Lung Cancer Non-Small Cell

What is non-small cell lung cancer?

Note: This document is specifically for the non-small cell type of lung cancer. The treatment for each type of lung cancer (small cell or non-small cell) is very different, so much of the information for one type will not apply to the other type. If you are not sure which type of lung cancer you have, ask your doctor so you can be sure you get the correct information.

Lung cancer is a cancer that starts in the lungs. To understand lung cancer, it helps to know about the normal structure and function of the lungs.

The lungs

Your lungs are 2 sponge-like organs found in your chest. Your right lung is divided into 3 sections, called lobes. Your left lung has 2 lobes. The left lung is smaller because the heart takes up more room on that side of the body.

When you breathe in, air enters through your mouth or nose and goes into your lungs through the trachea (windpipe). The trachea divides into tubes called the bronchi (singular, bronchus), which divide into smaller branches called bronchioles. At the end of the bronchioles are tiny air sacs known as alveoli.

Many tiny blood vessels run through the alveoli. They absorb oxygen from the inhaled air into your bloodstream and pass carbon dioxide from the body into the alveoli. This is expelled from the body when you exhale. Taking in oxygen and getting rid of carbon dioxide are your lungs’ main functions.

A thin lining layer called the pleura surrounds the lungs. The pleura protects your lungs and helps them slide back and forth as they expand and contract during breathing.

Below the lungs, a dome-shaped muscle called the diaphragm separates the chest from the abdomen. When you breathe, the diaphragm moves up and down, forcing air in and out of the lungs.

Start and spread of lung cancer

Most lung cancers start in the bronchi, but they can also begin in other areas such as the trachea, bronchioles, or alveoli.

Lung cancers are thought to develop over many years. They may start as areas of pre-cancerous changes in the lung. The first changes happen in the cells themselves, but at this point the cells do not form a mass or tumor. They cannot be seen on an x-ray and they do not cause symptoms. Over time, these pre-cancerous changes may progress to true cancer. As a cancer develops, the cancer cells may make chemicals that cause new blood vessels to form nearby. These new blood vessels nourish the cancer cells, which can continue to grow and form a tumor large enough to be seen on imaging tests such as x-rays.

At some point, cells from the cancer may break away from the original tumor and spread (metastasize) to other parts of the body. Lung cancer is a life-threatening disease because it often spreads in this way even before it can be detected on an imaging test such as a chest x-ray.

The lymph (lymphatic) system

The lymph system is important to understand because it is one of the ways in which lung cancers can spread. This system has several parts.

Lymph nodes are small, bean-shaped collections of immune system cells (cells that fight infections) that are connected by lymphatic vessels. Lymphatic vessels are like small veins, except that they carry a clear fluid called lymph (instead of blood) away from the lungs. Lymph contains excess fluid and waste products from body tissues, as well as immune system cells.

Lung cancer cells can enter lymphatic vessels and begin to grow in lymph nodes around the bronchi and in the mediastinum (the area between the 2 lungs). When lung cancer cells have reached the lymph nodes, they are more likely to have spread to other organs of the body as well. The stage (extent) of the cancer and decisions about treatment are based on whether or not the cancer has spread to the nearby lymph nodes in the mediastinum. These topics are discussed later in the section, “How is non-small cell lung cancer staged?”

Types of lung cancer

There are 2 major types of lung cancer:

• small cell lung cancer (SCLC)
• non-small cell lung cancer (NSCLC)

If a lung cancer has characteristics of both types it is called a mixed small cell/large cell cancer. This is uncommon.

The 2 types of lung cancer are treated very differently. This document focuses on non-small cell lung cancer. Small cell lung cancer is discussed in the separate document, Lung Cancer (Small Cell).

Non-small cell lung cancer

About 85% to 90% of lung cancers are non-small cell lung cancer (NSCLC). There are 3 subtypes of NSCLC. The cells in these subtypes differ in size, shape, and chemical make-up when looked at under a microscope.

Squamous cell carcinoma: About 25% to 30% of all lung cancers are squamous cell carcinomas. They are often linked to a history of smoking and tend to be found in the middle of the lungs, near a bronchus.

Adenocarcinoma: About 40% of lung cancers are adenocarcinomas. It is usually found in the outer region of lung. People with one type of adenocarcinoma, sometimes called bronchioloalveolar carcinoma, tend to have a better outlook (prognosis) than those with other types of lung cancer.

Large-cell (undifferentiated) carcinoma: This type of cancer accounts for about 10% to 15% of lung cancers. It may appear in any part of the lung. It tends to grow and spread quickly, which can make it harder to treat.

Small cell lung cancer

About 10% to 15% of all lung cancers are small cell lung cancer (SCLC), named for the small cells that make up these cancers. Other names for SCLC are oat cell cancer, oat cell carcinoma, and small cell undifferentiated carcinoma. It is very rare for someone who has never smoked to have small cell lung cancer.

SCLC often starts in the bronchi near the center of the chest, and it tends to spread widely through the body fairly early in the course of the disease. This cancer is discussed in the document, Lung Cancer (Small Cell).

Other types of lung cancer

Along with the 2 main types of lung cancer, other tumors can occur in the lungs.

Carcinoid tumors of the lung account for fewer than 5% of lung tumors. Most are slow-growing tumors that are called typical carcinoid tumors. They are generally cured by surgery. Some typical carcinoid tumors can spread, but they usually have a better prognosis than small cell or non-small cell lung cancer. Less common are atypical carcinoid tumors. The outlook for these tumors is somewhere in between typical carcinoids and small cell lung cancer. For more information about typical and atypical carcinoid tumors, see the separate document, Lung Carcinoid Tumor.

There are other, even more rare, lung tumors such as adenoid cystic carcinomas, hamartomas, lymphomas, and sarcomas. These tumors are treated differently from the more common lung cancers. They are not discussed in this document.

Cancer that starts in other organs (such as the breast, pancreas, kidney, or skin) and spreads (metastasizes) to the lungs is not the same as lung cancer. For example, cancer that starts in the breast and spreads to the lungs is still breast cancer, not lung cancer. Treatment for metastatic cancer to the lungs depends on where it started (the primary cancer site). For information on these primary cancers, see our separate documents on each.

What are the key statistics about lung cancer?

Most statistics concerning lung cancer include both small cell and non-small cell lung cancers.

Lung cancer (both small cell and non-small cell) is the second most common cancer in both men (after prostate cancer) and women (after breast cancer). It accounts for about 15% of all new cancers.

The American Cancer Society’s most recent estimates for lung cancer in the United States are for 2009:

• About 219,440 new cases of lung cancer will be diagnosed (116,090 among men and 103,350 among women).

• There will be an estimated 159,390 deaths from lung cancer (88,900 among men and 70,490 among women), accounting for about 28% of all cancer deaths.

Lung cancer is by far the leading cause of cancer death among both men and women. More people die of lung cancer than of colon, breast, and prostate cancers combined.

Lung cancer mainly occurs in older people. About 2 out of 3 people diagnosed with lung cancer are older than 65; fewer than 3% of all cases are found in people younger than 45. The average age at the time of diagnosis is about 71.

Overall, the chance that a man will develop lung cancer in his lifetime is about 1 in 13; for a woman, the risk is about 1 in 16. These numbers include both smokers and non-smokers. For smokers the risk is much higher, while for non-smokers the risk is lower.

Black men are about 40% more likely to develop lung cancer than white men. The rate is about the same in black women and in white women. Both black and white women have lower rates than men, but the gap is closing. The rate of lung cancer has been dropping among men for several years and is fairly stable among women.

Statistics on survival in people with lung cancer vary depending on the stage (extent) of the cancer when it is diagnosed. Survival statistics based on the stage of the cancer are discussed in the section, “How is non-small cell lung cancer staged?”

Despite the very serious prognosis (outlook) of lung cancer, some people are cured. More than 400,000 people alive today have been diagnosed with lung cancer at some point..

What are the risk factors for non-small cell lung cancer?

A risk factor is anything that affects a person’s chance of getting a disease such as cancer. Different cancers have different risk factors. For example, unprotected exposure to strong sunlight is a risk factor for skin cancer.

But risk factors don’t tell us everything. Having a risk factor, or even several risk factors, does not mean that you will get the disease. And many people who get the disease may not have had any known risk factors. Even if a person with lung cancer has a risk factor, it is often very hard to know how much that risk factor may have contributed to the cancer.

Several risk factors can make you more likely to develop lung cancer:

Tobacco smoke

Smoking is by far the leading risk factor for lung cancer. In the early 20th century, lung cancer was much less common than some other types of cancer. But this changed once manufactured cigarettes became readily available.

About 87% of lung cancer deaths are thought to result from smoking. The risk for lung cancer among smokers is many times higher than among non-smokers. The longer you smoke and the more packs a day you smoke, the greater your risk.

Cigar smoking and pipe smoking are almost as likely to cause lung cancer as cigarette smoking. Smoking low tar or “light” cigarettes increases lung cancer risk as much as regular cigarettes. There is concern that mentholated cigarettes may increase the risk even more since the menthol allows smokers to inhale more deeply.

If you stop smoking before a cancer develops, your damaged lung tissue gradually starts to repair itself. No matter what your age or how long you’ve smoked, quitting may help you live longer. People who stop smoking before age 50 cut their risk of dying in the next 15 years in half compared with those who continue to smoke. For help quitting, see our Guide to Quitting Smoking or call the American Cancer Society at 1-800-227-2345.

Secondhand smoke: If you don’t smoke, breathing in the smoke of others (called secondhand smoke or environmental tobacco smoke) can increase your risk of developing lung cancer. A non-smoker who lives with a smoker has about a 20% to 30% greater risk of developing lung cancer. Workers who have been exposed to tobacco smoke in the workplace are also more likely to get lung cancer. Secondhand smoke is thought to cause more than 3,000 deaths from lung cancer each year.

Some evidence suggests that certain people are more susceptible to the cancer-causing effect of tobacco smoke than others.

Radon

Radon is a naturally occurring radioactive gas that results from the breakdown of uranium in soil and rocks. It cannot be seen, tasted, or smelled. According to the U.S. Environmental Protection Agency (EPA), radon is the second leading cause of lung cancer, and is the leading cause among non-smokers.

Outdoors, there is so little radon that it is not dangerous. But indoors, radon can be more concentrated and become a possible risk for cancer. Houses in some parts of the United States built on soil with natural uranium deposits can have high indoor radon levels (especially in basements). Studies from these areas have found that the risk of lung cancer is higher in those who have lived for many years in a radon-contaminated house.

The lung cancer risk from radon is much lower than that from tobacco smoke. However, the risk from radon is much higher in people who smoke than in those who don’t.

If you are concerned about radon exposure, state and local offices of the EPA can give you the names of reliable companies that perform radon testing and renovation. For more information, see the document, Radon.

Asbestos

Workplace exposure to asbestos fibers is an important risk factor for lung cancer. Studies have found that people who work with asbestos (in some mines, mills, textile plants, places where insulation is used, shipyards, etc.) are several times more likely to die of lung cancer. In workers exposed to asbestos who also smoke, the lung cancer risk is much greater than even adding the risks from these exposures separately. It’s not clear to what extent low-level or short-term exposure to asbestos might raise lung cancer risk.

Both smokers and non-smokers exposed to asbestos also have a greater risk of developing mesothelioma, a type of cancer that starts in the pleura (the lining surrounding the lungs). Because it is not usually considered a type of lung cancer, mesothelioma is discussed in the document, Malignant Mesothelioma.

In recent years, government regulations have greatly reduced the use of asbestos in commercial and industrial products. It is still present in many homes and commercial buildings but is not usually considered harmful as long as it is not released into the air by deterioration, demolition, or renovation. For more information, see the document, Asbestos.

Other cancer-causing agents in the workplace

Other carcinogens (cancer-causing agents) found in some workplaces that can increase lung cancer risk include:

• radioactive ores such as uranium

• inhaled chemicals or minerals such as arsenic, beryllium, cadmium, silica, vinyl chloride, nickel compounds, chromium compounds, coal products, mustard gas, and chloromethyl ethers

• diesel exhaust

The government and industry have taken steps in recent years to protect workers. But the dangers are still present, and if you work around these agents, you should be careful to limit your exposure whenever possible.

Radiation therapy to the lungs

People who have had radiation therapy to the chest for cancer are at higher risk for lung cancer, particularly if they smoke. Typical patients are those treated for Hodgkin disease or women who get radiation after a mastectomy for breast cancer. Women who receive radiation therapy to the breast after a lumpectomy do not appear to have a higher than expected risk of lung cancer.

Arsenic

High levels of arsenic in drinking water may increase the risk of lung cancer. This is even more pronounced in smokers.

Personal or family history of lung cancer

If you have had lung cancer, you have a higher risk of developing another lung cancer. Brothers, sisters, and children of those who have had lung cancer may have a slightly higher risk of lung cancer themselves, especially if it was diagnosed when the relative was younger. It is not clear how much of this risk might be due to genetics and how much might be from shared exposures (such as tobacco smoke or radon).

Researchers have found that genetics does seem to play a role in some families with a strong history of lung cancer. People who inherit certain DNA changes in a particular chromosome (chromosome 6) are more likely to develop lung cancer, even if they only smoke a little. At this time these DNA changes cannot be routinely tested for. Research is ongoing in this area.

Certain dietary supplements

Studies looking at the possible role of antioxidant supplements in reducing lung cancer risk have not been promising thus far. In fact, 2 large studies found that smokers who took beta carotene supplements actually had an increased risk of lung cancer. The results of these studies suggest that smokers should avoid taking beta carotene supplements.

Air pollution

In cities, air pollution (especially from heavily trafficked roads) appears to raise the risk of lung cancer slightly. This risk is far less than the risk caused by smoking, but some researchers estimate that worldwide about 5% of all deaths from lung cancer may be due to outdoor air pollution.

Factors with uncertain or unproven effects on lung cancer risk

Marijuana: There are some reasons to think that marijuana smoking might increase lung cancer risk. Marijuana contains more tar than cigarettes. (Tar is the sticky, solid material that remains after burning, which is thought to contain most of the harmful substances in smoke.) Marijuana is also inhaled very deeply and the smoke is held in the lungs for a long time. Marijuana is smoked all the way to the end where tar content is the highest. Many of the cancer-causing substances in tobacco are also found in marijuana. And because marijuana is an illegal substance, it is not possible to control what other substances it might contain.

But it has been hard to study whether there is a link between marijuana and lung cancer because it is not easy to gather information about the use of illegal drugs. Also, many marijuana smokers also smoke cigarettes. This makes it hard to know how much of the risk is from tobacco and how much might be from marijuana. In the very limited studies done so far, marijuana use has not been strongly linked to lung cancer, but more research in this area is needed.

Talc and talcum powder: Talc is a mineral that in its natural form may contain asbestos. In the past, some studies suggested that talc miners and millers have a higher risk of lung cancer and other respiratory diseases because of their exposure to industrial grade talc. Recent studies of talc miners have not found an increase in lung cancer rate.

Talcum powder is made from talc. By law since 1973, all home-use talcum products (baby, body, and facial powders) have been asbestos-free. The use of cosmetic talcum powder has not been found to increase the risk of lung cancer.

Do we know what causes non-small cell lung cancer?

Tobacco smoking is by far the leading cause of lung cancer. About 85% to 90% of lung cancer deaths are caused directly by smoking, and many others are caused by exposure to secondhand smoke. Other known risk factors such as radon exposure were described in the section, “What are the risk factors for non-small cell lung cancer?” Still, a small portion of lung cancers occur in people with no apparent risk factors for the disease.

Scientists have begun to understand how the known risk factors may produce certain changes in the DNA of cells in the lungs, causing them to grow abnormally and form cancers. DNA is the chemical in each of our cells that makes up our genes — the instructions for how our cells function. We usually look like our parents because they are the source of our DNA. However, DNA affects more than how we look. It also can influence our risk for developing certain diseases, such as some kinds of cancer.

Some genes contain instructions for controlling when cells grow and divide. Genes that promote cell division are called oncogenes. Genes that slow down cell division or cause cells to die at the right time are called tumor suppressor genes. Cancers can be caused by DNA mutations (defects) that turn on oncogenes or turn off tumor suppressor genes.

Inherited gene changes

Some people inherit DNA mutations from their parents that greatly increase their risk for developing certain cancers. However, inherited mutations are not thought to cause very many lung cancers.

Still, genes do seem to play a role in some families with a history of lung cancer. For example, some people seem to inherit a reduced ability to break down or get rid of certain types of cancer-causing chemicals, such as those found in tobacco smoke. This could put them at higher risk for lung cancer.

Other people may inherit faulty DNA repair mechanisms that make it more likely they will end up with DNA changes. Every time a cell prepares to divide into 2 new cells, it must make a new copy of its DNA. This process is not perfect, and copying errors sometimes occur. Cells normally have repair enzymes that proofread the DNA to help prevent this. People with repair enzymes that don’t work as well might be especially vulnerable to cancer-causing chemicals and radiation.

Researchers are developing tests that may help identify such people, but these tests are not yet reliable enough for routine use. For now, doctors recommend that all people avoid tobacco smoke and other exposures that might increase their cancer risk.

Acquired gene changes

Gene changes related to lung cancer are usually acquired during life rather than inherited. Acquired mutations in lung cells often result from exposure to cancer-causing chemicals in tobacco smoke. Acquired changes in certain genes, such as the p53 or p16 tumor suppressor genes and the RAS oncogene, are thought to be important in the development of lung cancer. Changes in these and other genes may also make some lung cancers likely to grow and spread more rapidly than others.

Can non-small cell lung cancer be prevented?

The best way to reduce your risk of lung cancer is not to smoke and to avoid breathing in other people’s smoke. If you would like help quitting smoking, see our Guide to Quitting Smoking or call the American Cancer Society at 1-800-227-2345.

Radon is an important cause of lung cancer. Exposure to radon can be reduced or eliminated by having your home tested and treated, if needed. For more information, see the document, Radon.

Avoiding exposure to known cancer-causing chemicals, in the workplace and elsewhere, can also be helpful. When people work where these exposures are common, they should be kept to a minimum.

A healthy diet with lots of fruits and vegetables may also help reduce your risk of lung cancer. Some evidence suggests that a diet high in fruits and vegetables may help protect against lung cancer in both smokers and non-smokers. But any positive effect of fruits and vegetables on risk would be much less than the increased risk from smoking.

Attempts to reduce the risk of lung cancer in current or former smokers by giving them high doses of vitamins or vitamin-like drugs have not been successful so far. In fact, some studies have found that beta-carotene, a nutrient related to vitamin A, appears to increase the rate of lung cancer in these people.

Some people who get lung cancer do not have any apparent risk factors. Although we know how to prevent most lung cancers, at this time we don’t know how to prevent all of them.

Can non-small cell lung cancer be found early?

Usually symptoms of lung cancer do not appear until the disease is already in an advanced stage. Even when symptoms of lung cancer do appear, many people may mistake them for other problems, such as an infection or long-term effects from smoking. This may delay a diagnosis even further.

But some lung cancers are diagnosed early because they are found as a result of tests for other medical conditions. For example, a lung tumor may be noted by imaging tests (such as a chest x-ray or chest CT scan), bronchoscopy (viewing the inside of bronchi through a flexible lighted tube), or sputum cytology (microscopic examination of cells in coughed up phlegm) done for other reasons in patients with heart disease, pneumonia, or other lung conditions.

Screening for lung cancer

Screening is the use of tests or exams to detect a disease in people without symptoms of that disease. For example, the Pap test is used to screen for cervical cancer. Because lung cancer usually spreads beyond the lungs before causing any symptoms, an effective screening test for lung cancer could save many lives.

So far, no lung cancer screening test has been shown to prevent people from dying of this disease. Studies of chest x-rays and sputum cytology have concluded that these tests could not find many lung cancers early enough to improve a person’s chance for a cure. For this reason, major medical organizations have not recommended these tests for screening the general public or even for people at increased risk, such as smokers.

Recently, a special type of CT scan known as spiral or helical CT has shown some promise in detecting early lung cancers in smokers and former smokers. But it is not known whether this test will lower the chances of dying from lung cancer. A major drawback of this test is that it also finds a lot of abnormalities that turn out not to be cancer but that still need to be tested to be sure. This may lead to unnecessary and invasive tests such as biopsies, or even surgery.

A large clinical trial called the National Lung Screening Trial (NLST) is now testing whether spiral CT scanning of people at high risk of lung cancer will save lives. The results of this study, which includes about 50,000 people, are not expected until at least 2010. Until this information is available, people who are interested in testing should understand the limits and benefits of screening with spiral CT.

No major professional organizations, including the American Cancer Society, currently recommend routine screening for lung cancer.

The American Cancer Society recommends that, as much as possible, people who were smokers, are current smokers, have been exposed to secondhand smoke, or have worked around materials that increase the risk for lung cancer, be aware of their lung cancer risk. These people should talk with their doctors about their likelihood of developing lung cancer and about the potential benefits and risks of lung cancer screening. After discussing what is and is not known about the value of testing for early lung cancer detection, if you and your doctor decide in favor of testing, then be sure to have it done at a center that has experience in lung scanning and that supports a multidisciplinary program for testing people at high risk.

The United States Preventive Services Task Force (USPSTF), a group of experts gathered together by the US government, has concluded that there’s not enough evidence at this time to recommend for or against lung cancer screening in people without symptoms.

The American College of Chest Physicians (ACCP) does not recommend routine lung cancer screening at this time, advising that “individuals undergo screening only when it is administered as a component of a well-designed clinical trial.”

People who are current smokers should realize that the best way to avoid dying from lung cancer is to stop smoking. For help quitting smoking, see our Guide to Quitting Smoking or call the American Cancer Society at 1-800-227-2345.

How is non-small cell lung cancer diagnosed?

Most lung cancers are not found until they start to cause symptoms. Symptoms can suggest that a person may have lung cancer, but the actual diagnosis is made by looking at lung cells under a microscope.

Common signs and symptoms of lung cancer

Most lung cancers do not cause any symptoms until they have spread too far to be cured, but symptoms do occur in some people with early lung cancer. If you go to your doctor when you first notice symptoms, your cancer might be diagnosed at an earlier stage, when treatment is more likely to be effective. The most common symptoms of lung cancer are:

• a cough that does not go away
• chest pain that is often worse with deep breathing, coughing, or laughing
• hoarseness
• weight loss and loss of appetite
• coughing up blood or rust-colored sputum (spit or phlegm)
• shortness of breath
• feeling tired or weak
• recurring infections such as bronchitis and pneumonia
• new onset of wheezing

When lung cancer spreads to distant organs, it may cause:

• bone pain
• neurologic changes (such as headache, weakness or numbness of a limb, dizziness, or recent onset of a seizure)
• jaundice (yellowing of the skin and eyes)
• lumps near the surface of the body, due to cancer spreading to the skin or to lymph nodes (collections of immune system cells) in the neck or above the collarbone

Most of the symptoms listed above are more likely to be caused by conditions other than lung cancer. Still, if you have any of these problems, it’s important to see your doctor right away so the cause can be found and treated, if needed.

Some lung cancers can cause a group of very specific symptoms. These are often described as syndromes.

Horner syndrome

Cancers of the top part of the lungs (sometimes called Pancoast tumors) may damage a nerve that passes from the upper chest into your neck. This can cause severe shoulder pain. Sometimes these tumors also cause a group of symptoms called Horner syndrome:

• drooping or weakness of one eyelid
• having a smaller pupil (dark part in the center of the eye) in the same eye
• reduced or absent sweating on the same side of the face

Conditions other than lung cancer can also cause Horner syndrome.

Paraneoplastic syndromes

Some lung cancers may make hormone-like substances that enter the bloodstream and cause problems with distant tissues and organs, even though the cancer has not spread to those tissues or organs. These problems are called paraneoplastic syndromes. Sometimes these syndromes may be the first symptoms of lung cancer. Because the symptoms affect other organs, patients and their doctors may suspect at first that diseases other than lung cancer are causing them.

The most common paraneoplastic syndromes caused by non-small cell lung cancer are:

• high blood calcium levels (hypercalcemia), which can cause frequent urination, constipation, nausea, vomiting, weakness, dizziness, confusion, and other nervous system problems

• excess growth of certain bones, especially those in the finger tips, which is often painful

• blood clots

• excess breast growth in men (gynecomastia)

Again, many of the symptoms listed above are more likely to be caused by conditions other than lung cancer. Still, if you have any of these problems, it’s important to see your doctor right away so the cause can be found and treated, if needed.

Medical history and physical exam

If you have any signs or symptoms that suggest you might have lung cancer, your doctor will want to take a medical history (health-related interview) to check for risk factors and symptoms. Your doctor will also examine you to look for signs of lung cancer and other health problems.

If symptoms and/or the results of the physical exam suggest lung cancer might be present, more involved tests will probably be done. These might include imaging tests and/or getting biopsies of lung tissue.

Imaging tests

Imaging tests use x-rays, magnetic fields, sound waves, or radioactive substances to create pictures of the inside of your body. Imaging tests may be done for a number of reasons, including to help find a suspicious area that might be cancerous, to learn how far cancer may have spread, and to help determine if treatment has been effective.

Chest x-ray

This is often the first test your doctor will do to look for any masses or spots on the lungs. A plain x-ray of your chest can be done in any outpatient setting. If the x-ray is normal, you probably don’t have lung cancer (although some lung cancers may not show up on an x-ray). If something suspicious is seen, your doctor may order additional tests.

Computed tomography (CT) scan

The CT or CAT scan is an x-ray test that produces detailed cross-sectional images of your body. Instead of taking one picture, like a regular x-ray, a CT scanner takes many pictures as it rotates around you while you lie on a table. A computer then combines these pictures into images of slices of the part of your body being studied. Unlike a regular x-ray, a CT scan creates detailed images of the soft tissues in the body.

Before the CT scan, you may be asked to drink a contrast solution or receive an IV (intravenous) line through which a contrast dye is injected. This helps better outline structures in your body.

The contrast may cause some flushing (a feeling of warmth, especially in the face). Some people are allergic and get hives. Rarely, more serious reactions like trouble breathing or low blood pressure can occur. Be sure to tell the doctor if you have any allergies or if you ever had a reaction to any contrast material used for x-rays.

CT scans take longer than regular x-rays. You need to lie still on a table while they are being done. During the test, the table moves in and out of the scanner, a ring-shaped machine that completely surrounds the table. You might feel a bit confined by the ring you have to lie in while the pictures are being taken.

Spiral CT (also known as helical CT) is now available in many medical centers. This type of CT scan uses a faster machine. The scanner part of the machine rotates around the body continuously, allowing doctors to collect the images much more quickly than with standard CT. As a result, you do not have to hold your breath for as long while the image is taken. This lowers the chance that your breathing motion will cause blurred images. It also lowers the dose of radiation received during the test. The slices it images are thinner, which yields more detailed pictures.

A CT scan can provide precise information about the size, shape, and position of any tumors and can help find enlarged lymph nodes that might contain cancer that has spread from the lung. CT scans are more sensitive than routine chest x-rays in finding early lung cancers.

This test can also be used to look for masses in the adrenal glands, liver, brain, and other internal organs that may be affected by the spread of lung cancer.

CT guided needle biopsy: In cases where a suspected area of cancer lies deep within the body, a CT scan can be used to guide a biopsy needle precisely into the suspected area. For this procedure, you stay on the CT scanning table, while the doctor advances a biopsy needle through the skin and toward the mass. CT scans are repeated until the doctor can see that the needle is within the mass. A biopsy sample is then removed and looked at under a microscope.

Magnetic resonance imaging (MRI) scan

Like CT scans, MRI scans provide detailed images of soft tissues in the body. But MRI scans use radio waves and strong magnets instead of x-rays. The energy from the radio waves is absorbed and then released in a pattern formed by the type of body tissue and by certain diseases. A computer translates the pattern into a very detailed image of parts of the body. A contrast material called gadolinium is often injected into a vein before the scan to better see details.

MRI scans are a little more uncomfortable than CT scans. First, they take longer — often up to an hour. Second, you have to lie inside a narrow tube, which is confining and can upset people with claustrophobia (a fear of enclosed spaces). Newer, more open MRI machines can sometimes help with this if needed, although the images may not be as sharp in some cases. MRI machines make buzzing and clicking noises that you may find disturbing. Some centers provide earplugs to help block this noise out.

MRI scans are most often used to look for possible spread of lung cancer to the brain or spinal cord.

Positron emission tomography (PET) scan

For a PET scan, glucose (a form of sugar) that contains a radioactive atom is injected into the blood. The amount of radioactivity used is very low. Because cancer cells in the body are growing rapidly, they absorb large amounts of the radioactive sugar. After about an hour, you will be moved onto a table in the PET scanner. You lie on the table for about 30 minutes while a special camera creates a picture of areas of radioactivity in the body. The picture is not finely detailed like a CT or MRI scan, but it provides helpful information about your whole body.

This can be a very important test if you appear to have early stage lung cancer. Your doctor can use this test to see if the cancer has spread to lymph nodes, which can help determine if surgery may be an option for you. A PET scan can also be helpful in getting a better idea whether an abnormal area on your chest x-ray may be cancer.

PET scans are also useful if your doctor thinks the cancer may have spread but doesn’t know where. PET can reveal spread of cancer to the liver, bones, adrenal glands, or some other organs. It is not as useful for looking at the brain, since all brain cells use a lot of glucose.

Some newer machines are able to perform both a PET and CT scan at the same time (PET/CT scan). This lets the doctor compare areas of higher radioactivity on the PET with the more detailed appearance of that area on the CT.

Bone scan

A bone scan can help show if a cancer has metastasized (spread) to the bones. For this test, a small amount of low-level radioactive material is injected into a vein (intravenously, or IV). The substance settles in areas of bone changes throughout the entire skeleton over the course of a couple of hours. You then lie on a table for about 30 minutes while a special camera detects the radioactivity and creates a picture of your skeleton.

Areas of active bone changes show up as “hot spots” on your skeleton — that is, they attract the radioactivity. These areas may suggest the presence of metastatic cancer, but arthritis or other bone diseases can also cause the same pattern. To distinguish among these conditions, your cancer care team may use other imaging tests such as simple x-rays or MRI scans to get a better look at the areas that light up, or they may even take biopsy samples of the bone.

PET scans, which are often done in patients with non-small cell lung cancer, can usually show if cancer has spread to the bones, so bone scans aren’t needed very often. Bone scans are done mainly when there is reason to think the cancer may have spread to the bones (because of symptoms, etc.) and other test results aren’t clear.

Sampling tissues and cells

Symptoms and the results of imaging tests may strongly suggest that lung cancer is present, but the actual diagnosis of non-small cell lung cancer is made by looking at lung cells under a microscope.

The cells can be taken from lung secretions (phlegm), or the cells can be removed from a suspicious area (known as a biopsy). One or more of the tests below may be used to find out if a lung mass seen on imaging tests is indeed lung cancer. These tests can also be used to tell the exact type of lung cancer you have and to help determine how far it might have spread.

A pathologist, a doctor who uses lab tests to diagnose diseases such as cancer, will look at the cells under a microscope. The results will be described in a pathology report, which is usually available within about a week. If you have any questions about your pathology results or any diagnostic tests, talk to your doctor. If needed, you can get a second opinion of your pathology report by having your tissue samples sent to a pathologist at another lab recommended by your doctor.

Sputum cytology

A sample of phlegm (mucus you cough up from the lungs) is viewed under a microscope to see if cancer cells are present. The best way to do this is to get early morning samples from you 3 days in a row.

Fine needle aspiration (FNA) biopsy

A needle biopsy can often be used to get a small sample of cells from a suspicious area. For this test, the skin where the needle is to be inserted first may be numbed with local anesthesia. The doctor then guides a thin, hollow needle into the area while looking at your lungs with either fluoroscopy (which is like an x-ray, but the image is shown on a screen rather than on film) or CT scans. Unlike fluoroscopy, CT doesn’t give a continuous picture, so the needle is inserted toward the mass, a CT image is taken, and the direction of the needle is guided based on the image. This is repeated a few times until the needle is within the mass.

A tiny sample of the mass is then sucked into a syringe and sent to a lab, where it is looked at under the microscope to see if cancer cells are present.

A possible complication of this procedure is that air may leak out of the lung at the biopsy site and into the space between the lung and the chest wall. This can cause part of the lung to collapse and may cause trouble breathing. This complication, called a pneumothorax, often gets better without any treatment. If not, it is treated by putting a small tube into the chest space and sucking out the air over a day or two, after which it heals on its own.

An FNA biopsy may also be done to sample the lymph nodes around the trachea (windpipe) and bronchi (the larger tubes that carry air to the lungs). A thin needle is inserted through the wall of the trachea or bronchus using a bronchoscope (see below) to sample the nearby lymph nodes. This procedure, called a transtracheal FNA or transbronchial FNA, may be done using endobronchial ultrasound (see section describing this procedure) to guide the needle into place.

Bronchoscopy

For this exam, a lighted, flexible fiber-optic tube (bronchoscope) is passed through your mouth or nose and down into the windpipe and bronchi. The mouth and throat are sprayed first with a numbing medicine. You may also be given medicine through an intravenous (IV) line to make you feel relaxed.

Bronchoscopy can help the doctor find some tumors or blockages in the lungs. At the same time, small instruments can be passed down the bronchoscope to take biopsies (samples of tissue). The doctor can also sample cells from the lining of the airways with a small brush (bronchial brushing) or by rinsing the airways with sterile saltwater (bronchial washing). These tissue and cell samples are then looked at under a microscope.

Endobronchial ultrasound

Ultrasound is a type of imaging test that uses sound waves to create pictures of the inside of your body. For this test, a small, microphone-like instrument called a transducer emits sound waves and picks up the echoes as they bounce off body tissues. The echoes are converted by a computer into a black and white image on a computer screen.

For endobronchial ultrasound, a bronchoscope is fitted with an ultrasound transducer at its tip and is passed down into the windpipe. The transducer can be pointed in different directions to look at lymph nodes and other structures in the mediastinum (the area between the lungs). If suspicious areas (such as enlarged lymph nodes) are seen on the ultrasound, a hollow needle can be passed through the bronchoscope and guided into these areas to obtain a biopsy. The samples are then sent to a lab to be looked at under a microscope.

Endoscopic esophageal ultrasound

This technique is similar to endobronchial ultrasound, except the doctor passes an endoscope (a lighted, flexible scope) down the throat and into the esophagus (the tube connecting the throat to the stomach). This is done with numbing medicine (local anesthesia) and light sedation.

The esophagus lies just behind the windpipe and is close to some lymph nodes inside the chest to which lung cancer may spread. Ultrasound images taken from inside the esophagus can help find large lymph nodes inside the chest that might contain lung cancer. If enlarged lymph nodes are seen on the ultrasound, a hollow needle can be passed through the endoscope to get biopsy samples of them. The samples are then sent to a lab to be looked at under a microscope.

Mediastinoscopy and mediastinotomy

Both of these procedures allow the doctor to look more directly at and sample the structures in the mediastinum (the area between the lungs). They are done in an operating room while you are under general anesthesia (in a deep sleep). The main difference between the two is in the location and size of the incision.

Mediastinoscopy: A small cut is made in the front of the neck and a thin, hollow, lighted tube is inserted behind the sternum (breast bone) and in front of the windpipe to look at the area. Special instruments can be passed through this tube to take tissue samples from the lymph nodes along the windpipe and the major bronchial tube areas. Looking at the samples under a microscope can show whether cancer cells are present.

Mediastinotomy: The surgeon makes a slightly larger incision (usually about 2 inches long) between the left second and third ribs next to the breast bone. This allows the surgeon to reach lymph nodes that cannot be reached by mediastinoscopy.

Thoracentesis

Thoracentesis is done to find out if a build-up of fluid around the lungs (pleural effusion) is the result of cancer spreading to the lining of the lungs (pleura). The build-up might also be caused by other conditions, such as heart failure or an infection.

For this procedure, the skin is numbed and a hollow needle is inserted between the ribs to drain the fluid. (In a similar test called pericardiocentesis, fluid is removed from within the sac around the heart.) The fluid is checked under a microscope to look for cancer cells. Chemical tests of the fluid are also sometimes useful in telling a malignant (cancerous) pleural effusion from a benign (non-cancerous) one.

If a malignant pleural effusion has been diagnosed, thoracentesis may be repeated to remove more fluid. Fluid build-up can keep the lungs from filling with air, so thoracentesis can help the patient breathe better.

Thoracoscopy

Thoracoscopy can be done to find out if cancer has spread to the space between the lungs and the chest wall, as well as to the linings of these spaces. It can also be used to sample lymph nodes and fluid and assess whether a tumor is growing into nearby tissues or organs.

Most often this test is done in the operating room while you are under general anesthesia (in a deep sleep). A small cut (incision) is made in the chest wall. (Sometimes more than one cut is made.) The doctor then inserts a lighted tube with a small video camera on the end through the incision to view the space between the lungs and the chest wall. Using this, the doctor can see potential cancer deposits on the lining of the lung or chest wall and remove small pieces of tissue to be looked at under the microscope.

Lab tests of biopsy and other samples

Samples that have been collected during biopsies or other tests are sent to a pathology lab. There, a doctor looks at the samples under a microscope to find out if they contain cancer and if so, what type of cancer it is. Special tests may be needed to help better classify the cancer. Cancers from other organs can spread to the lungs. It’s very important to find out where the cancer started, because treatment is different for different types of cancer.

Immunohistochemistry

For this test, very thin slices of the sample are attached to glass microscope slides. The samples are then treated with special proteins (antibodies) designed to attach only to a specific substance found in certain cancer cells. If the patient’s cancer contains that substance, the antibody will attach to the cells. Chemicals are then added so that antibodies attached to the cells change color. The doctor who looks at the sample under a microscope can see this color change.

Molecular tests

In some cases, doctors may look for specific gene changes in the cancer cells that might affect how they are best treated. For example, the epidermal growth factor receptor (EGFR) is a protein that sometimes appears in high amounts on the surface of cancer cells and helps them grow. Some anti-cancer drugs target EGFR, but they only seem to work against certain cancers. Some doctors may test for changes in genes such as EGFR and K-RAS to determine if these treatments are likely to be helpful. Although these tests are available in specialized labs, they are not yet widely used for lung cancers.

Other tests

Blood tests

Blood tests are not used to diagnose lung cancer, but they are done to get a sense of a person’s overall health. For example, before surgery, blood tests can help tell if a person is healthy enough to have an operation.

A complete blood count (CBC) determines whether your blood has the correct number of various cell types. For example, it can show if you are anemic (have a low number of red blood cells), if you may have trouble with bleeding (due to a low number of blood platelets), or if you are at increased risk for infections (because of a low number of white blood cells).

This test will be repeated regularly if you are treated with chemotherapy, because these drugs can affect blood-forming cells of the bone marrow.

Blood chemistry tests can help spot abnormalities in some of your organs. If cancer has spread (metastasized) to the liver and bones, it may cause abnormal levels of certain chemicals in the blood. For example, spread to these areas may result in a higher than normal level of lactate dehydrogenase (LDH) in the blood.

Pulmonary function tests

Pulmonary function tests (PFTs) are often done after lung cancer is diagnosed to see how well your lungs are working (for example, how much emphysema or chronic obstructive lung disease is present). This is especially important if surgery might be an option in treating the cancer. Because surgery to remove part or all of a lung results in lower lung capacity, it’s important to know how well the lungs are working beforehand. These tests can give the surgeon an idea of whether surgery is a good option, and if so, how much lung can safely be removed.

There are different types of PFTs, but they all basically have you breathe in and out through a tube that is connected to different machines.

How is non-small cell lung cancer staged?

Staging is the process of finding out how far a cancer has spread. Your treatment and prognosis (outlook) depend, to a large extent, on the cancer’s stage. There are actually 2 types of staging.

• The clinical stage of the cancer is based on the results of the physical exam, biopsies, and imaging tests (CT scan, chest x-ray, PET scan, etc.), which are described in the section, “How is non-small cell lung cancer diagnosed?”

• If you have surgery, your doctor can also determine a pathologic stage, which is based on the same factors as the clinical stage, plus what is found as a result of the surgery.

The clinical and pathologic stages may be different in some cases. For example, during surgery the doctor may find cancer in an area that did not show up on imaging tests, which might give the cancer a more advanced pathologic stage.

Because most patients with lung cancer do not have surgery, the clinical stage is most often used when describing the extent of this cancer. However, when it is available, the pathologic stage is likely to be more accurate than the clinical stage, as it is based on your doctor’s firsthand impression of the extent of your disease.

The TNM staging system

The system used to describe the growth and spread of non-small cell lung cancer (NSCLC) is the American Joint Committee on Cancer (AJCC) TNM staging system. The TNM system describes 3 key pieces of information:

• T indicates the size of the main (primary) tumor and whether it has grown into nearby areas.

• N describes how much the cancer has spread to nearby (regional) lymph nodes. Lymph nodes are small bean-shaped collections of immune system cells that help fight infections. Cancers often spread to the lymph nodes before going to other parts of the body.

• M indicates whether the cancer has spread (metastasized) to other organs of the body. (The most common sites are the liver, bones, and brain.)

Numbers or letters appear after T, N, and M to provide more details about each of these factors. The numbers 0 through 4 indicate increasing severity. The letter X means “cannot be assessed because the information is not available.”

T categories for lung cancer

TX: The main (primary) tumor can’t be assessed, or cancer cells were seen on sputum cytology but no tumor can be found.

T0: There is no evidence of a primary tumor.

Tis: The cancer is found only in the top layers of cells lining the air passages. It has not invaded into deeper lung tissues. This stage is also known as carcinoma in situ.

T1: The tumor is no larger than 3 centimeters (slightly less than 1 1/4 inches) across, has not reached the membranes that surround the lungs (visceral pleura), and does not affect the main branches of the bronchi.

T2: The tumor has 1 or more of the following features:

• It is larger than 3 centimeters (cm) across.

• It involves a main bronchus, but is not closer than 2 cm (about 3/4 inch) to the carina (the point where the windpipe splits into the left and right main bronchi).

• It has grown into the membranes that surround the lungs (visceral pleura).

• The tumor partially clogs the airways, but this has not caused the entire lung to collapse or develop pneumonia.

T3: The tumor can be any size and has 1 or more of the following features:

• It has grown into the chest wall, the breathing muscle that separates the chest from the abdomen (diaphragm), the membranes surrounding the space between the two lungs (mediastinal pleura), or membranes of the sac surrounding the heart (parietal pericardium).

• It invades a main bronchus and is closer than 2 cm (about 3/4 inch) to the carina, but it does not involve the carina itself.

• It has grown into the airways enough to cause an entire lung to collapse or to cause pneumonia in the entire lung.

T4: The cancer has 1 or more of the following features:

• A tumor of any size has grown into the space behind the chest bone and in front of the heart (mediastinum), the heart, the large blood vessels near the heart (such as the aorta), the windpipe, the esophagus (tube connecting the throat to the stomach), the backbone, or the carina.

• Two or more separate tumor nodules are present in the same lobe of a lung.

• There is a fluid containing cancer cells in the space surrounding the lung (a malignant pleural effusion).

N categories for lung cancer

NX: Nearby lymph nodes cannot be assessed.

N0: There is no spread to nearby lymph nodes.

N1: The cancer has spread to lymph nodes within the lung and/or around the area where the bronchus enters the lung (hilar lymph nodes). Affected lymph nodes are on the same side as the primary tumor(s).

N2: The cancer has spread to lymph nodes around the carina (the point where the windpipe splits into the left and right bronchi) or in the space behind the breastbone and in front of the heart (mediastinum). Affected lymph nodes are on the same side as the primary tumor.

N3: The cancer has spread to lymph nodes near the collarbone on either side, and/or spread to hilar or mediastinal lymph nodes on the side opposite the primary tumor.

M categories for lung cancer

MX: Spread to distant areas cannot be assessed.

M0: No spread to distant organs or areas. This includes other lobes of the lungs, lymph nodes further away than those mentioned in the N stages above, and other organs or tissues such as the liver, bones, or brain.

M1: The cancer has spread to 1 or more distant sites. This can be to another lobe of the lung, to distant lymph nodes, or to other organs.

Stage grouping for non-small cell lung cancer

Once the T, N, and M categories have been assigned, this information is combined (stage grouping) to assign an overall stage of 0, I, II, III, or IV. Some stages are subdivided into A and B. The stages identify tumors that have a similar prognosis and thus are treated in a similar way. Patients with lower stage numbers tend to have a better prognosis.

Occult cancer

TX, N0, M0: Cancer cells are seen in a sample of sputum or other lung fluids, but the location of the cancer can’t be determined.

Stage 0

Tis, N0, M0: The cancer is found only in the top layers of cells lining the air passages. It has not invaded deeper into other lung tissues and has not spread to lymph nodes or distant sites.

Stage IA

T1, N0, M0: The cancer is no larger than 3 centimeters (cm) across, has not reached the membranes that surround the lungs, and does not affect the main branches of the bronchi. It has not spread to lymph nodes or distant sites.

Stage IB

T2, N0, M0: The cancer has 1 or more of the following features:

• The main tumor is larger than 3 cm across.
• The tumor involves a main bronchus, but is not within 2 cm of the carina.
• The tumor has grown into the visceral pleura (the membranes surrounding the lungs).
• The cancer is partially clogging the airways.  The cancer has not spread to lymph nodes or distant sites.

Stage IIA

T1, N1, M0: The cancer is no larger than 3 centimeters, has not grown into the membranes that surround the lungs, and does not affect the main branches of the bronchi. It has spread to lymph nodes within the lung and/or around the area where the bronchus enters the lung (hilar lymph nodes). It has not spread to distant sites.

Stage IIB

There are 2 combinations of categories that make up this stage.

T2, N1, M0: The cancer has 1 or more of the following features:

• The main tumor is larger than 3 cm across.
• The tumor involves a main bronchus, but is not within 2 cm of the carina.
• The tumor has grown into the visceral pleura (the membranes surrounding the lungs).
• The cancer is partially clogging the airways.

It has also spread to lymph nodes within the lung and/or around the area where the bronchusenters the lung (hilar lymph nodes). It has not spread to distant sites.

T3, N0, M0: The main tumor can be any size and has 1 or more of the following features:

• It has grown into the chest wall, the breathing muscle that separates the chest from the abdomen (diaphragm), the membranes surrounding the space between the lungs (mediastinal pleura), or membranes of the sac surrounding the heart (parietal pericardium).

• It invades a main bronchus and is closer than 2 cm (about 3/4 inch) to the carina, but it does not involve the carina itself.

• It has grown into the airways enough to cause an entire lung to collapse or to cause pneumonia in the entire lung.

The cancer has not spread to lymph nodes or distant sites.

Stage IIIA

There are 4 main combinations of categories that make up this stage.

T1, N2, M0: The cancer is no larger than 3 centimeters, has not grown into the membranes that surround the lungs, and does not affect the main branches of the bronchi. The cancer has spread to lymph nodes around the carina (the point where the windpipe splits into the left and right bronchi) or in the space behind the breastbone and in front of the heart (mediastinum). Affected lymph nodes are on the same side as the primary tumor. The cancer has not spread to distant sites.

T2, N2, M0: The cancer has 1 or more of the following features:

• The main tumor is larger than 3 cm across.
• The tumor involves a main bronchus, but is not within 2 cm of the carina.
• The tumor has grown into the visceral pleura (the membranes surrounding the lungs).
• The cancer is partially clogging the airways.

The cancer has also spread to lymph nodes around the carina (the point where the windpipe splits into the left and right bronchi) or in the space behind the breastbone and in front of the heart (mediastinum). Affected lymph nodes are on the same side as the primary tumor. The cancer has not spread to distant sites.

T3, N1, M0: The tumor can be any size and has 1 or more of the following features:

• It has grown into the chest wall, the breathing muscle that separates the chest from the abdomen (diaphragm), the membranes surrounding the space between the two lungs (mediastinal pleura), or membranes of the sac surrounding the heart (parietal pericardium).

• It invades a main bronchus and is closer than 2 cm to the carina, but it does not involve the carina itself.

• It has grown into the airways enough to cause an entire lung to collapse or to cause pneumonia in the entire lung.

It has also spread to lymph nodes within the lung and/or around the area where the bronchus enters the lung (hilar lymph nodes). It has not spread to distant sites.

T3, N2, M0: The tumor can be any size and has 1 or more of the following features:

• It has grown into the chest wall, the breathing muscle that separates the chest from the abdomen (diaphragm), the membranes surrounding the space between the two lungs (mediastinal pleura), or membranes of the sac surrounding the heart (parietal pericardium).

• It invades a main bronchus and is closer than 2 cm to the carina, but it does not involve the carina itself.

• It has grown into the airways enough to cause an entire lung to collapse or to cause pneumonia in the entire lung.

The cancer has also spread to lymph nodes around the carina (the point where the windpipe splits into the left and right bronchi) or in the space behind the breastbone and in front of the heart (mediastinum). Affected lymph nodes are on the same side as the primary tumor. The cancer has not spread to distant sites.

Stage IIIB

There are 2 combinations of categories that make up this stage.

Any T, N3, M0: The cancer can be of any size. It may or may not have grown into nearby structures or caused pneumonia or lung collapse. It has spread to lymph nodes near the collarbone on either side, and/or has spread to hilar or mediastinal lymph nodes on the side opposite the primary tumor. The cancer has not spread to distant sites.

T4, any N, M0: The cancer has 1 or more of the following features:

• A tumor of any size has grown into the space behind the chest bone and in front of the heart (mediastinum), the heart, the large blood vessels near the heart (such as the aorta), the windpipe, the esophagus (tube connecting the throat to the stomach), the backbone, or the carina.

• Two or more separate tumor nodules are present in the same lobe of a lung.

• There is a fluid containing cancer cells in the space surrounding the lung (a malignant pleural effusion).

The cancer may or may not have spread to nearby lymph nodes. It has not spread to distant sites.

Stage IV

Any T, any N, M1: The cancer can be any size and may or may not have grown into nearby structures or reached nearby lymph nodes. It has spread to distant sites, such as another organ or another lobe of either lung.

Non-small cell lung cancer survival rates by stage

Survival rates are a way for doctors and patients to get a general idea of the outlook for people with a certain type and stage of cancer. Some people want to know the statistics for people in their situation, while others may not find them helpful, or may even not want to know them. Whether or not you want to read about the survival statistics below for non-small cell lung cancer is up to you.

The numbers below are relative survival rates calculated from the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) database, based on people who were diagnosed with non-small cell lung cancer between 1988 and 2001. There are some important points to note about these numbers:

• The 5-year survival rate refers to the percentage of patients who live at least 5 years after being diagnosed. Many of these patients live much longer than 5 years after diagnosis. Five-year relative survival rates (such as the numbers below) adjust for patients who die from causes other than their cancer. They are considered to be a more accurate way to describe the outlook for patients with a particular type and stage of cancer.

• These numbers were derived from patients treated at least several years ago. They are among the most current numbers we have available, but improvements in treatment since then mean that the survival rates for people now being diagnosed with these cancers may be higher.

• Survival statistics can sometimes be useful as a general guide, but they may not accurately represent any one person’s prognosis. A number of other factors, including other tumor characteristics and a person’s age, gender, and general health, can also affect outlook. Your doctor is likely to be a good source as to whether these numbers may apply to you, as he or she is familiar with the aspects of your particular situation.

Stage	5-year Relative Survival Rate
I	56%
II	34%
III	10%
IV	2%

These survival rates aren’t broken down by substages, but the rates would likely be slightly higher than those above for the A subgroups and slightly lower for the B subgroups.

How is non-small cell lung cancer treated?

This information represents the views of the doctors and nurses serving on the American Cancer Society’s Cancer Information Database Editorial Board. These views are based on their interpretation of studies published in medical journals, as well as their own professional experience.

The treatment information in this document is not official policy of the Society and is not intended as medical advice to replace the expertise and judgment of your cancer care team. It is intended to help you and your family make informed decisions, together with your doctor.

Your doctor may have reasons for suggesting a treatment plan different from these general treatment options. Don’t hesitate to ask him or her questions about your treatment options.

The first part of this section describes the various types of treatments used for non-small cell lung cancer. This is followed by a description of the most common approaches used for these cancers based on the stage of the cancer.

Making treatment decisions

Depending on the stage of the disease and other factors, the main treatment options for people with non-small cell lung cancer (NSCLC) include:

• surgery
• radiation therapy
• other local treatments
• chemotherapy
• targeted therapy

In many cases, more than one of these treatments may be used.

After the cancer is found and staged, your cancer care team will discuss your treatment options with you. It is important to take time and think about your options. In choosing a treatment plan, one of the most important factors is the stage of the cancer. For this reason, it is very important that your doctor order all the tests needed to determine the cancer’s stage. Other factors to consider include your overall health, the likely side effects of the treatment, and the probability of curing the disease, extending life, or relieving symptoms. Age alone should not be a barrier to treatment. Older people can benefit from treatment as much as younger people, as long as their general health is good.

In considering your treatment options it is often a good idea to get a second opinion, if possible. This may provide you with more information and help you feel more confident about the treatment plan you have chosen. Your doctor should not mind that you want to get a second opinion. In fact, some insurance companies require you to get a second opinion. If your first doctor has done tests, the results can be sent to the second doctor so that you will not have to have them done again.

Surgery

Depending on the type and stage of a lung cancer, surgery may be used to remove the cancer along with some surrounding lung tissue. Surgery is usually recommended (often along with other treatments) for early stage lung cancers. If surgery can be done, it provides the best chance to cure NSCLC. Lung cancer surgery is a complex operation that can have serious consequences, so it should be done by a surgeon who has a lot of experience operating on lung cancers.

If your doctor thinks the lung cancer can be treated with surgery, pulmonary function tests will be done beforehand to determine if you will have enough healthy lung tissue left after surgery.

Types of lung surgery

Several different operations can be used to treat (and possibly cure) non-small cell lung cancer. These operations require general anesthesia (where you are in a deep sleep) and a surgical incision between the ribs in the chest (thoracotomy).

• pneumonectomy: an entire lung is removed in this surgery.
• lobectomy: a section (lobe) of the lung is removed in this surgery.
• segmentectomy or wedge resection: part of a lobe is removed in this surgery.

Another type of operation, known as a sleeve resection, may be used to treat some cancers in large airways in the lungs. If you think of the large airway with a tumor as similar to the sleeve of a shirt with a stain an inch or 2 above the wrist, the sleeve resection would be like cutting across the sleeve above and below the stain and sewing the cuff back onto the shortened sleeve. A surgeon may be able to do this operation instead of a pneumonectomy to preserve more lung function.

With any of these operations, nearby lymph nodes are also removed to look for possible spread of the cancer.

The type of operation your doctor recommends depends on the size and location of the tumor and on how well your lungs are functioning. In some cases, doctors may prefer to do a more extensive operation (for example, a lobectomy instead of a segmentectomy) if a person’s lungs are healthy enough, as it may provide a better chance to cure the cancer.

Generally, you will need to spend 5 to 7 days in the hospital after the surgery.

Video-assisted thoracic surgery: Recently, some doctors have begun treating some early stage lung cancers near the outside of the lung with a less invasive procedure called video-assisted thoracic surgery (VATS).

During this operation, a thin rigid tube with a tiny video camera on the end is placed through a small hole in the chest to help the surgeon see the chest cavity on a TV monitor. One or two other small holes are created in the skin, and long instruments passed through these holes are used to perform the same operation that would be done using an open approach (thoracotomy). One of the incisions is enlarged if a lobectomy or pneumonectomy is done to allow the specimen to be removed. Because only small incisions are needed, there is a little less pain after the surgery and a shorter hospital stay — usually 4 to 5 days.

Most experts recommend that only early stage tumors smaller than 3 to 4 centimeters (about 1 1/2 inches) near the outside of the lung be treated this way. The cure rate after this surgery seems to be the same as with older techniques. But it is important that the surgeon doing this procedure is experienced since it requires a great deal of technical skill.

Possible side effects of lung surgery

Possible complications depend on the extent of the surgery and a person’s health beforehand. Serious complications can include excessive bleeding, wound infections, and pneumonia. While it is rare, in some cases people may not survive the surgery, which is why it is important that surgeons select patients carefully.

Because the surgeon must spread ribs to get to the lung when doing a thoracotomy, the incision will hurt for some time after surgery. Your activity will be limited for at least a month or two.

If your lungs are in good condition (other than the presence of the cancer) you can usually return to normal activities after a lobe or even an entire lung has been removed. If you also have non-cancerous lung diseases such as emphysema or chronic bronchitis (which are common among heavy smokers), you may become short of breath with activities after surgery.

Surgery for lung cancers with limited spread to other organs

If the lung cancer has spread to the brain or adrenal gland and there is only one tumor, you may benefit from having the metastasis removed. This surgery should be considered only if the tumor in the lung can also be completely removed. Even then, not all lung cancer experts agree with this approach, especially if the tumor is in the adrenal gland.

For tumors in the brain, this is done by surgery through a hole in the skull (craniotomy). It should only be done if the tumor can be removed without damaging vital areas of the brain that control movement, sensation, and speech.

Surgery to relieve symptoms of NSCLC

If you can’t have major surgery because of reduced lung function or other serious medical problems, or if the cancer is widespread, other types of surgery may be used to relieve some symptoms. For example, laser surgery can be used to relieve blockage of airways that may be causing pneumonia or shortness of breath. Other techniques, such as photodynamic therapy may also be used. In some cases, a stent (rubber or metal tube) may be placed in the airway after treatment to help keep it open. These procedures are described in the section “Other local treatments.”

Sometimes fluid can build up in the chest cavity (outside of the lungs) and cause trouble breathing. To remove the fluid and keep it from coming back, doctors sometimes perform a procedure called pleurodesis. A small cut is made in the skin of the chest wall, and a hollow tube is placed into the chest to remove the fluid. Either talc or a drug such as doxycycline or a chemotherapy drug is then instilled into the chest cavity. This causes the linings of the lung (visceral pleura) and chest wall (parietal pleura) to stick together, sealing the space and limiting further fluid buildup. The tube is generally left in for a day or two to drain any new fluid that might accumulate.

For more general information about surgery, please see the separate document, Surgery.

Radiation therapy

Radiation therapy uses high-energy rays (such as x-rays) or particles to kill cancer cells. There are 2 main types of radiation therapy — external beam radiation therapy and brachytherapy (internal radiation therapy).

External beam radiation therapy

External beam radiation therapy (EBRT) focuses radiation delivered from outside the body on the cancer. This is the type of radiation therapy most often used to treat a primary lung cancer or its metastases to other organs.

Before your treatments start, the radiation team will take careful measurements to determine the correct angles for aiming the radiation beams and the proper dose of radiation. Radiation therapy is much like getting an x-ray, but the radiation is stronger. The procedure itself is painless. Each treatment lasts only a few minutes, although the setup time — getting you into place for treatment — usually takes longer. Most often, radiation treatments are given 5 days a week for 5 to 8 weeks.

Standard (conventional) EBRT is used much less often than in the past. Newer techniques allow doctors to be more accurate in treating lung cancers while reducing the radiation exposure to nearby healthy tissues. These techniques may offer better chances of increasing the success rate and reducing side effects.

Three-dimensional conformal radiation therapy (3D-CRT): 3D-CRT uses special computers to precisely map the location of the tumor(s). Radiation beams are shaped and aimed at the tumor(s) from several directions, which makes it less likely to damage normal tissues. Most doctors now recommend using 3D-CRT when it is available.

Intensity modulated radiation therapy (IMRT): IMRT is an advanced form of 3D therapy. It uses a computer-driven machine that moves around the patient as it delivers radiation. Along with shaping the beams and aiming them at the tumor from several angles, the intensity (strength) of the beams can be adjusted to minimize the dose reaching the most sensitive normal tissues. This technique is used most often if tumors are near important structures such as the spinal cord. Many major hospitals and cancer centers are now able to provide IMRT.

Stereotactic radiation therapy: A newer form of treatment, known as stereotactic body radiation therapy (SBRT), is sometimes used to treat very early stage lung cancers. It is described in more detail in the section, “What’s new in non-small cell lung cancer research and treatment?”

Another type of stereotactic radiation therapy can sometimes be used instead of surgery for single tumors that have spread to the brain. Using a machine called a Gamma Knife®, many beams of high-dose radiation are focused on the tumor from different angles over a few minutes to hours. The head is kept in the same position by placing it in a rigid frame.

Brachytherapy (internal radiation therapy)

Brachytherapy is used most often to shrink tumors to relieve symptoms caused by the cancer, although in some cases it may be part of a larger treatment regimen trying to cure the cancer. For this type of treatment, the doctor places a small source of radioactive material (often in the form of pellets) directly into the cancer or into the airway next to the cancer. This is usually done through a bronchoscope, although it may also be done during surgery. The radiation travels only a short distance from the source, limiting the effects on surrounding healthy tissues. The radiation source is usually removed after a short time. Less often, small radioactive “seeds” are left in place permanently, and the radiation gets weaker over several weeks.

When is radiation therapy used?

External beam radiation therapy is sometimes used as the main treatment of lung cancer (sometimes together with chemotherapy), especially if the lung tumor cannot be removed by surgery because of its size or location, or because the person’s health is too poor for surgery. Brachytherapy is most often used to help relieve blockage of large airways by cancer.

After surgery, radiation therapy can be used (alone or along with chemotherapy) to try to kill very small deposits of cancer that surgery may have missed.

Radiation therapy can also be used to relieve (palliate) symptoms of advanced lung cancer such as pain, bleeding, trouble swallowing, cough, and problems caused by brain metastases.

Possible side effects

Side effects of external radiation therapy might include sunburn-like skin problems where the radiation enters the body, nausea, vomiting, and fatigue. Often these go away after treatment. Radiation might also make the side effects of chemotherapy worse.

Chest radiation therapy may damage your lungs and cause problems breathing and shortness of breath. Your esophagus, which is in the middle of your chest, may be exposed to radiation, which could cause trouble swallowing during treatment. This usually improves after treatment is over.

Radiation therapy to large areas of the brain can sometimes cause changes in brain function. Some people notice memory loss, headache, trouble thinking, or reduced sexual desire. Usually these symptoms are minor compared with those caused by a brain tumor, but they can reduce your quality of life. Side effects of radiation therapy to the brain usually become most serious 1or 2 years after treatment.

For more information about radiation therapy, please see the document, Understanding Radiation Therapy: A Guide for Patients and Families.

Other local treatments

At times, treatments other than surgery or radiation therapy may be used to treat lung tumors at a specific location.

Radiofrequency ablation (RFA)

This technique is being studied for small lung tumors that are near the outer edge of the lungs, especially in people who can’t have or don’t want surgery. It uses high-energy radio waves to heat the tumor. A thin, needle-like probe is placed through the skin and moved along until the end is in the tumor. Placement of the probe is guided by CT scans. Once it is in place, an electric current is passed through the probe, which heats the tumor and destroys the cancer cells. RFA is usually done as an outpatient procedure, using local anesthesia (numbing medicine) where the probe is inserted. You may be given medicine to help you relax as well.

Major complications are uncommon, but they can include the partial collapse of a lung (which often resolves on its own) or bleeding into the lung.

Photodynamic therapy

Photodynamic therapy is sometimes used to treat smaller lung cancers near airways when other treatments aren’t appropriate, or to help open up airways blocked by tumors to help people breathe better.

For this technique, a light-activated drug called porfimer sodium (Photofrin) is injected into a vein. Over the next couple of days, the drug is more likely to collect in cancer cells than in normal cells. A bronchoscope is then passed down the throat and into the lung. This may be done with either local anesthesia (where the throat is numbed) or general anesthesia (where you are in a deep sleep). A special red light on the end of the bronchoscope is aimed at the tumor, which activates the drug and causes the cells to die. The dead cells are then removed a few days later during a bronchoscopy. This process can be repeated if needed.

Some of this drug also collects in normal cells in the body, such as skin and eye cells. This can make you very sensitive to sunlight or strong indoor lights. Too much exposure can cause serious skin reactions, which is why doctors recommend staying out of any strong light for 4 to 6 weeks after the injection.

For more information, please see the document, Photodynamic Therapy.

Laser therapy

Lasers can sometimes be used to treat very small lung cancers in the linings of airways. They can also be used to help open up airways blocked by larger tumors to help people breathe better.

You are usually asleep (under general anesthesia) for this type of treatment. The laser is on the end of a bronchoscope, which is passed down the throat and next to the tumor. The doctor then aims the laser beam at the tumor to burn it away. This treatment can usually be repeated, if needed.

Stent placement

Lung tumors that have grown into an airway can sometimes cause trouble breathing or other problems. To help keep the airway open (often after other treatments such as photodynamic therapy or laser therapy), a stent may be placed in the airway. Stents are hard rubber or metal tubes that can be put in place in the airway with a bronchoscope.

Chemotherapy

Chemotherapy is treatment with anti-cancer drugs injected into a vein or taken by mouth. These drugs enter the bloodstream and go throughout the body, making this treatment useful for cancer that has spread (metastasized) to distant organs. Depending on the stage of lung cancer, chemotherapy may be used in different situations:

• Chemotherapy (sometimes along with radiation therapy) may be used to try to shrink a tumor before surgery. This is known as neoadjuvant therapy.

• Chemotherapy (sometimes along with radiation therapy) may be given after surgery to try to kill any cancer cells that may have been left behind. This is known as adjuvant therapy.

• Chemotherapy may be given as the main treatment (sometimes along with radiation therapy) for more advanced cancers or for some people who aren’t healthy enough for surgery.

Doctors give chemotherapy in cycles, with each period of treatment followed by a rest period to allow the body time to recover. Chemotherapy cycles generally last about 3 to 4 weeks, and treatment typically involves 4 to 6 cycles. Chemotherapy is often not recommended for patients in poor health, but advanced age by itself is not a barrier to getting chemotherapy.

Most often, treatment for lung cancer uses a combination of 2 chemotherapy drugs. Studies have shown that adding a third chemotherapy drug doesn’t add much benefit and is likely to cause more side effects. Single-drug chemotherapy is sometimes used for people who might not tolerate combination chemotherapy well, such as those in poor overall health.

The drugs most frequently used for chemotherapy for non-small cell lung cancer are:

• cisplatin
• carboplatin
• paclitaxel
• docetaxel
• gemcitabine
• vinorelbine
• irinotecan
• etoposide
• vinblastine
• pemetrexed

The most common combinations include either cisplatin or carboplatin plus one other drug, although some studies have found that using combinations with less severe side effects, such as gemcitabine with vinorelbine or paclitaxel, may be just as effective for many patients.

For people with advanced cancers who meet certain criteria, targeted therapy drugs such as bevacizumab (Avastin) or cetuximab (Erbitux) may be added to initial treatment as well (see the “Targeted therapies” section).

If the initial chemotherapy treatment for advanced cancer is no longer working, second-line treatment usually consists of a single drug such as docetaxel or pemetrexed. Another option may be the targeted therapy erlotinib (Tarceva) (see the “Targeted therapies” section).

Again, advanced age is no barrier to receiving these drugs as long as the person is in good general health.

Possible side effects

Chemotherapy drugs work by attacking cells that are dividing quickly, which is why they work against cancer cells. But other cells in the body, such as those in the bone marrow, the lining of the mouth and intestines, and the hair follicles, also divide quickly. These cells are also likely to be affected by chemotherapy, which can lead to side effects.

The side effects of chemotherapy depend on the type and dose of drugs given and the length of time they are taken. These side effects can include:

• hair loss
• mouth sores
• loss of appetite
• nausea and vomiting
• increased chance of infections (due to low white blood cell counts)
• easy bruising or bleeding (due to low blood platelet counts)
• fatigue (due to low red blood cell counts)

These side effects are usually short-term and go away after treatment is finished. There are often ways to lessen these side effects. For example, there are drugs that can be given to help prevent or reduce nausea and vomiting.

Some drugs such as cisplatin, vinorelbine, docetaxel, or paclitaxel can damage nerves. This can sometimes lead to symptoms (mainly in the hands and feet) such as pain, burning or tingling sensations, sensitivity to cold or heat, or weakness. This is called peripheral neuropathy. In most cases this goes away once treatment is stopped, but it may be long lasting in some people.

You should report this or any other side effects you notice while getting chemotherapy to your medical team so that they can be treated promptly. In some cases, the doses of the chemotherapy drugs may need to be reduced or treatment may need to be delayed or stopped to prevent the effects from getting worse.

For more general information about chemotherapy, please see the separate document, Understanding Chemotherapy: A Guide for Patients and Families.

Targeted therapies

As researchers have learned more about the gene changes in cells that cause cancer, they have been able to develop newer drugs that specifically target these changes. These targeted drugs work differently from standard chemotherapy drugs. They often have different (and less severe) side effects. At this time, they are most often used either along with chemotherapy or in cases where chemotherapy is no longer working.

Drugs that target tumor blood vessel growth (angiogenesis)

For tumors to grow, they must form new blood vessels to keep them nourished. This process is called angiogenesis. Some targeted drugs block this new vessel growth.

Bevacizumab (Avastin): Bevacizumab is a type of drug known as a monoclonal antibody (a man-made version of a specific immune system protein). It targets vascular endothelial growth factor (VEGF), a protein that helps new blood vessels to form. This drug has been shown to prolong survival of patients with advanced lung cancer when it is added to standard chemotherapy regimens as part of first-line treatment.

Bevacizumab is given by infusion into a vein every 2 to 3 weeks.

The possible side effects of this drug are different from those of chemotherapy drugs. Some of these effects can be serious. It can cause bleeding, which limits its use to some extent. It is not used in patients who are coughing up blood, who have cancer that has spread to the brain, or who are on “blood thinners” such as aspirin or warfarin (Coumadin). Most current guidelines do not recommend using bevacizumab in patients with the squamous cell type of lung cancer, because it may lead to serious bleeding. However, studies are under way to see if bevacizumab is safe as long as the squamous cell cancer is not located near large blood vessels in the center of the chest cavity.

Other rare but possibly serious side effects include blood clots, holes forming in the intestines, heart problems, and slow wound healing. More common side effects include high blood pressure, tiredness, low white blood cell counts, headaches, mouth sores, loss of appetite, and diarrhea.

Drugs that target EGFR

Epidermal growth factor receptor (EGFR) is a protein found on the surface of cells. It normally helps the cells to grow and divide. Some lung cancer cells have too much EGFR, which causes them to grow faster.

Erlotinib (Tarceva): Erlotinib is a drug that blocks EGFR from signaling the cell to grow. It has been shown to help keep some lung tumors under control, especially in women and in people who never smoked. It is most often used for advanced lung cancers if initial treatment with chemotherapy is no longer working.

This drug is taken daily as a pill. The most common side effects of erlotinib include an acne-like rash on the face and chest, diarrhea, loss of appetite, and feeling tired.

Cetuximab (Erbitux): Cetuximab is a monoclonal antibody that targets EGFR. For patients with advanced lung cancer, some doctors may add it to standard chemotherapy as part of first-line treatment.

Cetuximab is not FDA approved for use against lung cancer at this time, although it is approved for use against other cancers, and doctors can prescribe it for use in lung cancer. This drug is expensive, and not all insurance companies may cover the cost. If you are considering taking this drug, it is important to find out beforehand if your insurance will cover it.

Cetuximab is given by IV infusion, usually once a week. A rare but serious side effect of cetuximab is an allergic reaction during the first infusion, which could cause problems with breathing and low blood pressure. You may be given medicine before treatment to help prevent this. Many people develop skin problems such as an acne-like rash on the face and chest during treatment, which in some cases can lead to infections. Other side effects may include headache, tiredness, fever, and diarrhea.

Clinical trials

You may have had to make a lot of decisions since you’ve been told you have cancer. One of the most important decisions you will make is choosing which treatment is best for you. You may have heard about clinical trials being done for your type of cancer. Or maybe someone on your health care team has mentioned a clinical trial to you.

Clinical trials are carefully controlled research studies that are done with patients who volunteer for them. They are done to get a closer look at promising new treatments or procedures.

If you would like to take part in a clinical trial, you should start by asking your doctor if your clinic or hospital conducts clinical trials. You can also call our clinical trials matching service for a list of clinical trials that meet your medical needs. You can reach this service at 1-800-303-5691 or on our Web site at http://clinicaltrials.cancer.org. You can also get a list of current clinical trials by calling the National Cancer Institute’s Cancer Information Service toll-free at 1-800-4-CANCER (1-800-422-6237) or by visiting the NCI clinical trials Web site at www.cancer.gov/clinicaltrials.

There are requirements you must meet to take part in any clinical trial. If you do qualify for a clinical trial, it is up to you whether or not to enter (enroll in) it.

Clinical trials are one way to get state-of-the art cancer treatment. They are the only way for doctors to learn better methods to treat cancer. Still, they are not right for everyone.

You can get a lot more information on clinical trials in our document called Clinical Trials: What You Need to Know. You can read it on our Web site or call our toll-free number and have it sent to you.

Complementary and alternative therapies

When you have cancer you are likely to hear about ways to treat your cancer or relieve symptoms that your doctor hasn’t mentioned. Everyone from friends and family to Internet groups and Web sites offer ideas for what might help you. These methods can include vitamins, herbs, and special diets, or other methods such as acupuncture or massage, to name a few.

What exactly are complementary and alternative therapies?

Not everyone uses these terms the same way, and they are used to refer to many different methods, so it can be confusing. We use complementary to refer to treatments that are used along with your regular medical care. Alternative treatments are used instead of a doctor’s medical treatment.

Complementary methods: Most complementary treatment methods are not offered as cures for cancer. Mainly, they are used to help you feel better. Some methods that are used along with regular treatment are meditation to reduce stress, acupuncture to help relieve pain, or peppermint tea to relieve nausea. Some complementary methods are known to help, while others have not been tested. Some have been proven not be helpful, and a few have even been found harmful.

Alternative treatments: Alternative treatments may be offered as cancer cures. These treatments have not been proven safe and effective in clinical trials. Some of these methods may pose danger, or have life-threatening side effects. But the biggest danger in most cases is that you may lose the chance to be helped by standard medical treatment. Delays or interruptions in your medical treatments may give the cancer more time to grow and make it less likely that treatment will help.

Finding out more

It is easy to see why people with cancer think about alternative methods. You want to do all you can to fight the cancer, and the idea of a treatment with no side effects sounds great. Sometimes medical treatments like chemotherapy can be hard to take, or they may no longer be working. But the truth is that most of these alternative methods have not been tested and proven to work in treating cancer.

As you consider your options, here are 3 important steps you can take:

• Look for “red flags” that suggest fraud. Does the method promise to cure all or mostcancers? Are you told not to have regular medical treatments? Is the treatment a”secret” that requires you to visit certain providers or travel to another country?

• Talk to your doctor or nurse about any method you are thinking about using.

• Contact us at 1-800-ACS-2345 to learn more about complementary and alternative methods in general and to find out about the specific methods you are looking at.

The choice is yours

Decisions about how to treat or manage your cancer are always yours to make. If you want to use a non-standard treatment, learn all you can about the method and talk to your doctor about it. With good information and the support of your health care team, you may be able to safely use the methods that can help you while avoiding those that could be harmful.

Treatment choices by stage for non-small cell lung cancer

The treatment options for non-small cell lung cancer (NSCLC) are based mainly on the stage (extent) of the cancer, but other factors, such as a person’s overall health and lung function, are also important.

If you smoke, one of the most important things you can do to be ready for treatment is to quit. Studies have shown that patients who stop smoking after a diagnosis of lung cancer tend to have better outcomes than those who don’t.

Occult cancer

For these cancers, malignant cells are seen on sputum cytology but no obvious tumor can be found with bronchoscopy or imaging tests. They are usually early stage cancers. Bronchoscopy is usually repeated about every 3 months to look for a tumor. If a tumor is found, treatment will depend on the stage.

Stage 0

Because stage 0 NSCLC is limited to the lining layer of airways and has not invaded deeper into the lung tissue or other areas, it is usually curable by surgery alone. No chemotherapy or radiation therapy is needed.

If you are healthy enough for surgery, you can usually be treated by segmentectomy or wedge resection (removal of defined segments or small wedges of the lung). Cancers in some locations, such as where the windpipe divides into the left and right main bronchi, may be hard to remove completely by surgery without removing a lobe or even an entire lung.

In some cases, photodynamic therapy, laser therapy, or brachytherapy may be useful alternatives to surgery for stage 0 cancers. If you are truly stage 0, these treatments will probably cure you.

Stage I

If you have stage I NSCLC, surgery may be the only treatment you need. The tumor may be removed either by taking out one lung lobe (lobectomy) or by taking out a smaller piece of a lung (sleeve resection, segmentectomy, or wedge resection). At least some lymph nodes within the lung and outside the lung in the mediastinum will be removed to check them for cancer cells.

Segmentectomy or wedge resection is recommended only for treating the smallest stage I cancers and for patients with other medical conditions that make removing the entire lobe dangerous. This stage is most suited for video-assisted thoracic surgery (VATS). Most surgeons believe it is better to perform a lobectomy if the patient can tolerate it, as it offers the best chance for cure.

For some people with stage I NSCLC, adjuvant chemotherapy after surgery may lower the risk that cancer will return. But doctors aren’t sure how best to determine in which people the benefits outweigh the downsides, so most don’t recommend chemotherapy if it looks like all of the cancer was removed with surgery. New lab tests that look at the patterns of certain genes in the cancer cells appear promising and may help with this. Studies are now under way to see if these tests are accurate.

After surgery, chemotherapy and/or radiation therapy may also be recommended if the pathology report shows that there were cancer cells at the edge of the surgery specimen. This means that some cancer may have been left behind. Another approach would be to have a second surgery to try to ensure that all the cancer has been removed. (This might be followed by chemotherapy as well.)

If you have serious medical problems that would prevent you from having surgery, you may receive only radiation therapy as your main treatment.

Stage II

People who have stage II NSCLC and are healthy enough for surgery usually have the cancer removed by lobectomy, sleeve resection, or, less often, segmentectomy. Sometimes removing the whole lung (pneumonectomy) is needed.

Any lymph nodes likely to have cancer in them are also removed. The extent of lymph node involvement and whether or not cancer cells are found at the edges of the removed tissues are important factors when planning the next step of treatment.

After surgery, chemotherapy (with or without radiation therapy) is typically recommended to try to destroy any cancer cells left behind. As with stage I cancers, newer lab tests now being studied may allow doctors to tell which patients need this adjuvant treatment and which are less likely to benefit from it.

If cancer cells are found at the edge of the tissue removed by surgery, chemotherapy and radiation therapy may be used. Or your doctor may recommend a second, more extensive surgery, followed by chemotherapy.

If you have serious medical problems that would prevent you from having surgery, you may receive only radiation therapy as your main treatment.

Stage IIIA

Treatment for stage IIIA NSCLC may include radiation therapy, chemotherapy, surgery, or some combination of these. For this reason, planning treatment for stage IIIA NSCLC will often require input from a medical oncologist, radiation oncologist, and surgeon. Treatment options will depend on the size of the tumor, where it is located in your lung, which lymph nodes it has spread to, your overall health, and how well you are tolerating treatment.

For patients who can tolerate it, treatment usually starts with chemotherapy, with or without radiation therapy. Surgery may be an option after this if the doctor thinks any remaining cancer can be removed and the patient is healthy enough. (In selected T3N1 cases, where the cancer has not reached the lymph nodes in the middle of the chest, surgery may be an option as the first treatment.) This is often followed by chemotherapy, and possibly radiation therapy if it hasn’t been given before.

For people who can’t tolerate chemotherapy or surgery, radiation therapy is usually the treatment of choice.

Stage IIIB

Stage IIIB NSCLC has usually spread too widely to be completely removed by surgery. If you are in fairly good health you may be helped by chemotherapy and radiation therapy.

In very selected cases where all of the cancer may be removable (such as certain T4N0 tumors), you may be able to have surgery. Chemotherapy (with or without radiation therapy) may be given first. After surgery, chemotherapy is recommended. Radiation therapy may also be given if it was not used before surgery.

For stage IIIB cancers that have caused a malignant pleural effusion (fluid in the space around the lungs), the fluid may be drained and pleurodesis may be done to help prevent it from coming back. Treatment is then generally the same as for stage IV disease (see next section).

Again, treatment depends on a person’s overall health and how well they are tolerating it. For people who can’t have chemotherapy or surgery, radiation therapy is usually the treatment of choice.

Because treatment is unlikely to cure these cancers, taking part in a clinical trial of newer treatments may be a good option. Several clinical trials are in progress to determine the best treatment for people with this stage of lung cancer.

Stage IV

Stage IV NSCLC is widespread when it is diagnosed. Because these cancers have spread to distant organs, they are very hard to cure. Treatment options depend on the site of the distant spread, the number of tumors, and your overall health. If you are in otherwise good health, treatments such as surgery, chemotherapy, and radiation therapy may help you live longer and make you feel better by relieving symptoms, even though they aren’t likely to cure you. Other treatments, such as photodynamic therapy or laser therapy, may also be used to help relieve symptoms. In any case, if you are going to receive treatment for advanced NSCLC, the goals of treatment should be clear to you before you start.

Cancer that has spread widely throughout the body is treated with chemotherapy, as long as the person is healthy enough to tolerate it. The targeted therapy bevacizumab (Avastin) is FDA-approved for use with chemotherapy in people who are not at high risk for bleeding (that is, they do not have squamous cell NSCLC, do not have cancer spread to the brain, have not coughed up blood, and are not taking “blood thinning” medicine). However, some doctors may use it for certain patients with squamous cell cancer as long as the tumor is not near large blood vessels in the center of the chest. Adding the targeted drug cetuximab (Erbitux) to chemotherapy may be another option, especially in people who cannot get bevacizumab.

Cancer that is limited in the lungs and has only spread to one other site (such as the brain) is not common but can sometimes be treated with surgery and/or radiation therapy. For example, a single tumor in the brain may be treated with surgery or stereotactic radiation (such as the Gamma Knife), followed by radiation to the whole brain. Treatment for the lung tumor is then based on its T and N stages, and may include surgery and/or chemotherapy.

As with other stages, treatment for stage IV lung cancer depends on a person’s overall health and how well they are tolerating it. For example, some people not in good health might get only 1 chemotherapy drug instead of 2. For people who can’t tolerate chemotherapy or surgery, radiation therapy is usually the treatment of choice. Local treatments such as laser therapy, photodynamic therapy, or stent placement may also be used to help relieve symptoms caused by lung tumors.

Because treatment is unlikely to cure these cancers, taking part in a clinical trial of newer treatments may be a good option.

Cancer that progresses or recurs after treatment

If cancer continues to grow during treatment or comes back, further treatment will depend on the extent of the cancer, what treatments have been used, and a person’s health and desire for further treatment. Again, it is important to understand the goal of any further treatment — if it is to try to cure the cancer, to slow its growth, or to help relieve symptoms — as well as the likelihood of benefits and risks.

If cancer continues to grow during initial treatment such as radiation therapy, chemotherapy may be tried. If a cancer continues to grow during combination chemotherapy, second line treatment most often consists of a single chemotherapy drug such as docetaxel or pemetrexed, or the targeted therapy erlotinib (Tarceva).

Smaller cancers that recur locally in the lungs can sometimes be retreated with surgery or radiation therapy (if it hasn’t been used before). Cancers that recur in the lymph nodes between the lungs are usually treated with chemotherapy, possibly along with radiation if it hasn’t been used before. For cancers that return at distant sites, chemotherapy and/or targeted therapies are often the treatments of choice.

At some point, it may become clear that standard treatments are no longer controlling the cancer. If you want to continue anti-cancer treatment, you might think about taking part in a clinical trial of newer lung cancer treatments. While these are not always the best option for every person, they may benefit you as well as future patients.

Even if you have incurable lung cancer you should be as free of symptoms as possible. If curative treatment is not an option, treatment aimed at specific sites can often relieve symptoms and may even slow the spread of the disease. Symptoms such as shortness of breath or coughing up blood caused by cancer in the lung airways can often be treated effectively with radiation therapy, brachytherapy, laser therapy, photodynamic therapy, stent placement, or even surgery if needed. Radiation therapy can be used to help control cancer spread in the brain or relieve pain in a specific area if cancer has spread.

Many people with lung cancer are concerned about pain. As the cancer grows near certain nerves it can sometimes cause pain, but this can almost always be treated effectively with pain medicines. Sometimes radiation therapy will help as well. It is important that you talk to your doctor and take advantage of these treatments.

Deciding on the right time to stop treatment aimed at curing the cancer and focus on care that relieves symptoms is never easy. Good communication with doctors, nurses, family, friends, and clergy can often help people facing this situation.

More treatment information

For more details on treatment options — including some that may not be addressed in this document — the National Cancer Institute (NCI) and the National Comprehensive Cancer Network (NCCN) are good sources of information.

The NCI provides treatment guidelines via its telephone information center (1-800-4-CANCER) and its Web site (www.cancer.gov). Detailed guidelines intended for use by cancer care professionals are also available on www.cancer.gov.

The NCCN, made up of experts from many of the nation’s leading cancer centers, develops cancer treatment guidelines for doctors to use when treating patients. These are available on the NCCN Web site (www.nccn.org).

What should you ask your doctor about non-small cell lung cancer?

It is important for you to have honest, open discussions with your cancer care team. They want to answer all of your questions, no matter how minor you might think they are. Some questions to consider:

• What kind of lung cancer do I have?
• Has my cancer spread beyond the primary site?
• What is the stage of my cancer, and what does that mean in my case?
• Are there other tests that need to be done before we can decide on treatment?
• How much experience do you have treating this type of cancer?
• What treatment choices do I have?
• What do you recommend and why?
• What is the goal of the treatment?
• What are the chances my cancer can be cured with these options?
• What risks or side effects are there to the treatments you suggest?
• What should I do to be ready for treatment?
• How long will treatment last? What will it involve? Where will it be done?
• What would we do if the treatment doesn’t work or if the cancer recurs?
• What type of follow-up will I need after treatment?

Along with these sample questions, be sure to write down some of your own. For instance, you might want more information about recovery times so you can plan your work schedule. Or you may want to ask about second opinions or about clinical trials for which you may qualify.

What happens after treatment for non-small cell lung cancer?

Completing treatment can be both stressful and exciting. You will be relieved to finish treatment, yet it is hard not to worry about cancer coming back. (When cancer returns, it is called recurrence.) This is a very common concern among those who have had cancer.

It may take a while before your confidence in your own recovery begins to feel real and your fears are somewhat relieved. You can learn more about what to look for and how to learn to live with the possibility of cancer coming back in our document, Living With Uncertainty: The Fear of Cancer Recurrence, available at 1-800-ACS-2345 (1-800-227-2345).

Follow-up care

After your treatment is over, it is very important to keep all follow-up appointments. During these visits, your doctors will ask about symptoms, do physical exams, and may order blood tests or imaging tests such as CT scans or x-rays.

Most doctors recommend follow-up visits and CT scans every 4 to 6 months for the first 2 years after treatment, and yearly visits and CT scans after this.

Follow-up is needed to check for cancer recurrence or spread, as well as possible side effects of certain treatments. This is the time for you to ask your health care team any questions you need answered and to discuss any concerns you might have.

Almost any cancer treatment can have side effects. Some may last for a few weeks to several months, but others can be permanent. Don’t hesitate to tell your cancer care team about any symptoms or side effects that bother you so they can help you manage them.

If cancer does recur, treatment will depend on the location of the cancer and what treatments you’ve had before. It may be surgery, radiation therapy, chemotherapy, targeted therapy, or some combination of these. For more information on how recurrent cancer is treated, see the section “How is non-small cell lung cancer treated?” For more general information on dealing with a recurrence, you may also want to see the document, When Your Cancer Comes Back: Cancer Recurrence. You can get this document by calling 1-800-227-2345.

Keep medical insurance and copies of your medical records

At some point after your cancer diagnosis and treatment, you may find yourself in the office of a new doctor. Your original doctor may have moved or retired, or you may have moved or changed doctors for some reason. It is important that you be able to give your new doctor the exact details of your diagnosis and treatment. Make sure you have the following information handy:

• a copy of your pathology report(s) from any biopsy or surgery
• if you had surgery, a copy of your operative report(s)
• if you were hospitalized, a copy of the discharge summary that doctors must prepare when patients are sent home
• if you had radiation therapy, a summary of the type and dose of radiation and when and where it was given
• if you had chemotherapy or targeted therapies, a list of your drugs, drug doses, and when you took them

It is also important to keep medical insurance. Even though no one wants to think of their cancer coming back, it is always a possibility. If it happens, the last thing you want is to have to worry about paying for treatment.

Lifestyle changes to consider during and after treatment

Having cancer and dealing with treatment can be time-consuming and emotionally draining, but it can also be a time to look at your life in new ways. Maybe you are thinking about how to improve your health over the long term. Some people even begin this process during cancer treatment.

Make healthier choices

Think about your life before you learned you had cancer. Were there things you did that might have made you less healthy? Maybe you drank too much alcohol, or ate more than you needed, or smoked, or didn’t exercise very often. Emotionally, maybe you kept your feelings bottled up, or maybe you let stressful situations go on too long.

Now is not the time to feel guilty or to blame yourself. However, you can start making changes today that can have positive effects for the rest of your life. Not only will you feel better but you will also be healthier. What better time than now to take advantage of the motivation you have as a result of going through a life-changing experience like having cancer?

You can start by working on those things that you feel most concerned about. Get help with those that are harder for you. For instance, if you smoke, one of the most important things you can do to improve your chances for treatment success is to quit. Studies have shown that patients who stop smoking after a diagnosis of lung cancer have better outcomes than those who don’t. If you are thinking about quitting smoking and need help, call the American Cancer Society’s Quitline® tobacco cessation program at 1-800-227-2345.

Diet and nutrition

Eating right can be a challenge for anyone, but it can get even tougher during and after cancer treatment. For instance, treatment often may change your sense of taste. Nausea can be a problem. You may lose your appetite for a while and lose weight when you don’t want to. On the other hand, some people gain weight even without eating more. This can be frustrating, too.

If you are losing weight or have taste problems during treatment, do the best you can with eating and remember that these problems usually improve over time. You may want to ask your cancer team for a referral to a dietitian, an expert in nutrition who can give you ideas on how to fight some of the side effects of your treatment. You may also find it helps to eat small portions every 2 to 3 hours until you feel better and can go back to a more normal schedule.

One of the best things you can do after treatment is to put healthy eating habits into place. You will be surprised at the long-term benefits of some simple changes, like increasing the variety of healthy foods you eat. Try to eat 5 or more servings of vegetables and fruits each day. Choose whole grain foods instead of white flour and sugars. Try to limit meats that are high in fat. Cut back on processed meats like hot dogs, bologna, and bacon. Get rid of them altogether if you can. If you drink alcohol, limit yourself to 1 or 2 drinks a day at the most. And don’t forget to get some type of regular exercise. The combination of a good diet and regular exercise will help you maintain a healthy weight and keep you feeling more energetic.

Rest, fatigue, work, and exercise

Fatigue is a very common symptom in people being treated for cancer. This is often not an ordinary type of tiredness but a “bone-weary” exhaustion that doesn’t get better with rest. For some, this fatigue lasts a long time after treatment, and can discourage them from physical activity.

However, exercise can actually help you reduce fatigue. Studies have shown that patients who follow an exercise program tailored to their personal needs feel physically and emotionally improved and can cope better.

If you are ill and need to be on bed rest during treatment, it is normal to expect your fitness, endurance, and muscle strength to decline some. Physical therapy can help you maintain strength and range of motion in your muscles, which can help fight fatigue and the sense of depression that sometimes comes with feeling so tired.

Any program of physical activity should fit your own situation. An older person who has never exercised will not be able to take on the same amount of exercise as a 20-year-old who plays tennis 3 times a week. If you haven’t exercised in a few years but can still get around, you may want to think about taking short walks.

Talk with your health care team before starting, and get their opinion about your exercise plans. Then, try to get an exercise buddy so that you’re not doing it alone. Having family or friends involved when starting a new exercise program can give you that extra boost of support to keep you going when the push just isn’t there.

If you are very tired, though, you will need to balance activity with rest. It is okay to rest when you need to. It is really hard for some people to allow themselves to do that when they are used to working all day or taking care of a household.

Exercise can improve your physical and emotional health.

• It improves your cardiovascular (heart and circulation) fitness.
• It strengthens your muscles.
• It reduces fatigue.
• It lowers anxiety and depression.
• It makes you feel generally happier.
• It helps you feel better about yourself.

And long term, we know that exercise plays a role in preventing some cancers. The American Cancer Society, in its guidelines on physical activity for cancer prevention, recommends that adults take part in at least 1 physical activity for 30 minutes or more on 5 days or more of the week.

How about your emotional health?

Once your treatment ends, you may find yourself overwhelmed by emotions. This happens to a lot of people. You may have been going through so much during treatment that you could only focus on getting through your treatment.

Now you may find that you think about the potential of your own death, or the effect of your cancer on your family, friends, and career. You may also begin to re-evaluate your relationship with your spouse or partner. Unexpected issues may also cause concern — for instance, as you become healthier and have fewer doctor visits, you will see your health care team less often. That can be a source of anxiety for some.

This is an ideal time to seek out emotional and social support. You need people you can turn to for strength and comfort. Support can come in many forms: family, friends, cancer support groups, church or spiritual groups, online support communities, or individual counselors.

Almost everyone who has been through cancer can benefit from getting some type of support. What’s best for you depends on your situation and personality. Some people feel safe in peer-support groups or education groups. Others would rather talk in an informal setting, such as church. Others may feel more at ease talking one-on-one with a trusted friend or counselor. Whatever your source of strength or comfort, make sure you have a place to go with your concerns.

The cancer journey can feel very lonely. It is not necessary or realistic to go it all by yourself. And your friends and family may feel shut out if you decide not to include them. Let them in — and let in anyone else who you feel may help. If you aren’t sure who can help, call your American Cancer Society at 1-800-227-2345 and we can put you in touch with an appropriate group or resource.

You can’t change the fact that you have had cancer. What you can change is how you live the rest of your life — making healthy choices and feeling as well as possible, physically and emotionally.

What happens if treatment is no longer working?

If cancer continues to grow after one kind of treatment, or if it returns, it is often possible to try another treatment plan that might still cure the cancer, or at least shrink the tumors enough to help you live longer and feel better. On the other hand, when a person has received several different medical treatments and the cancer has not been cured, over time the cancer tends to become resistant to all treatment. At this time it’s important to weigh the possible limited benefit of a new treatment against the possible downsides, including continued doctor visits and treatment side effects.

Everyone has his or her own way of looking at this. Some people may want to continue treatment for as long as possible, while others may want to focus on remaining comfortable during their limited time left.

This is likely to be the most difficult time in your battle with cancer — when you have tried everything medically within reason and it’s just not working anymore. Although your doctor may offer you new treatment, you need to consider that at some point, continuing treatment is not likely to improve your health or change your prognosis or survival.

If you want to continue treatment to fight your cancer as long as you can, you still need to consider the odds of more treatment having any benefit. In many cases, your doctor can estimate the response rate for the treatment you are considering. Some people are tempted to try more chemotherapy or radiation, for example, even when their doctors say that the odds of benefit are less than 1%. In this situation, you need to think about and understand your reasons for choosing this plan.

No matter what you decide to do, it is important that you be as comfortable as possible. Make sure you are asking for and getting treatment for any symptoms you might have, such as pain. This type of treatment is called palliative treatment.

Palliative treatment helps relieve these symptoms, but is not expected to cure the disease; its main purpose is to improve your quality of life. Sometimes, the treatments you get to control your symptoms are similar to the treatments used to treat cancer. For example, radiation therapy might be given to help relieve bone pain from bone metastasis. Or chemotherapy might be given to help shrink a tumor and keep it from causing a bowel obstruction. But this is not the same as receiving treatment to try to cure the cancer.

At some point, you may benefit from hospice care. Most of the time, this can be given at home. Your cancer may be causing symptoms or problems that need attention, and hospice focuses on your comfort. You should know that receiving hospice care doesn’t mean you can’t have treatment for the problems caused by your cancer or other health conditions. It just means that the focus of your care is on living life as fully as possible and feeling as well as you can at this difficult stage of your cancer.

Remember also that maintaining hope is important. Your hope for a cure may not be as bright, but there is still hope for good times with family and friends — times that are filled with happiness and meaning. In a way, pausing at this time in your cancer treatment is an opportunity to refocus on the most important things in your life. This is the time to do some things you’ve always wanted to do and to stop doing the things you no longer want to do.

What’s new in non-small cell lung cancer research and treatment?

Lung cancer research is currently being done in medical centers throughout the world. Progress in prevention, early detection, and treatment based on current research is expected to save many thousands of lives each year.

Prevention

Tobacco

At this time, many researchers believe that prevention offers the greatest opportunity to fight lung cancer. Although decades have passed since the link between smoking and lung cancers was clearly identified, scientists estimate that smoking is still responsible for about 85% to 90% of lung cancer deaths. Research is continuing on:

• ways to help people quit smoking through counseling, nicotine replacement, and other medicines

• ways to convince young people to never start smoking

• inherited differences in genes that may make some people much more likely to get lung cancer if they smoke or are exposed to someone else’s smoke

Diet and nutrition

Although researchers are looking for ways to use vitamins or medicines to prevent lung cancer in people at high risk, these have so far not proved successful. For now, most researchers think that simply following the American Cancer Society dietary recommendations (such as maintaining a healthy weight and eating at least 5 servings of fruits and vegetables each day) may be the best strategy.

Early detection

In the past, large studies were done to determine whether routine chest x-rays and sputum cytology testing could save lives. Most researchers concluded that these tests did not find lung cancers early enough to significantly lower the risk of death from lung cancer. However, some researchers disagree about the best way to interpret the studies’ data, and the debate continues.

A large clinical trial called the National Lung Screening Trial (NLST) is under way to test whether spiral CT scanning of people at high risk of lung cancer will save lives. The results of this study should be coming out in the next few years.

Another approach uses new, sensitive tests to detect cancer cells in sputum samples. Researchers have recently found several changes that often affect the DNA of lung cancer cells. Current studies are looking at new diagnostic tests that specifically recognize these DNA changes to see if this approach is useful in finding lung cancers at an earlier stage.

Diagnosis

Virtual bronchoscopy

This imaging test uses CT scans to create detailed 3-dimensional pictures of the airways in the lung. The images can be viewed as if the doctor were actually using a bronchoscope.

Virtual bronchoscopy has some possible advantages over standard bronchoscopy. First, it is non-invasive and doesn’t require anesthesia. It also allows doctors to see some airways that might not be visible with standard bronchoscopy, such as those being blocked by a tumor. But it has some drawbacks as well. For example, it doesn’t show color changes in the airways that might indicate a problem. It also doesn’t allow a doctor to take samples of suspicious areas like bronchoscopy does. Still, it can be a useful tool in some situations, such as in people who might be too sick to get a standard bronchoscopy.

This test will likely become more available as the technology improves.

Treatment

Stereotactic body radiation therapy

Stereotactic body radiation therapy (SBRT) is a newer type of treatment. It can be used for some very early stage (small) lung cancers when surgery isn’t an option, usually for other medical reasons.

Instead of giving small doses of radiation each day for several weeks, SBRT involves giving very focused beams of high-dose radiation on one or a few days. Several beams are aimed at the tumor from different angles. In order to precisely target the radiation, the person is put in a specially designed body frame for each treatment. This reduces the movement of the lung tumor during breathing. Like other forms of external radiation, the treatment itself is painless.

Early results with SBRT have been very promising, and it seems to have a low risk of complications. But because it is still a fairly new technique, there isn’t much long-term data on its use.

Chemotherapy

Many clinical trials in progress are comparing the effectiveness of newer combinations of chemotherapy drugs. These studies are also providing information about reducing side effects, especially in patients who are older and have other health problems.

Doctors know that adjuvant chemotherapy after surgery may be more helpful for some people with early (stage I or II) cancers than for others, but figuring out which patients to give it to is not easy. In early studies, newer lab tests that look at patterns of certain genes in the cancer cells have shown promise in telling which people might benefit most. Larger studies of these tests are now under way to try to confirm their usefulness.

For people with advanced lung cancers who can tolerate chemotherapy, combinations of 2 drugs are typically given for about 4 cycles. Doctors do not usually give more chemotherapy unless the cancer starts growing again. But some recent studies have found that maintenance therapy — continuing treatment with a single drug such as pemetrexed after the first 4 cycles — may help some people live longer. Research in this area continues.

Doctors are also studying better ways to combine chemotherapy with radiation therapy and other treatments.

Targeted therapies

Researchers are learning more about the molecules within lung cancer cells that control their growth and spread. This is being used to develop new targeted therapies. Some of these treatments are already being used to treat non-small cell lung cancer. Others are now being tested in clinical trials to see if they can help people with advanced lung cancer live longer or relieve their symptoms.

Some of the drugs that are in late stage clinical trials include vandetanib (ZD6474, Zactima), DMXAA (ASA404), and motesanib (AMG 706). Some targeted drugs already approved for use against other types of cancer, such as sorafenib (Nexavar) and sunitinib (Sutent), are also being tested for use against NSCLC.

Researchers are also working on lab tests to help predict which patients will benefit from which drugs. Several clinical trials have already reported that some patients do not benefit from certain targeted therapies, whereas others have quite remarkable shrinkage of their tumors. Predicting who might benefit could save some people from trying treatments that are unlikely to work for them and would probably cause unneeded side effects.

Vaccines: Several types of vaccines for boosting the body’s immune response against lung cancer cells are being tested in clinical trials. Unlike vaccines against infections like measles or mumps, these vaccines are designed to help treat, not prevent, lung cancer. One possible advantage of these types of treatments is that they seem to have very limited side effects, so they might be useful in people who can’t tolerate other treatments.

Some vaccines are made up of lung cancer cells that have been grown in the lab, or even of cell components, such as parts of proteins commonly found on cancer cells. For example, L-BLP25 (Stimuvax) is a vaccine made up of a piece of a protein (MUC1) that is encased in a fat droplet (liposome) to make it more effective. A small study of patients with advanced NSCLC suggested it may improve survival time. Larger studies are being done to try to confirm this.

At this time, vaccines are only available in clinical trials.

Additional resources

More information from your American Cancer Society

The following related information may also be helpful to you. These materials may be ordered from our toll-free number, 1-800-227-2345.

After Diagnosis: A Guide for Patients and Families (also available in Spanish)

Asbestos

Caring for the Patient With Cancer at Home: A Guide for Patients and Families (also available in Spanish)

Guide to Quitting Smoking (also available in Spanish)

Living With Uncertainty: The Fear of Cancer Recurrence

Pain Control: A Guide for People With Cancer and Their Families (also available in Spanish)

Photodynamic Therapy

Questions About Smoking, Tobacco, and Health (also available in Spanish)

Radon

Surgery (also available in Spanish)

Understanding Chemotherapy: A Guide for Patients and Families (also available in Spanish)

Understanding Radiation Therapy: A Guide for Patients and Families (also available in Spanish)

When Your Cancer Comes Back: Cancer Recurrence

The following books are available from the American Cancer Society. Call us at 1-800-227-2345 to ask about costs or to place your order.

American Cancer Society’s Guide to Pain Control

Cancer in the Family: Helping Children Cope with a Parent’s Illness

Caregiving: A Step-by-Step Approach for Caring for the Person with Cancer at Home

What Helped Get Me Through: Cancer Patients Share Wisdom and Hope

What to Eat During Cancer Treatment

When the Focus is on Care: Palliative Care and Cancer

National organizations and Web sites*

In addition to the American Cancer Society, other sources of patient information and support include:

American Lung Association
Toll-free number: 1-800-586-4872 (1-800-LUNGUSA)
Web site: www.lungusa.org

Lungcancer.org
Toll-free number: 1-800-813-4673 (1-800-813-HOPE)
Web site: www.lungcancer.org

Lung Cancer Alliance
Toll-free number: 1-800-298-2436
Web site: www.lungcanceralliance.org

National Cancer Institute
Toll-free number: 1-800-422-6237 (1-800-4-CANCER)
Web site: www.cancer.gov

*Inclusion on this list does not imply endorsement by the American Cancer Society.

No matter who you are, we can help. Contact us anytime, day or night, for information and support. Call us at 1-800-227-2345 or visit www.cancer.org.

References

Alberg AJ, Brock MV, Stuart JM. Epidemiology of lung cancer: Looking to the future. J Clin Oncol. 2005;23:3175–3185.

American Cancer Society. Cancer Facts & Figures 2009. Atlanta, Ga: American Cancer Society; 2009.

American Joint Committee on Cancer. Lung. AJCC Cancer Staging Manual. 6th ed. New York: Springer. 2002:167–177.

Bach PB, Silvestri GA, Hanger M, Jett JR. Screening for lung cancer: ACCP evidence-based clinical practice guidelines. Chest. 2007:69S–77.

Belani CP, Brodowicz T, Ciuleanu TE, et al. Maintenance pemetrexed plus best supportive care (BSC) versus placebo plus BSC: a phase III study [abstract]. J Clin Oncol. 2008;26:8011.

Bailey-Wilson JE, Amos CI, Pinney SM, et al. A major lung cancer susceptibility locus mapsto chromosome 6q23-25. Am J Hum Genet. 2004;75:460–474.

Butts C, Murray N, Maksymiuk A, et al. Randomized phase IIB trial of BLP25 liposomevaccine in stage IIIB and IV non-small-cell lung cancer. J Clin Oncol. 2005;23:6674–6681.

Cohen AJ, Ross Anderson H, Ostro B, et al. The global burden of disease due to outdoor airpollution. J Toxicol Environ Health A. 2005;68:1301–1307.

Horner MJ, Ries LAG, Krapcho M, Neyman N, Aminou R, Howlader N, Altekruse SF, Feuer EJ, Huang L, Mariotto A, Miller BA, Lewis DR, Eisner MP, Stinchcomb DG, EdwardsBK (eds). SEER Cancer Statistics Review, 1975-2006, National Cancer Institute. Bethesda, MD, http://seer.cancer.gov/csr/1975_2006/, based on November 2008 SEER datasubmission, posted to the SEER web site, 2009.

Johnson DH, Blot WJ, Carbone DP, et al. Cancer of the lung: non-small cell lung cancer and small cell lung cancer. In: Abeloff MD, Armitage JO, Niederhuber JE. Kastan MB, McKennaWG, eds. Abeloff’s Clinical Oncology. 4th ed. Philadelphia, Pa: Elsevier; 2008:1307–1366.

Kaufman EL, Jacobson JS, Hershman DL, et al. Effect of breast cancer radiotherapy and cigarette smoking on risk of second primary lung cancer. J Clin Oncol. 2008;26:392–398.

National Cancer Institute. Physician Data Query (PDQ). Non-Small Cell Lung CancerTreatment. 2009. Accessed at www.cancer.gov/cancertopics/pdq/treatment/non-small-cell-lung/healthprofessional on August 26, 2009.

National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology:Non-Small Cell Lung Cancer. V.2.2009. Accessed atwww.nccn.org/professionals/physician_gls/PDF/nscl.pdf on August 26, 2009.

Obedian E, Fischer DB, Haffty BG. Second malignancies after treatment of early-stagebreast cancer: lumpectomy and radiation therapy versus mastectomy. J Clin Oncol. 2000;18:2406–2412.

Posther KE, Harpole DH. The surgical management of lung cancer. Cancer Investigation. 2006;24:56–67.

Ries LAG, Eisner MP. Cancer of the lung. In: Ries LAG, Young JL, Keel GE, Eisner MP, Lin YD, Horner M-J, eds. SEER Survival Monograph: Cancer Survival Among Adults: U.S. SEER Program, 1988-2001, Patient and Tumor Characteristics. National Cancer Institute, SEER Program, NIH Pub. No. 07-6215, Bethesda, MD, 2007.

Schrump DS, Giaccone G, Kelsey CR, Marks LB. Non-small cell lung cancer. In: DeVita VT, Lawrence TS, Rosenberg SA, eds. DeVita, Hellman, and Rosenberg’s Cancer: Principles and Practice of Oncology. 8th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2008:896–946.

U.S. Department of Health and Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Washington, DC: Department of Health and Human Services; 2006. Accessed at www.surgeongeneral.gov/library/secondhandsmoke on August 27, 2009.

U.S. Preventive Services Task Force. Lung cancer screening. Ann Int Med. 2004;140:738–739.

Schottenfeld D, Searle JG. The etiology and epidemiology of lung cancer. In: Pass HI, Carbone DP, Johnson DH, Minna JD, Turrisi AT, eds. Lung Cancer: Principles and Practice. 3rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins. 2005:3–24.

Last Medical Review: 10/13/2009
Last Revised: 10/13/2009
2009 Copyright American Cancer Society