Lung cancer treatment depends on the type and the stage of cancer. Lung cancer can be treated with surgery, chemotherapy and radiation; and these are often combined to offer the most effective treatment.1 Options for treating a metastatic tumor depend on the stage of the primary cancer. The various lung cancer treatments are described in detail below.
Surgery or surgical resection is often used to remove a tumor. For early stage lung cancer, the preferred treatment for otherwise healthy patients is a lobectomy, in which the surgeon removes a lobe of the lung. Lobectomies can be performed in two ways. One method is called a thoracotomy, in which the ribs are cut and spread to allow the surgeon to access the lobe of lung that needs to be removed. The second type of lobectomy is less invasive and done using video-assisted thorocoscopic surgery (VATS). During this procedure, small incisions are made and a camera is placed in the chest to guide the surgeon performing the surgery. Some patients with early stage lung cancer may not require that an entire lobe be removed. This procedure is called a wedge resection or segmentectomy, and can reduce the amount of normal lung tissue removed.
To be effective as possible, lung cancer surgery must not only remove the visible tumor, but eliminate any microscopic traces of the disease that remain in the surrounding tissue. Studies comparing lobectomies to wedge resections have shown that the lobectomy results in better survival rates and is more effective in removing all of a patient’s disease.
For those patients whose primary lung cancer is more advanced, as well as those who have large tumors or multiple metastatic tumors that cannot be removed by lobectomy or segmentectomy, more extensive surgery is required. In these cases, surgeons may perform a pneumonectomy, during which the entire lung is removed.
Although surgery is effective for some stages of lung cancer, patients can experience significant risk of complications, including infection, bleeding, and respiratory and cardiac problems. These complications can also lead to loss of lung function and/or a decreased quality of life.3 Open lobectomy and video assisted thorascopic surgery have local control rates and 5-year survival rates of 60-80%.4-7
Lung cancer surgery is typically used alone for patients with very small tumors and early-stage lung cancer. However, some patients may not be well enough to undergo surgery because they suffer from other cardiac or breathing problems. For later stages of lung cancer, typically stage II and higher, surgery is often combined with chemotherapy and, perhaps, radiation therapy.
Radiation therapy, also referred to as radiotherapy, is a non-invasive procedure that uses radiation to kill lung cancer cells. Five-year survival rates for early stage primary lung cancer patients undergoing this type of treatment have been reported in the range of 10-30%, which is lower than the survival rates of patients treated with surgery.10-12
Conventional radiation therapy, called external beam radiation therapy, typically involves delivery of wide beams of radiation that encompass both the tumor and a significant amount of surrounding healthy tissue. These wide beams of radiation are necessary because tumors move as patients breathe. During this treatment, the radiation dose is limited to decrease the toxicity to the patient that can result from injuring healthy lung tissue. Therefore, conventional external beam radiation therapy is usually delivered in small doses of 30 to 40 sessions over four to six weeks. Rates of toxicity range widely in published studies,3-16 with short-term severe toxicity ranging from 10-30%13 and long-term severe toxicity (radiation pneumonitis) reported as 18%; attempts to increase the dose of radiation being delivered using conventional radiation therapy methods have resulted in even greater toxicity.15
Because tumors with the chest can move large amounts as the patient breathes, it is necessary to irradiate with wide fields that include a large amount of normal surrounding tissue during this treatment. However, several techniques – such as respiratory gating, breath holding and the use of frames – have been developed to better compensate for this tumor motion and allow for smaller radiation fields to be used.
Respiratory gating is a technique in which radiation is delivered when the tumor is thought to be in a certain location during a patient’s breathing cycle. Gating makes a number of assumptions about the location of the lung tumor, such as: it is always in that same location during a specific point in a patient’s breathing pattern; a patient’s breathing pattern does not change throughout a treatment; and a patient is breathing the same during a treatment as he or she was breathing during the planning phase. In reality, many patients breathe differently throughout the treatment, particularly if they are nervous or fall asleep. These changes in breathing patterns may result in errors in radiation delivery.
Breath holding involves a patient taking a full breath and then holding it for several seconds. As the patient holds his or her breath, the radiation beam is switched on and then turned off just before the patient begins to breathe normally again. Breath holding assumes a tumor will be in a certain location when the patient breaths in. This may not always be the case, depending on the depth of a patient’s breath. Breath holding also may be very difficult for patients with advanced lung disease.
Frames enable physicians to apply pressure to a patient’s abdomen to decrease the movement of the diaphragm and chest cavity. Although frames reduce tumor movement within the chest, they do not completely eliminate it. This technique also can be uncomfortable and may be very restrictive for patients who have baseline breathing problems or advanced lung disease.
Techniques such as gating, breath holding and frames have allowed physicians to deliver much higher doses of radiation in as few as three to five sessions with a procedure called stereotactic body radiation therapy (SBRT). This alternative treatment for lung cancer has been shown to be more effective than conventional radiation therapy, with three-year survival rates ranging from 52-88%17-20 and a five-year local control rate of 95%.21 Although SBRT enables doctors to spare more normal lung tissue than conventional methods, it still typically requires large margins around tumors to ensure that the radiation is delivered to the tumor and to account for the inaccuracies of gating, breath holding or frame usage.
Chemotherapy is used when cancer cells are thought to be located throughout the body or they are present in a patient’s blood or other fluids, which is often the case with metastatic lung tumors and advanced-stage lung cancer. Chemotherapy medication is delivered orally or through an IV (into a vein), and is given to a patient either as the sole treatment or in combination with surgery or radiation. Chemotherapy affects both normal tissue and the cancer cells, so patients may experience side effects, such as severe nausea and vomiting, infections, fatigue and weight loss.22 Based on randomized clinical trials chemotherapy is recommended in addition to local treatment for patients with later-stage disease.22 Disease-free 5-year survival for patients treated with chemotherapy following surgery range from 48-89% depending on how advanced the disease is.22
Radiosurgery devices, such as the CyberKnife Robotic Radiosurgery System, offer patients a new option for the treatment of lung cancer. The CyberKnife® System is used to treat lung cancer patients who cannot tolerate surgery, have an inoperable tumor, or are seeking an alternative to surgery. The challenge that doctors face with tumors in the lung is that those tumors move as the patient breathes. Unlike traditional radiation therapy, the CyberKnife System precisely identifies the tumor location as the patient breathes normally during treatment and can be used, in some cases, to treat lung tumors non-invasively.