may be recommended, followed by immunotherapy treatment. 
• Stage 4: Treatment of stage 4 NSCLC depends on the subtype (squamous or non-squamous) as well as the molecular profile of the tumour, and comprises various options such as chemotherapy, targeted therapy and/or immunotherapy. 

Side Effects from Treatment 

• Surgery: Breathlessness, pain the chest wall, cough and tiredness 
• Chemotherapy: Hair loss, fatigue, change in taste, nausea, vomiting and low blood counts 
• Radiotherapy: Breathlessness, cough, difficulty swallowing and skin changes 
• Targeted therapy: rashes, diarrhoea, paronychia (nail bed infection), nausea, vomiting and oral ulcers 
• Immunotherapy: Besides fatigue, the side effects are mainly related to overactivity of the immune system resulting in inflammation of various organs, of which the common ones affected are skin, thyroid, lungs and liver.