The Wellness Community

Frankly speaking about lung cancer

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(third edition)

Table Of Contents
Main Page Being Patient Active with Lung Cancer   10 Actions People with Lung Cancer Can Take   Communicating with Your Health Care Team Understanding Lung Cancer   Non-Small Cell Lung Cancer (NSCLC)   Small Cell Lung Cancer (SCLC)   Symptoms   Risk Factors   Screening   Diagnosis and Staging Getting a Proper Diagnosis   Seeking a Second Opinion Making Treatment Decisions   Learning the Language   Preparing for Treatment   Scheduling Treatment   Evaluating the Effects of Treatment   Considerations After Initial Treatment   Treatment Decision-Making Tool Understanding Treatment for Lung Cancer   Standard Therapies   Newer Therapies   Clinical Trials Treating Non-Small Cell Lung Cancer   Staging of NSCLC   Treatment of NSCLC by Stage   Treatment of Recurrent NSCLC Treating Small Cell Lung Cancer   Staging of SCLC   Treatment of SCLC by Stage   Treatment of Recurrent SCLC Managing Symptoms and Side Effects   Coping with Side Effects That Affect Energy   Coping with Side Effects That Cause Infection   Coping with Side Effects That Affect Nutrition   Appearance: Hair and Skin   Pain and Discomfort   Neuropathy, Hypertension and Toxicities   Sexual Functioning and Fertility   The Importance of Physical Activity   Chemobrain   Complementary and Alternative Medicine Managing Your Emotions and Stress   Stress and its Impact on the Immune System   Living with a Long-term Illness   The Stigma of Lung Cancer   Family and Friends   The Value of Emotional Support   Spiritual Issues   Integrating Mind-Body Practices into Treatment   Mind-Body Therapies Managing Practical Matters   Disability Insurance   Life Insurance   Employment and Legal Issues   Wills and Advanced Directives Resources Organizations That Can Help go

Treatment of NSCLC by Stage

Stages IA and IB

People diagnosed at these early stages have the best chance of recovery.

Surgery. Surgery alone is the standard of care for patients with Stage I lung cancer. People diagnosed with Stage IA or IB NSCLC are usually treated with a type of surgery called lobectomy, in which a whole section, or lobe of the lung is removed. Lobectomies are considered superior to a wedge resection, which removes only a small portion of a lobe. In some cases, it might be necessary to remove an entire lung (pneumonectomy) if tumors are found in more than one lobe or one side of the chest.

During lung surgery, the surgeon should definitely perform a complete examination of the lymph nodes in the chest cavity, including the mediastinum. One of the biggest problems with surgeries performed by non-cancer specialists is inadequate assessment of the mediastinal lymph nodes. Ask your surgeon specifically if he/she plans to remove these lymph nodes for examination.

Additional therapy. It is possible, but unproven, that chemotherapy after surgery improves survival in people with Stage IB disease. You might want to discuss with a medical oncologist the possibility of chemotherapy in addition to surgery. This therapy will usually consist of a platinum-based drug (cisplatin or carboplatin) and one of several other chemo agents (gemcitabine, taxol, docetaxel, or vinorelbine).

NCI-recommended standard treatment options for Stage I lung cancers:

• Surgical removal of a wedge, segment, or lobe of one lung, possibly with removal of part of a bronchial tube
• Radiation therapy (if the person has other health conditions that would make surgery inadvisable)
• Clinical trials of adjuvant chemotherapy after surgical resection
• Prevention trials to reduce the risk of a second lung cancer
• Endoscopic photodynamic therapy (under clinical evaluation in select persons)
• Clinical trials of targeted therapy with or without other modalities after curative surgery

Stages IIA and IIB

If you are diagnosed with Stage IIA or IIB NSCLC, it is recommended that you meet with a surgeon, a medical oncologist and a radiation oncologist to discuss possible therapeutic options including clinical trials for your stage of disease.

Surgery. Surgery has been the standard of treatment for Stage IIA and IIB and selected stage IIIA disease (such as a lobectomy, bilobectomy, or pneumonectomy) if the person can medically tolerate the procedure.

Chemotherapy. Recent studies have shown that chemotherapy after surgery improves survival in people with Stage IIA and IIB lung cancer and consists of a platinum-based regimen. If the chest is involved with the IIB cancer you may benefit from treatment with radiation and/or chemotherapy before surgery. The hope is to shrink the tumor to improve the chances that the surgical procedure will be successful in removing all of the tumor. Ask your doctor if chemotherapy would be a good option for you.

Radiation Therapy. If you have a stage IIB tumor that involves the chest wall, radiation may be given prior to surgery to improve the chances of removing all the cancer cells with surgery.

NCI-recommended standard treatment option:

• Surgical removal of the whole lung, one lobe, a wedge or segment, or part of a bronchial tube
• Radiation therapy for people who could have surgery but have other health problems that make surgery impossible
• Clinical trials of adjuvant chemotherapy with or without other therapies after curative surgery
• Clinical trials of radiation therapy after surgery
• Clinical trials of a novel targeted therapy, with or without other modalities after curative surgery

Stage IIIA

Stage IIIA NSCLC is a somewhat complex stage of lung cancer to manage. Several treatment options are potentially effective. However, there is not enough evidence to determine which treatment is best in any one individual. Treatment at this stage is determined by whether the tumor can be operated on or not.

Operable Stage IIIA NSCLC

The standard of care for potentially operable Stage IIIA NSCLC is controversial. Recent data from clinical trials has been inconclusive as to which treatment is most effective.

Depending on the details of your case, options may include:

• Surgery followed by chemotherapy
• Chemotherapy and/or radiation followed by surgery
• Chemotherapy and radiation alone
• Surgery followed by chemotherapy with or without radiation

Surgery. Surgery without chemotherapy may be possible in some cases if the tumor can be easily removed, especially when the lymph nodes were found to be involved only at the time of surgery. When mediastinal lymph nodes are involved, most commonly chemotherapy with or without radiation is given before or after surgery.

Radiation. Radiation is sometimes used for Stage IIIA NSCLC either with chemotherapy or in combination with surgery. Radiation combined with chemotherapy may be used instead of surgery to eliminate the tumor and is probably the most common form of therapy at this stage.

NCI-recommended standard treatment options:

• Surgery followed by chemotherapy in people with operable tumors and minimal lymph node involvement
• Radiation alone for those who cannot physically tolerate chemotherapy and surgery
• Chemotherapy combined with radiation

Inoperable Stage IIIA NSCLC

Surgery. Stage IIIA NSCLC is considered inoperable when the tumor is too large, in a location that is difficult for the surgeon to reach, or the patient has other complicating factors that puts him or her at risk for surgery.

Chemotherapy. The standard of care for inoperable Stage IIIA is chemotherapy combined with radiation therapy in a fit patient. Commonly used chemotherapy drugs include a platinum drug together with one of several non-platinum based drugs. Delivery of chemotherapy and radiation therapy concurrently (at the same time) appears to be superior to the sequential administration of chemotherapy and radiation treatments.

Radiation therapy. Radiation therapy is often used as part of the treatment for this stage of cancer.

Several clinical trials are evaluating different types and timing of chemotherapy.

NCI-recommended standard treatment options:

• Chemotherapy together with radiation therapy.

Stage IIIB and Stage IV

The treatment for Stage IIIB and Stage IV NSCLC depends on whether the stage III tumor is associated with pleural effusion (leakage of fluid between the lungs and chest wall). If there is a pleural effusion, the tumor is often referred to as a "wet" IIIB. A stage IIIB tumor without pleural effusion (a "dry" IIIB) is generally treated much different than wet tumors.

• People who have Stage IIIB NSCLC without a pleural effusion are usually offered the same treatment options as those patients with inoperable Stage IIIA NSCLC, though surgery may be an option based on the tumor location.
• People with Stage IIIB NSCLC who also have a pleural effusion are usually treated with similar therapies as patients with Stage IV.
• Most people with Stage IIIB wet and Stage IV NSCLC are treated with radiation therapy only for areas of cancer that cause specific symptoms, such as pain or obstruction of a vital organ.

Cure is rarely achieved in patients with stage IIIB wet or IV lung cancer, so the goal of treatment is to improve quality of life and prolong survival.

Surgery. Surgery is rarely indicated for people with Stage IIIB wet or Stage IV NSCLC.

Chemotherapy. Chemotherapy improves survival and quality of life when compared to best supportive care (to relieve symptoms only) in some people with Stage IIIB (with pleural effusion) and Stage IV NSCLC who are healthy enough to tolerate the side-effects. Current clinical trials have shown that a combination of different drugs, is superior to giving one drug alone. Avastin^TM (bevacizumab) combined with chemotherapy may be used in select patients.

• Approximately 50-60% of people with advanced NSCLC who receive chemotherapy achieve some clinical benefit
• Approximately 25% achieve a partial response (tumor shrinkage of 50% or more)
• A small percentage will experience a disappearance of the entire disease, while others have a stabilization of their disease

NCI-recommended standard treatment options:

Chemotherapy consisting of carboplatin plus paclitaxel with the anti-angiogenesis agent Avastin (bevacizumab), in patients without contradictions (such as: squamous cell history, brain metastases, coughing up blood).

Chemotherapy combinations:

• Gemzar® (gemcitabine) + platinum agent
• Taxol® (paclitaxel) + platinum agent
• Navelbine® (vinorelbine) + platinum agent
• Taxotere® (docetaxel) + platinum agent

Radiation. Radiation therapy is often used to shrink the tumor size and relieve symptoms to improve a person's quality of life.

Targeted Therapy. See Newer Therapies for information about epidermal growth factor receptor (EGFR) inhibitors and others.

Chemotherapy Options for advanced NSCLC

First Line Treatment	Second Line Treatment
Two-drug chemotherapy combination plus Avastin using any of the following: Navelbine/Carboplatin/Cisplatin Gemzar/Taxol/Taxotere/Navelbine Clinical Trial	Tarceva® Navelbine Alimta Clinical Trial

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