Non-small cell lung cancer treatment; stage I to III cancer

Non-small cell lung cancer treatment; stage I to III cancer

Author
Howard J West, MD
Section Editor
James R Jett, MD
Deputy Editor
Michael E Ross, MD

Disclosures

NON-SMALL CELL LUNG CANCER OVERVIEW — Non-small cell lung cancer (NSCLC) accounts for between 85 and 90 percent of all lung cancers; the remaining 10 to 15 percent are small cell lung cancers. This distinction is important when considering treatment.

This article will discuss the treatment of non-small cell lung cancer confined to the chest (stage I, stage II, and stage III disease). The treatment of stage IV non-small cell lung cancer is discussed separately. (See “Patient information: Non-small cell lung cancer treatment; stage IV cancer”.) The risks, symptoms, and diagnosis of non-small cell lung cancer are also discussed separately. (See “Patient information: Lung cancer risks, symptoms, and diagnosis”.)

Small cell lung cancer is discussed separately. (See “Patient information: Small cell lung cancer treatment”.)

STAGING NON-SMALL CELL LUNG CANCER — Once lung cancer is diagnosed, the next step is to determine its stage. Staging is a system used to describe the aggressiveness and spread of a cancer. A non-small cell lung cancer’s stage is based on:

The size and location of the tumor
Whether the tumor has invaded lymph nodes or tissues in the chest but outside the lung
Whether the tumor has spread to places distant from the chest (eg, brain, bones)
Non-small cell lung cancer stages range from I to IV:

Stage I — The tumor has not spread outside the chest or to the lymph nodes (figure 1).
Stage II — Stage II means that the tumor is 7 cm or larger or has spread to the lymph nodes, invaded the tissues surrounding the lung, or started to invade the large bronchial tubes (figure 2). The affected lymph nodes are only within the lung where the tumor is located.
Stage III — Stage III disease means that the tumor has spread to the lymph nodes in the center of the chest (called the mediastinum) (figure 3).
Stage IV — With stage IV, the cancer has spread to the opposite lung, to a fluid collection outside of the lung or heart, or to distant locations, like the brain or bones (figure 4). (See “Patient information: Non-small cell lung cancer treatment; stage IV cancer”.)
In general, lower-stage cancers are less aggressive and require less treatment than do higher-stage cancers. Stage I to III non-small cell lung cancers are referred to as localized cancers, while stage IV is called advanced cancer.

STAGE I AND II TREATMENT — Whenever possible, surgery is recommended first in people with stage I or II non-small cell lung cancer. Radiation therapy may be recommended for people who are not good candidates for surgery due to severe lung disease or other underlying medical problems.

Surgery — Surgery to remove the cancer is the preferred treatment for stage I and stage II NSCLC. Options for surgery include the following:

Lobectomy, which involves removal of one lobe of the lung.
In some people, it is necessary to remove the entire affected lung (called pneumonectomy) because lobectomy cannot completely remove the tumor. Pneumonectomy requires that the remaining lung be healthy and strong.
A surgery that removes less than a lobe of the lung is possible for people who could not tolerate conventional lobectomy. This might happen in a person whose lungs do not work well, and it is sometimes considered for smaller lung tumors that are felt likely to have a very favorable prognosis.
Radiation therapy — Radiation therapy involves the use of X-rays to destroy cancer cells. Radiation therapy may be recommended for people with stage I or II NSCLC in the following situations:

After surgery, radiation therapy may be recommended for patients with tumor left behind at the margins of the surgical resection or for patients felt to have a high risk for locoregional (nearby) recurrence. It is not a clear standard therapy, and it is relatively contraindicated in patients with lung cancer and no lymph node involvement, with some evidence suggesting that it can have a net harmful effect in such patients.
Radiation therapy may be used alone, without surgery, in people who are unable to tolerate or who do not want surgery.
Radiation treatments are brief and not painful, similar to having an X-ray. Treatments are usually done five days per week for several weeks. A different technique, called stereotactic body radiation technique (SBRT), involves giving more radiation to a small area over a few daily treatments (five or fewer). Studies of SBRT demonstrate very promising outcomes, although long-term outcome results are not available and it has yet to be studied in large numbers of patients.

Radiation side effects — Radiation therapy can cause side effects during treatment. Side effects usually resolve after treatment ends. The most common side effects of radiation therapy for lung cancer are:

Difficulty swallowing due to swelling and irritation of the esophagus (the tube between the mouth and stomach); this is called esophagitis.
Swelling and irritation of the normal lung surrounding the tumor (called pneumonitis).
Fatigue.
Skin irritation in the area being treated; this can look like a sunburn on the chest.
Chemotherapy — Chemotherapy is a treatment given to slow or stop the growth of cancer cells. Even after a cancer has been removed with surgery, cancer cells can remain in the body, increasing the risk of a relapse. Chemotherapy can get rid of these cancer cells and increase the chance of cure, but it is indicated only in patients with a high enough risk of recurrence to justify the side effects of chemotherapy. Chemotherapy in the postoperative setting is called adjuvant, therapy, meaning “helper”.

Chemotherapy is not given every day but instead is given in cycles. A cycle of chemotherapy, which is typically 21 or 28 days, refers to the time it takes to give the treatment and then allow the body to recover from the side effects of the medicines. Most treatments involve a combination of several chemotherapy drugs (called regimens). Most of the drugs are given into a vein (intravenous, IV). Most adjuvant treatment regimens for non-small cell lung cancer last about three months.

Your healthcare provider can describe which chemotherapy drugs will be needed.

Side effects — The most common side effects of chemotherapy used for NSCLC include:

A lowered white blood cell count (which can increase the risk of infection)
Fever related to a low white blood cell count
Nausea and vomiting
Bowel changes, which may include constipation or diarrhea
Other side effects may occur, and these vary with the exact regimen of therapy being administered. Fortunately, the common side effects of chemotherapy are, with rare exception, only temporary.

STAGE III TREATMENT — There is no one “best” treatment for people with stage III NSCLC. Treatment depends upon the size and location of your tumor, lymph node involvement, and whether surgery has been done. The options generally include:

Radiation therapy (see ‘Radiation therapy’ above)
Chemotherapy (see ‘Chemotherapy’ above)
Surgery (see ‘Surgery’ above)
In many people with stage III NSCLC, a combination of chemotherapy and radiation therapy are recommended as the cornerstone of treatment, and in some cases, surgery may be pursued after initial chemotherapy or chemotherapy with radiation (this is called chemoradiotherapy). Chemotherapy and radiation therapy may be given together (called concurrent chemoradiotherapy) or one treatment after the other (called sequential chemoradiotherapy). It is appropriate for recommendations for stage III disease to be individualized by a multi-speciality team to a particular patient’s needs, based on their tumor bulk, pattern of spread, and underlying health.

PANCOAST TUMORS — The term Pancoast tumor (also called superior sulcus tumor) refers to a non-small cell lung cancer that is located in the top part of one of the lungs, in a region called the superior sulcus. Pancoast tumors can involve nerves, causing a unique set of symptoms referred to as Pancoast’s syndrome.

Initially, symptoms may include shoulder or arm pain, weakness of the muscles of the hand, and flushing or excessive sweating on one side of the face. As the tumor progresses, the flushing can disappear, the eyelid may droop, and the involved side may not sweat.

Treatment of Pancoast tumors usually consists of a combination of chemotherapy and radiation followed by surgery, as long as there is no evidence of distant spread.

STAGE IV TREATMENT — Treatment of stage IV non-small cell lung cancer is discussed separately. (See “Patient information: Non-small cell lung cancer treatment; stage IV cancer”.)

CLINICAL TRIALS — Progress in treating lung cancer requires that better treatments be identified through clinical trials, which are conducted all over the world. A clinical trial is a carefully controlled way to study the effectiveness of new treatments or new combinations of known therapies. Whenever possible, patients with lung cancer are encouraged to enroll in a clinical trial. Ask for more information about clinical trials, or read about clinical trials at:

www.cancer.gov/clinicaltrials/learning/
file://clinicaltrials.gov/
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

 

Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient Level Information:

Patient information: Non-small cell lung cancer treatment; stage IV cancer
Patient information: Lung cancer risks, symptoms, and diagnosis
Patient information: Small cell lung cancer treatment

Professional Level Information:

Adjuvant systemic therapy in resectable non-small cell lung cancer
Bronchioloalveolar carcinoma, including adenocarcinoma in situ
Cigarette smoking and other risk factors for lung cancer
Diagnosis and staging of non-small cell lung cancer
Initial systemic therapy for advanced non-small cell lung cancer without an epidermal growth factor receptor mutation or the ALK fusion oncogene
Investigational approaches for advanced non-small cell lung cancer
Management of malignant pleural effusions
Management of stage I and stage II non-small cell lung cancer
Management of stage III non-small cell lung cancer
Molecular markers in non-small cell lung cancer
Multiple primary lung cancers
Overview of the initial evaluation, treatment and prognosis of lung cancer
Pancoast’s syndrome and superior (pulmonary) sulcus tumors
Pathology of lung malignancies
Role of imaging in the staging of non-small cell lung cancer
Maintenance therapy for patients with advanced non-small cell lung cancer who respond to initial chemotherapy
Small molecule epidermal growth factor receptor inhibitors for advanced non-small cell lung cancer

The following organizations also provide reliable health information.

The National Library of Medicine
(www.nlm.nih.gov/medlineplus/lungcancer.html)

National Cancer Institute
(www.cancernet.nci.nih.gov/)

American Society of Clinical Oncology
(www.cancer.net/portal/site/patient)

Global Resource for Advancing Cancer Education (GRACE)
(www.cancerGRACE.org/lung)

Lung Cancer Alliance
(www.lungcanceralliance.org)

 

REFERENCES
Mountain CF. Revisions in the International System for Staging Lung Cancer. Chest 1997; 111:1710.
Rowell NP, Williams CJ. Radical radiotherapy for stage I/II non-small cell lung cancer in patients not sufficiently fit for or declining surgery (medically inoperable). Cochrane Database Syst Rev 2001; :CD002935.
Postoperative radiotherapy in non-small-cell lung cancer: systematic review and meta-analysis of individual patient data from nine randomised controlled trials. PORT Meta-analysis Trialists Group. Lancet 1998; 352:257.
Pisters KM, Evans WK, Azzoli CG, et al. Cancer Care Ontario and American Society of Clinical Oncology adjuvant chemotherapy and adjuvant radiation therapy for stages I-IIIA resectable non small-cell lung cancer guideline. J Clin Oncol 2007; 25:5506.
National Comprehensive Cancer Network (NCCN) guidelines. Available at: www.nccn.org (Accessed on October 13, 2011).