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Non-small cell lung cancer

Description

An in-depth report on the causes, diagnosis, treatment, and prevention of non-small cell lung cancer (NSCLC).

Alternative Names

Lung cancer -  non-small cell; NSCLC

Treatment Options by Stages

Occult Stage

In the occult stage (TX, N0, M0), cancer cells are found in a sample of a patient's coughed-up sputum but no cancer cells have yet been detected in the lung.

Treatment Options. Surgical removal of the tumor, if one can be located, allows identification of its stage and often results in cure.

Stage 0 or Carcinoma in Situ

Stage 0 or carcinoma in situ (Tis, N0, M0) are noninvasive cancers and only a few layers of cancer cells are detected within one local area. The cancer has not grown through to the top lining in the lung and can be surgically removed. There is a high risk for development of a second tumor, however.

Treatment Options:

• Surgery, often a limited procedure, where only part of a lobe is removed from the lung.
• In patients who cannot be treated surgically, consider photodynamic therapy, cryotherapy, or brachytherapy.

Stage I

In stage I, the cancer has reached higher layers of the lung but has not spread into the lymph nodes or beyond the lung.

General Treatment Options. The primary treatment is surgery, such as lobectomy (removal of a whole lobe), if possible. Patients with poor lung function should undergo partial lobectomy if possible. Radiation treatments may be appropriate and beneficial for patients who cannot have surgery. It is not clear if early-stage lung cancer patients, who have radiation or chemotherapy in addition to surgery, have higher survival rates. A 2002 analysis suggested that the use of radiotherapy after surgery in patients whose tumors had been completely removed might be associated with reduced survival rates. An analysis of studies using chemotherapy in addition to surgery or radiotherapy, however, indicated benefits in survival. The overall 5-year survival rates for early stage-cancer are in the range of 30 - 50%. Patients should consider clinical trials for prevention of recurring (returning) cancer after the initial treatment. The risk for recurrence is highest in patients who continue to smoke.

• Stage IA (T1, N0, M0). The five-year survival rates for stage IA patients after successful treatment can be as high as 80%. Treatment options are:
  • Lobectomy or sometimes pneumonectomy (removal of one lung)
  • Wedge or segment removal may be appropriate, particularly in patients with poor lung function who cannot withstand lobectomy.
  • Radiation in selected patients whose condition is inoperable (e.g., frail patients with T1 tumors). Five-year survival rates can be equal to those with surgery, between 32 - 60%.
  • Clinical trials of adjuvant chemotherapy following surgery
• Stage 1B (T2, N0, M0). Stage IB survival rates after treatment can be better than 60%. Treatment options are:
  • Lobectomy or sometimes pneumonectomy; wedge or segment removal might be appropriate, particularly patients with poor lung function.
  • Clinical trials of chemotherapy following surgery
  • Clinical trials of chemotherapy before surgery (induction therapy; Studies are promising)
  • Clinical trials for radiation treatments in selected patients whose condition is inoperable
  • Clinical trials of chemotherapy before, after, or during radiation treatments

Stage II

In stage II the cancer cells have spread to nearby lymph nodes.

General Treatment Options. Surgery, usually removal of a lobe (lobectomy) or one lung (pneumonectomy) is the treatment of choice. Five-year survival rates associated with stage II surgery can vary. A 2000 review of existing research places the numbers as high as 40 - 50%, but notes that they can drop to 25% and below if the cancer has spread beyond the immediate lymph nodes.

Patients whose cancer is inoperable may consider radiation treatments. In patients who can complete treatment, five-year survival rates average 20 - 30%, with higher rates for stage IIA. Patients should consider clinical trials for prevention of recurring cancer after primary treatment. To date, however, supplementing surgical treatment with radiation or chemotherapy does not appear to prolong survival rates.

• Stage IIA (T1, N1, M0). Survival rates can be as high as 60%. Treatment options are:
  • Surgery
  • Radiation
  • Clinical trials of chemotherapy following surgery
  • Clinical trials of chemotherapy before, after, or during radiation treatments
  • Clinical trials of chemotherapy to reduce tumor size before surgery (induction therapy)
• Stage IIB (T2, N1, M0) or (T3, N0, M0). Survival rates can be over 40%. Treatment options are:
  • Surgery
  • Radiation
  • Clinical trials of chemotherapy following surgery
  • Clinical trials of chemotherapy before surgery (induction therapy)
  • Clinical trials of chemotherapy before, after, or given at the same time as radiation treatments

Stage III

In stage III, the cancer cells have spread beyond the lung to the chest wall, diaphragm, or further lymph nodes, such as those in the neck.

General Treatment Options. Generally, the treatment of choice for stage III tumors is radiation and sometimes surgery, chemotherapy, or combinations of all three.

Combination approaches may be significantly more effective than single treatments. For example, of particular interest is a treatment approach that starts with chemotherapy and radiation, given at the same time, followed by surgery. In one study, 5-year survival in stage III patients treated this way was nearly 50%.

• Stage IIIA (T1, N2, M0) or (T2, N2, M0) or (T3, N1, M0) or (T3, N2, M0).
  • Surgery, if the tumor and affected lymph nodes can be completely removed. Consider platinum-based chemotherapy or radiation therapy after surgery.
  • Radiation treatment plus platinum-based chemotherapy, given at the same time, is an option for those in otherwise good health. This regimen should be followed by surgery, if possible.
  • Consider clinical trials using advanced radiation techniques, including continuous hyperfractionated accelerated radiation, or 3-D conformal radiation.
  • Consider other clinical trials, including those of various combination treatments, preventive radiation therapy to the brain, and new second-line drugs.
• Stage IIIB (Any T, N3, M0) or (T4, Any N, M0). Some patients may consider surgery if there is no lymph node involvement (T4, N0), and tumor can be removed. Surgery is not an option for other patients with stage IIIB cancer. Treatment options are:
  • Radiation alone, usually for symptom control; it may improve survival in certain patients, such as those with lymph node involvement above the collar bone
  • Chemotherapy alone
  • Concurrent (given at the same time) cisplatin-based chemotherapy plus radiation, sometimes followed by surgery if possible
  • Clinical trials using induction chemotherapy alone to shrink tumors, which may then be treated with surgery or radiation
  • Clinical trials using advanced radiation techniques, including continuous hyperfractionated accelerated radiation, or 3-D conformal radiation
  • Other clinical trials, including those of various combination treatments, preventive radiation therapy to the brain, and new second-line drugs

Stage IV

In stage IV (any T, any N, M1), the cancer has spread (metastasized) to other parts of the body.

Treatment Options are:

• Combination of two- or three-drug chemotherapies that include platinum-based drugs and newer agents; the best patient candidates are those in otherwise good health, who have a limited number of distant metastasized sites. Chemotherapy not recommended for patients who are too ill.
• External-beam radiation for symptoms
• Paclitaxel or gemcitabine as a single agent
• Other clinical trials
• If metastasized cancer involves only one or two areas in the brain, it may respond to surgery followed by radiation to the brain

Recurring or Additional New Tumors

Recurring or additional new tumors occur, usually in the lung again, in half of treated patients. Research shows that a single tumor in the lung is more often a new tumor that, in many cases, may be operable.

Treatment Options are:

• Radiation for symptom control
• Chemotherapy
• If the cancer spread to only one site in the brain, it may respond to surgery, followed by whole-brain radiation. Extended disease-free survival is possible. If the brain tumor is not operable, it is treated with radiation. Even if cancer returns in the brain (in 50% of cases), treating it again is possible in many patients, if the disease has not spread elsewhere
• Laser therapy or interstitial radiation for tumors inside the airways
• Stereotactic radiosurgery (in a few selected patients)

• Review Date: 6/30/2006
• Reviewed By: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.

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