Medically reviewed by C.H. Weaver M.D. updated 3/2022
In general treatment for non-small cell lung (NSCLC) may require surgery, radiation, and/or systemic therapy with chemotherapy, immunotherapy or precision cancer medicines. The specific treatment for each person is individualized and is based on the stage of the cancer and its genomic profile.1,2,3
For patients with NSCLC limited to the chest surgical resection is not only an important therapeutic modality, but in many cases, the most effective method of controlling the disease. Patients with stages I-II localized cancer without spread to lymph nodes are considered to have early stage lung cancer and are almost always treated with surgery to remove the cancer. Some individuals with stage IIIA NSCLC can be treated with surgery as well however surgery for stage IIIB and IV disease is ineffective because the lung cancer has already spread.1,2,3
Radiation therapy uses high-powered energy beams, such as X-rays or protons, to kill cancer cells. Radiation therapy may be used alone or with chemotherapy before surgery to shrink a tumor or after surgery to kill any remaining cancer cells.(1-6)
Systemic Therapy: Precision Cancer Medicines, Chemotherapy & Immunotherpay
Systemic therapy is any treatment directed at destroying cancer cells throughout the body. Many patients with NSCLC already have small amounts of cancer that have spread outside the lungs that cannot be treated with surgery or radiation. These cancer cells cannot be detected with any of the currently available tests and are referred to as micrometastases. The presence of micrometastases causes NSCLC recurrence following local treatment with surgery and/or radiation therapy alone. An effective systemic treatment is needed to cleanse the body of micrometastases in order to improve a patient’s duration of survival and potential for cure.
Systemic Therapy For NSCLC
Precision Cancer Medicines
The purpose of precision cancer medicine is to define the genomic alterations in the cancers DNA that are driving that specific cancer. Precision cancer medicine utilizes molecular diagnostic testing, including DNA sequencing, to identify cancer-driving abnormalities in a cancer’s genome. Once a genetic abnormality is identified, a specific targeted therapy can be designed to attack a specific mutation or other cancer-related change in the DNA programming of the cancer cells. Precision cancer medicine uses targeted drugs and immunotherapies engineered to directly attack the cancer cells with specific abnormalities, leaving normal cells largely unharmed.
- Large-scale screening for epidermal growth factor receptor (EGFR) PD-1, ROS1, ALK, RET, BRAF, MET, TRK and other mutations in lung cancer is now considered standard of care because it allows for customization of treatment leading to improved outcomes. Genomic biomarker testing should be performed at the time of a new lung cancer diagnosis.7-11
Chemotherapy uses medications that can be taken orally as a pill or are injected into a vein to kill cancer cells. In some situations chemotherapy is combined with radiation therapy or other precision cancer medicines to achieve the best results.
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Treatment of Non Small Cell Lung Cancer by Stage
Stage I: The cancer measures 5 centimeters or smaller and does not involve the lymph nodes.
Stage II: The cancer has not spread to the lymph nodes but is larger than 5 centimeters or involves structures near the lung such as the chest wall or diaphragm. NSCLC is also considered to be Stage II if it measures 7 centimeters or less and involves the lymph nodes within the lung or near the bronchus.
Stage IIIA: The cancer involves lymph nodes in the space between the lungs (mediastinum) or near where the windpipe divides; is large or extensive but the only lymph node involvement is within the lung or near the bronchus; or there is no lymph node involvement but the cancer extends to other organs or tissues such as the heart, great vessels, trachea, or other lobes of the lung.
Stage IIIB: The cancer involves lymph nodes on the opposite side of the chest or above the collar bone, or is extensive (involves organs such as the heart or trachea) and also involves lymph nodes in the center of the chest (mediastinum) or near where the windpipe divides.
Stage IV: Cancer is found in both lungs, in the fluid that surrounds the lungs or heart, or has spread to other parts of the body such as the liver, brain, or bones.
Recurrent/Relapsed: Cancer has progressed or returned (recurred/relapsed) following an initial treatment with surgery, radiation therapy and/or chemotherapy.
Radiation therapy uses high-powered energy beams, such as X-rays or protons, to kill cancer cells. Radiation therapy may be used as part of an overall strategy to treat stage III disease, treat single metastases, or control the cancer in individuals unable to undergo surgery systemic chemotherapy treatment.
Some patients with NSCLC are not able to undergo the surgery to remove their cancer. Advanced age and other medical conditions such as heart disease and diminished lung capacity make it more difficult for these patients to withstand surgery. Studies have demonstrated that patients with stages IIIA NSCLC who are not able to, or do not wish to undergo surgery may be treated with radiation therapy alone. Results indicated that radiation therapy alone produced an average survival time of over 30 and 34 months, respectively.2,4
Prophylactic brain radiation: Researchers have found that the most common site for cancer to spread in patients is the brain.3 These patients may benefit from radiation treatment to the brain during their initial therapy, which is called prophylactic treatment. Results of a clinical trial indicate that prophylactic brain radiation reduced the rate of cancer recurrence in the brain from 30% to 8% and the overall chance of relapse in the brain from 54% to 13%. Researchers reported that patients who received prophylactic brain radiation did not experience impaired attention or visual memory after treatment.2,5,6
- Keep Current With The Lung Cancer Community Newsletter
- Connect With Others In The Lung Cancer Community To Share Information And Support
- American Cancer Society. Cancer Facts & Figures 2017.
- Jeremic B, Calssen J, Bamberg M. Radiotherapy alone in technically operable, medically inoperable, early-stage (I/II) non-small-cell lung cancer. International Journal of Radiation Oncology, Biology, Physics 2002;54:119.
- Stuschke M, Eberhardt W, Pottgen C, Stamatis G, Wilke H, Stuben G, Stoblen F, Wilhelm HH, Menker H, Teschler H, Muller RD, Budach V, Seeber S, Sack H. Prophylactic cranial irradiation in locally advanced non-small-cell lung cancer after multimodality treatment: long-term follow-up and investigations of late neuropsychologic effects. Journal of Clinical Oncology. 1999 Sep;17(9):2700-9.
- Mamon H, Yeap B, Jänne P, et al. High Risk of Brain Metastases in Surgically Staged IIIA Non–Small-Cell Lung Cancer Patients Treated With Surgery, Chemotherapy, and Radiation. Journal of Clinical Oncology. 2005; 23: 1530-1537.
- Rosell R, Moran T, Queralt C, et al. Screening for epidermal growth factor receptor mutations in lung cancer. New EnglandJournal of Medicine. [early online publication]. August 19, 2009.
- Quest Diagnostics Press Release. Quest Diagnostics Introduces Dako’s PD-L1 Complementary Diagnostic Test to Support Bristol-Myers Squibb’s OPDIVO® Anti-PD-1 Therapy for Non-squamous Non-small Cell Lung Cancer. The new Quest test service is based on the first FDA-approved complementary diagnostic. Available online at: . Accessed November 8, 2015.
- Keytruda (pembrolizumab) demonstrates superior progression-free and overall survival compared to chemotherapy as first line treatment in patients with advanced non-small cell lung cancer. [Press release.] mercknewsroom.com/news-release/oncology-newsroom/mercks-keytruda%C2%A0pembrolizumab-demonstrates-superior-progression-free- Accessed June 21, 2016.
- Borghaei H, Paz-Ares L, Horn L, et al. Nivolumab versus Docetaxel in Advanced Nonsquamous Non–Small-Cell Lung Cancer. New England Journal of Medicine. 2015; 373:1627-1639.
- OSI Pharmaceuticals. FDA Approves Tarceva as a Maintenance Therapy for Advanced Non-small Cell Lung Cancer. Available at: investor.osip.com/releasedetail.cfm?ReleaseID=460783. Accessed April 19, 2010.
- Zhou C, Wu Y-L, Chen G et al. Erlotinib versus chemotherapy as first-line treatment for patients with advanced EGFR mutation-positive non-small-cell lung cancer (OPTIMAL, CTONG-0802): A multicentre, open-label, randomized, phase 3 study. Lancet Oncology. Early online publication July 22, 2011.
- Shaw AT, Kim DW, Mehra R, et al: Ceritinib in ALK-rearranged non–small-cell lung cancer. New England Journal of Medicine. 2014; 370: 1189-1197.
- Leighl NB, Rekhtman N, Biermann WA, et al. Molecular testing for selection of patients with lung cancer for epidermal growth factor receptor and anaplastic lymphoma kinase tyrosine kinase inhibitors: American Society of Clinical Oncology endorsement of the College of American Pathologists/International Association for the Study of Lung Cancer/Association for Molecular Pathology Guideline. Journal of Clinical Oncology. 2014;32(32):3673-79. Available at: http://jco.ascopubs.org/content/32/32/3673. Accessed September 30, 2016.
- United States Food and Drug Administration (FDA). FDA expands use of Xalkori to treat rare form of advanced non-small cell lung cancer. Available at: FDA expands use of Xalkori to treat rare form of advanced non-small cell lung cancer. Accessed March 11, 2016.
- FDA grants regular approval to dabrafenib and trametinib combination for metastatic NSCLC with BRAF V600E mutation
- Gainor JF, et al. Abstract 9008. Presented at: ASCO Annual Meeting; May 31-June 4, 2019; Chicago.
- Efficacy of Larotrectinib in TRK Fusion–Positive Cancers in Adults and Children
- Entrectinib Granted Priority Review by FDA for NTRK+ Tumors and ROS1+ NSCLC
- US Food and Drug Administration. FDA approves third oncology drug that targets a key genetic driver of cancer, rather than a specific type of tumor. August 15, 2019.