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Treatment options for lung cancer may include surgery, chemotherapy, radiation therapy, targeted medications, and immunotherapy, or combinations of these treatments. Palliative therapy does not treat lung cancer itself, but manages symptoms to improve quality of life. Doctors recommend treatment plans for lung cancer based on which options will be safest and most effective given the specific factors involved in each case.
Treatment options for lung cancer depend first on the type of lung cancer you have. The two main types of lung cancer are non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC). Overall, NSCLC accounts for 84 percent of cases, and SCLC 13 percent. While most treatment options overlap, NSCLC and SCLC ultimately are different diseases that have separate therapies.
Your cancer care team will consider many factors when planning lung cancer treatment:
Treatment options will be different for every case of lung cancer. Options available to treat both NSCLC and SCLC include surgery, radiation, chemotherapy, and immunotherapy, as well as palliative care to improve quality of life. Targeted therapies have also been developed to treat NSCLC.
Most treatments will be administered at a cancer center or as outpatient procedures. Special considerations are made for people undergoing treatment for lung cancer during the COVID-19 pandemic to ensure their health and safety.
A comprehensive team of health care professionals will determine a treatment plan best suited for you. Specialists on a lung cancer care team may include:
Doctors and nurses on your cancer care team will work together to develop a treatment plan designed to meet your needs, but treatment decisions are ultimately up to you.
Surgery is often considered to be the best option when a tumor has not spread, as in some cases of early stage NSCLC and carcinoid tumors. The type of lung cancer surgery will depend on the size of the tumor, its location and stage, and your overall health.
A lobectomy is the most commonly performed surgery to treat lung cancer. In this surgery, an entire lung lobe affected by cancer is removed. The left lung has two lobes, and the right lung has three. A bilobectomy involves removal of two lobes. This is only done for tumors in the right lung that affect lobes next to each other.
A pneumonectomy is the removal of an entire lung. This is performed in cases where the cancer cannot be removed with a lobectomy alone or where the tumor is centrally located in the lung.
Each lung lobe has three to five lung segments. Depending on the tumor’s location in the lung, a surgeon can remove between one and four segments in certain lobes, preserving the unaffected tissue.
A wedge resection involves removal of a small, wedge-shaped piece of lung tissue that surrounds a tumor.
A sleeve resection is a two-part procedure that begins with removal of the lung lobe containing the tumor and part of the main bronchus in that lung. Then, the remaining piece of the bronchus is attached to another bronchus in a healthy lobe. A successful sleeve resection can prevent the need to remove an entire lung.
Video-assisted thoracic surgery (VATS) is a minimally invasive surgery used to treat lung cancer. A tiny camera (thoracoscope) and surgical tools are inserted through one or more small incisions in the chest wall. The camera allows doctors to see inside the chest cavity, which guides the surgical process.
During robotically assisted thoracic surgery (RATS), a surgeon sits at a console in the operating room and controls robotic instruments during the procedure. A camera is inserted through a small incision (similar to VATS) to help the surgeon see inside the chest cavity. The robotic instruments are inserted into another incision and are guided to remove tissue or perform other procedures.
Chemotherapy is a broad term used to describe drugs that target and kill rapidly dividing cells in the body. Chemotherapy drugs are typically given through an intravenous (IV) infusion, allowing the drugs to travel through the bloodstream and reach almost every part of the body to kill cancer cells. There are different chemotherapy regimens to treat NSCLC or SCLC.
Radiation therapy, also known as radiotherapy, uses an intense beam of radiation to kill cancer cells and shrink tumors. The type of radiation is similar to that used in X-rays, but it is much more concentrated for cancer treatment. This therapy works by damaging the DNA of cancer cells beyond repair, causing the cells to die or to stop dividing. There are different radiotherapy regimens used to treat NSCLC or SCLC.
Radiofrequency ablation (RFA) may be an option for some people with small tumors located near the outer edge of the lungs, particularly if they cannot undergo surgery. In RFA, CT scans are used to guide the placement of a thin, needle-like probe into the tumor. Then high-energy radio waves are sent through the probe to heat the tumor and destroy the cancer cells.
Targeted therapy refers to the class of drugs that work by “targeting” specific mutations or growth factors in cancer. Because these drugs are so specific, they minimize damage to healthy cells and cause fewer side effects. Targeted therapy is used specifically for the treatment of NSCLC. Cancer cells can be tested for biomarkers to see if any of the following medications will be effective against them.
Vascular endothelial growth factor (VEGF) is responsible for initiating the growth of new blood vessels in a process called angiogenesis. Large tumors need their own blood supply in order to absorb oxygen and nutrients. As a result, some cancer cells have learned to make their own VEGF to grow new blood vessels.
Bevacizumab (Avastin) and ramucirumab (Cyramza) are monoclonal antibody drugs that work by blocking VEGF from binding to its receptor, stopping the tumor from forming its own new blood vessels.
Epidermal growth factor receptor (EGFR) is one of the most common mutations in NSCLC. Small-molecule inhibitors have been developed to target EGFR mutations, such as:
These small-molecule inhibitors can shrink tumors for an extended period of time. However, for many taking these medications, the cancer cells eventually acquire another EGFR mutation and the medication stops working. Osimertinib (Tagrisso) is another EGFR inhibitor that specifically targets one of these acquired EGFR mutations, the T790M mutation.
In around 5 percent of NSCLC cases, the ALK gene is mistakenly moved to a different part of the chromosome, resulting in a gene rearrangement. This makes an abnormal ALK protein that tells cells to rapidly grow and divide, resulting in a tumor. The ALK gene rearrangement is usually seen in younger adults who are nonsmokers or light smokers. Small-molecule inhibitors that treat ALK mutations include:
ROS1 gene rearrangements can occur in a similar fashion to those seen with the ALK gene and can sometimes be treated with the same targeted therapies. The ROS1 rearrangement is present in between 1 percent and 2 percent of NSCLC cases. It is usually seen in people with NSCLC who do not have EGFR, ALK, or KRAS mutations. Medications that target the ROS1 gene rearrangement include:
In a small number of NSCLC cases, there are mutations in one of the NRTK genes that cause cells to rapidly grow and divide. Entrectinib (Rozlytrek) and Larotrectinib (Vitrakvi) both work to inhibit the function of NRTK proteins for people whose lung cancer carries this gene mutation.
In a handful of NSCLC cases, mutations in the RET gene produce a protein that causes cancer cells to grow. Two inhibitors have been developed to block the function of the RET protein: Selpercatinib (Retevmo) and Pralsetinib (Gavreto).
In some cases of NSCLC, a MET gene mutation produces a protein that encourages tumor cells to spread and grow. Capmatinib (Tabrecta) directly blocks the function of MET proteins. Tabrecta can be used to treat metastatic NSCLC if tumors have changes in the MET gene.
In some cases of NSCLC, there may be BRAF gene mutations that tell cells to rapidly grow and divide, leading to tumor growth. Two inhibitors used to treat these mutations are Dabrafenib (Tafinlar), which targets BRAF directly, and Trametinib (Mekinist), which targets the related proteins MEK.
Immunotherapy is a relatively recent advancement in the treatment of cancer. Immunotherapy uses bioengineered immune proteins known as antibodies that help activate the immune system to target and kill cancer cells. Because immunotherapy treatments consist of one type of antibody only, they are known as monoclonal antibodies. They are also referred to as biologics. Immunotherapy targets specific cells in the body, which helps avoid many of the side effects seen in treatments like chemotherapy.
Immunotherapy can be used to treat both NSCLC and SCLC. The therapies focus on interrupting communication between cancer cells and T cells, which are important cells in the immune system. The immune system produces “checkpoint” proteins that help prevent it from attacking normal cells in the body. Some cancer cells can hijack the checkpoint system to avoid being seen and destroyed by the immune system.
Fortunately, monoclonal antibodies have been developed that prevent this type of communication through these checkpoints. Nivolumab (Opdivo) and Pembrolizumab (Keytruda) target the PD-1 protein found on T cells, boosting the immune system’s response to the cancer cells. Atezolizumab (Tecentriq) and Durvalumab (Imfinzi) target the PD-L1 protein found on cancer cells, blocking it and leaving the cells more vulnerable to immune system attack.
Ipilimumab (Yervoy) targets CTLA-4, a protein found on T cells. CTLA-4 is another type of checkpoint that can be exploited by cancer cells, and blocking it boosts the immune system to shrink tumors. This therapy is currently only approved in combination with other therapies for treating certain cases of NSCLC.
Palliative care focuses on treatments and medications that help relieve symptoms of lung cancer and improve a person’s quality of life during any stage of cancer. These treatments do not treat the cancer itself, but rather symptoms caused by cancer.
Palliative care options are fairly similar between NSCLC and SCLC:
Lung cancer treatments continue to improve over time. Whether a case of lung cancer is curable or not depends on many factors. In some cases, surgery with radiation and/or chemotherapy can provide remission for NSCLC or SCLC.
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Todd Gersten, M.D. is a hematologist-oncologist at the Florida Cancer Specialists & Research Institute in Wellington, Florida. Review provided by VeriMed Healthcare Network. Learn more about him here.
Emily Wagner, M.S. holds a Master of Science in biomedical sciences with a focus in pharmacology. She is passionate about immunology, cancer biology, and molecular biology. Learn more about her here.
