Chemoprevention trials (drugs studied to prevent tumors in subjects at high risk) for these patients are also in progress. These are being done in patients whose stage I NSCLC is curable but who are at risk for developing a second lung cancer.
The greatest risk for patients with stage I NSCLC is that micrometastases (deposits of cancer too small to be detected by imaging tests) are present even when surgeons believe that the lung tumor has been completely removed. The value of adjuvant chemotherapy after surgical removal of stage I NSCLC or after primary radiation therapy has not been proven, but clinical trials with chemotherapy intended to destroy micrometastases are in progress.
Five year survival rates for people with NSCLC in this stage who undergo surgery average about 60%.
Stage II: As in stage I NSCLC, most patients with stage II NSCLC have their cancer surgically removed by lobectomy or by some less extensive surgery such as a segmentectomy or wedge resection for those people who cannot withstand lobectomy.
Radiation therapy may be used to destroy cancer cells left behind after surgery if cancer cells are present at the edge of the tissue removed by surgery. Even if the edges of the sample have no detectable cancer cells, some doctors may recommend additional radiation therapy.
Radiation therapy alone can be used for patients who cannot undergo surgery due to other serious health problems.
The role of adjuvant chemotherapy for completely resected Stage II lung cancer is being studied in clinical trials. It may also be used for patients who cannot tolerate surgery and are treated with radiation only.
Five-year survival rates are about 35% for patients who are treated with surgery.
Stage IIIA: Treatment of stage IIIA NSCLC depends on the location of the cancer in the lung and if it has spread to lymph nodes.
Surgery may be used alone, if the surgeon thinks all the cancer can be removed successfully. Sometimes chemotherapy or radiation therapy or a combination of both will follow the surgery. Some doctors will recommend that chemotherapy or radiation therapy or both be given before surgery, with the goal of shrinking the tumor enough that it can be completely removed by surgery. If surgery is not performed, either because chemotherapy did not shrink the cancer enough or because the patient has other serious medical conditions and could not withstand surgery, the cancer can be treated by radiation therapy or by both radiation therapy and additional chemotherapy. There are several clinical trials in progress to determine the best treatment for people with this stage of lung cancer.
Brachytherapy is sometimes used. In some cases, a laser can be passed through a bronchoscope to destroy part of the cancer within the airway.
Average five year survival rates vary in the range of 10% to 20%, but some stage IIIA patients (such as those without lymph node metastases) may have a better outlook.
Stage IIIB: Stage IIIB NSCLC has spread too widely to be completely removed by surgery. Overall five-year survival is about 5%, but patients in relatively good health can undergo combined chemotherapy and radiation therapy that offers a five-year survival rate of about 10% to 20%. In selected cases, surgery may be done after chemotherapy or radiation therapy. There are several clinical trials in progress to determine the best treatment for people with this stage of lung cancer.
Stage IV: Because Stage IV NSCLC has spread to distant organs, a cure is not possible. If any aggressive therapy is used, the goal of treatment should be clear to the patient and family. In patients in otherwise good health, chemotherapy can extend survival. Blockage of an airway by cancer may be treated by interstitial radiation therapy or by using a laser passed through a bronchoscope to destroy the part of the cancer within the airway. External beam radiation therapy can also treat complications of cancer in the lungs as well as problems from metastatic growth such as bone pain and nervous system symptoms.
Several reports have shown that chemotherapy prolongs the life of patients with stage IV lung cancer. It also improves their quality of life, even though there are side effects from the chemotherapy. Only 20% to 25% of people with stage IV lung cancer live one year.
For some patients, palliative care may be the best choice, perhaps in the setting of a good hospice program. Pain is a significant concern for patients with lung cancer. Growth of the cancer around certain nerves may cause severe pain. However, it is possible to effectively relieve this pain by medications. Sometimes radiation therapy will help. It is important that patients do not hesitate to take advantage of these treatments.
Once the doctor has found that a chemotherapy regimen is not working, palliative care may be the best option. A second kind of chemotherapy will rarely help people with lung cancer. People with incurable lung cancer should try to get the most out of their lives by making every day count. That means they should be as free of symptoms as possible. Clinical trials of new chemotherapy drugs or other new treatments such as immunotherapy or gene therapy are a worthwhile option that may benefit the individual patient as well as future patients.
Small Cell Lung Cancer (SCLC)
This type of cancer is usually staged as either limited or extensive. Studies show that this type of lung cancer has usually spread by the time it is found (even if that spread is not shown by x-rays and other imaging tests) so SCLC usually cannot be cured by surgery alone.
Limited stage: Most cases of limited stage SCLC are treated first with chemotherapy in which two or more chemotherapy drugs are given to kill cancer cells throughout the body. The standard treatment is either cisplatin or carboplatin combined with etoposide. There are trials in progress to determine whether adding the drug paclitaxel will improve the outcome. Many studies have been performed to determine whether radiation treatment to the chest (usually the middle where the cancer spreads to lymph nodes) will improve the results over chemotherapy alone. These studies have shown that radiation does provide a small benefit. However there is added toxicity when giving radiation therapy with chemotherapy.
Chest radiation therapy is not given to patients with severe lung diseases (in addition to their cancer) or some other types of serious health problems. These patients have a worse prognosis (outlook) than those who can tolerate both chemotherapy and chest radiation therapy. In a few patients whose SCLC is very localized, the lobe is removed by surgery and followed by combination chemotherapy.
The brain is a common place where SCLC spreads. If no prevention is done, about 50% of people with SCLC will have spread to their brain. For this reason, patients who have a good response to initial treatment may be given head radiation therapy before evidence of a brain metastasis appears. This can prevent or delay complications due to brain metastasis, and may slightly increase overall survival time. Several groups of doctors have reported that patients given brain irradiation may suffer side effects such as trouble with memory and clumsiness. It is not totally clear that these symptoms are a direct result of the radiation. Most doctors will recommend brain radiation therapy for people who have had a complete remission (all the apparent cancer is gone) after chemotherapy.
When most SCLC patients are treated with chemotherapy, with or without radiation therapy, their tumors will shrink and they experience remission. Sooner or later, though, most small cell lung cancer becomes resistant to treatment and the cancer begins to grow again.
The one-year survival rate for people with limited stage SCLC who receive treatment with chemotherapy and radiation therapy (this is the most favorable group) is 60%. It goes down to 30% at two years and 10% to 15% by five years. Because of this lack of success, doctors are studying other methods of treating these cancers. Clinical trials of new chemotherapy drugs or other new treatments such as immunotherapy or gene therapy are a worthwhile option that may benefit the individual patient as well as future patients.
Extensive stage: Extensive SCLC has a very poor outlook when left untreated. Chemotherapy may be used to treat symptoms and to extend short-term survival. Chemotherapy with two or more drugs can shrink tumors for about 70% to 80% of these patients. Once again, carboplatin or cisplatin along with etoposide are the usual drugs given. However, this cancer usually becomes resistant to treatment. Radiation therapy is sometimes used to control symptoms of growth within the lung or spread to the bones or brain. Preventive brain radiation therapy is sometimes given.
About 20 to 30% of people with extensive SCLC live one year. By two years, only about 5% are still alive. Only 1-2% of people with extensive SCLC survive five years after the cancer is found. For patients too ill to have chemotherapy, the best plan may be to provide supportive care. This would include treatment of pain, breathing problems, weight loss, and other symptoms. Pain is a significant concern for patients with lung cancer. Growth of the cancer around certain nerves may cause severe pain. However, it is possible to effectively relieve this pain by medications. Radiation therapy may also be helpful. It is important that patients do not hesitate to take advantage of these treatments. People with incurable lung cancer should try to get the most out of their lives by making every day count. That means people should be as free of symptoms as possible. It also means people should question whether treatment is not likely to help them. Clinical trials of new chemotherapy drugs or other new treatments such as immunotherapy or gene therapy are a worthwhile option that may benefit the individual patient as well as future patients.
Bibliography
dr. justin warner “how to kill cancer”