Lung cancer - Treating lung cancer

You will be cared for by a team of specialists who will work together to provide the best possible treatment.

This team will contain all the specialists required to make a proper diagnosis, to stage your cancer and to plan the best treatment. If you want to know more, ask your specialist about this.

The type of treatment you will receive for lung cancer depends on several factors, including:

• the type of lung cancer you have (non-small-cell or small-cell cancer) 
• the size and position of the cancer 
• how far advanced your cancer is (the stage) 
• your overall health

Deciding what treatment is best for you can be difficult. Your cancer team will make recommendations, but the final decision will be yours.

The main treatment options include surgery, radiotherapy and chemotherapy. Depending on your type of cancer and how advanced it is, you may receive a combination of these treatments.

Your treatment plan

Your treatment plan will depend on whether you have non-small-cell lung cancer or small-cell lung cancer.

Non-small-cell lung cancer

If you have non-small-cell lung cancer that is confined to one lung and you are in good general health, you'll probably have surgery to remove the cancerous cells. This may be followed by a course of chemotherapy to destroy any cancer cells that may have remained in the body.

If the cancer has not spread too far but surgery is not possible (for example, if your general health means you have an increased risk of developing complications), radiotherapy to destroy the cancerous cells will usually be recommended. In some cases, this may be combined with chemotherapy (known as chemoradiotherapy).

If the cancer has spread too far for surgery or radiotherapy to be effective, chemotherapy is usually recommended. If the cancer starts to grow again after initial chemotherapy treatment, another course of treatment may be recommended.

In some cases, a treatment called biological or targeted therapy may be recommended as an alternative to chemotherapy, or after chemotherapy. Biological therapies are medications that can control or stop the growth of cancer cells. 

Small-cell lung cancer

Small-cell lung cancer is usually treated with chemotherapy, either on its own or in combination with radiotherapy. This can help prolong life and relieve symptoms.

Surgery isn't usually used to treat this type of lung cancer. This is because often the cancer has already spread to other areas of the body by the time it's diagnosed. However, if the cancer is found very early, surgery may be used. In these cases, chemotherapy or radiotherapy may be given after surgery to help reduce the risk of the cancer returning.

Surgery

There are three types of lung cancer surgery:

• Lobectomy – where one or more large parts of the lung (called lobes) are removed. Your doctors will suggest this operation if the cancer is just in one section of one lung. 
• Pneumonectomy – where the entire lung is removed. This is used when the cancer is located in the middle of the lung or has spread throughout the lung.
• Wedge resection or segmentectomy – where a small piece of the lung is removed. This procedure is only suitable for a small number of patients as it is only used if your doctors think your cancer is small and limited to one area of the lung. This is usually very early-stage non-small-cell lung cancer.

People are naturally concerned that they will not be able to breathe if some or all of a lung is removed, but it is possible to breathe normally with one lung. However, if you have breathing problems before the operation, such as breathlessness, it is likely that these symptoms will continue after surgery.

Tests before surgery

Before surgery can take place, you will need to have a number of tests to check your general state of health and your lung function. These may include:

• an electrocardiograph (ECG) – electrodes are used to monitor the electrical activity of your heart
• spirometry – you will breathe into a machine called a spirometer, which measures how much air your lungs can breathe in and out

How it's performed

Surgery is usually performed by making a cut (incision) in your chest or side, and removing a section or all of the affected lung. Nearby lymph nodes may also be removed if it is thought that the cancer may have spread to them.

In some cases, an alternative to this approach, called video-assisted thoracoscopic surgery (VATS), may be suitable. VATS is a type of keyhole surgery, where small incisions are made in the chest. A small fibre-optic camera is inserted into one of the incisions, so the surgeon can see images of the inside of your chest on a monitor.

After the operation

You will probably be able to go home five to 10 days after your operation. However, it can take many weeks to recover fully from a lung operation.

After your operation, you will be encouraged to start moving about as soon as possible. Even if you have to stay in bed, you will need to keep doing regular leg movements to help your circulation and prevent blood clots from forming. A physiotherapist will show you breathing exercises to help prevent complications.

When you go home, you will need to exercise gently to build up your strength and fitness. Walking and swimming are good forms of exercise that are suitable for most people after treatment for lung cancer. Talk to your care team about which types of exercise are suitable for you.

Complications

As with all surgery, lung surgery carries a risk of complications. These are estimated to occur in one out of every five cases. These complications can usually be treated using medication or additional surgery, which may mean you need to stay longer in hospital.

Complications of lung surgery can include:

• inflammation or infection of the lung (pneumonia) 
• excessive bleeding 
• a blood clot in the leg (deep vein thrombosis), which could potentially travel up to the lung (pulmonary embolism)

Radiotherapy

Radiotherapy is a type of treatment that uses pulses of radiation to destroy cancer cells. There are a number of ways it can be used to treat people with lung cancer.

An intensive course of radiotherapy, known as radical radiotherapy, can be used to try to cure non-small-cell lung cancer if the person is not healthy enough for surgery. For very small tumours, a special type of radiotherapy called stereotactic radiotherapy may be used instead of surgery.

Radiotherapy can also be used to control the symptoms and slow the spread of cancer when a cure is not possible (this is known as palliative radiotherapy).

A type of radiotherapy known as prophylactic cranial irradiation (PCI) is also sometimes used during the treatment of small-cell lung cancer. PCI involves treating the whole brain with a low dose of radiation. It is used as a preventative measure because there is a risk that small-cell lung cancer will spread to your brain.

The three main ways that radiotherapy can be given are described below:

• Conventional external beam radiotherapy – a machine is used to direct beams of radiation at affected parts of your body. 
• Stereotactic radiotherapy – a more accurate type of external beam radiotherapy where several high-energy beams are used to deliver a higher dose of radiation to the tumour, while sparing the surrounding healthy tissue as much as possible.
• Internal radiotherapy – a catheter (thin tube) is inserted into your lung. A small piece of radioactive material is placed inside the catheter and positioned against the site of the tumour before being removed after a few minutes.

For lung cancer, external beam radiotherapy is used more often than internal radiotherapy, particularly if it is thought that a cure is possible. Stereotactic radiotherapy may be used to treat tumours that are very small, as it is more effective than standard radiotherapy alone in these circumstances.

Internal radiotherapy only tends to be used as a palliative treatment where the cancer is blocking or partly blocking your airway.

Courses of treatment

A course of radiotherapy treatment can be planned in several different ways.

Radical radiotherapy is usually given five days a week, with a break at weekends. Each session of radiotherapy lasts 10-15 minutes and the course usually lasts between four and seven weeks.

Continuous hyperfractionated accelerated radiotherapy (CHART) is an alternative method of delivering radical radiotherapy. CHART is given three times a day for 12 days in a row.

For stereotactic radiotherapy, fewer treatment sessions are needed because a higher dose of radiation is delivered with each treatment. People having conventional radical radiotherapy are likely to have around 20-32 treatment sessions, whereas stereotactic radiotherapy typically only requires between three and 10 sessions.

Palliative radiotherapy usually only requires one to five sessions to control your symptoms. 

Side effects

Side effects of radiotherapy to the chest include:

• chest pain 
• fatigue 
• persistent cough that may bring up blood-stained phlegm (this is normal and nothing to worry about) 
• difficulties swallowing (dysphagia) 
• redness and soreness of the skin, which looks and feels like sunburn 
• hair loss on your chest 

Side effects should pass once the course of radiotherapy has been completed.

Chemotherapy

Chemotherapy uses powerful cancer-killing medication to treat cancer. There are several different ways that chemotherapy can be used to treat lung cancer. For example, it can be:

• given before surgery to shrink a tumour, which can increase the chance of successful surgery (this is usually only done as part of a clinical trial)
• given after surgery to prevent the cancer returning 
• used to relieve symptoms and slow the spread of cancer when a cure is not possible 
• combined with radiotherapy

Chemotherapy treatments are usually given in cycles. A cycle involves taking the chemotherapy medication for several days, then having a break for a few weeks to let your body recover from the effects of the treatment.

The number of cycles of chemotherapy that you need will depend on the type and the grade of your lung cancer. Most people require between four and six courses of treatment over three to six months.

Chemotherapy for lung cancer involves taking a combination of different medications. The medications are usually delivered through a drip into your vein, or into a tube that is connected to one of the blood vessels in your chest.

Side effects

Side effects of chemotherapy can include:

• fatigue 
• nausea
• vomiting 
• mouth ulcers
• hair loss

These side effects should gradually pass once your treatment has finished, or you may be able to take other medicines to make you feel better during your chemotherapy.

Chemotherapy can also weaken your immune system, making you more vulnerable to infection. Tell your care team or GP as soon as possible if you have the possible signs of an infection, such as a high temperature (fever) of 38C (100.4F) or higher, or suddenly feeling generally unwell.

Other treatments

As well as surgery, radiotherapy and chemotherapy, there are a number of other treatments that are sometimes used to treat lung cancer. These are described below.

Biological therapies

Biological therapies are new medications that are sometimes recommended as an alternative treatment to chemotherapy for non-small-cell cancer that has spread too far for surgery or radiotherapy to be effective.

Examples of biological therapies include erlotinib and gefitinib. These are also called growth factor inhibitors because they work by disrupting the growth of the cancer cells.

Biological therapies are only suitable for people who have certain proteins in their cancerous cells. Your doctor may be able to request tests on a small sample of cells removed from your lung (biopsy) to determine whether these treatments are likely to be suitable for you.

Radiofrequency ablation

Radiofrequency ablation is a new type of treatment that can treat non-small-cell lung cancer diagnosed at an early stage.

The doctor carrying out the treatment will use a computerised tomography (CT) scanner to guide a needle to the site of the tumour. The needle will be pressed into the tumour and radio waves will be sent through the needle. These waves generate heat, which kills the cancer cells.

The most common complication of radiofrequency ablation is that a pocket of air gets trapped between the inner and outer layer of your lungs (pneumothorax). This can be treated by placing a tube into the lungs to drain away the trapped air.

Cryotherapy

Cryotherapy is a treatment that can be used if the cancer starts to block your airways. This is known as endobronchial obstruction, and it can cause symptoms such as:

• breathing problems 
• cough
• coughing up blood

Cryotherapy is performed in a similar way to internal radiotherapy, except that instead of using a radioactive source, a device known as a cryoprobe is placed against the tumour. The cryoprobe can generate very cold temperatures, which help shrink the tumour.

Photodynamic therapy

Photodynamic therapy (PDT) is a treatment that can be used to treat early-stage lung cancer when a person is unable or unwilling to have surgery. It can also be used to remove a tumour that is blocking the airways.

Photodynamic therapy is carried out in two stages. Firstly, you will be given an injection of a medication that will make the cells in your body very sensitive to light.

The next stage is carried out 24-72 hours later. A thin tube will be guided to the site of the tumour, and a laser will be beamed through it. The cancerous cells, which are now more sensitive to light, will be destroyed by the laser beam.

Side effects of photodynamic therapy can include inflammation of the airways and a build-up of fluid in the lungs. Both these side effects can cause symptoms of breathlessness and lung and throat pain. However, these symptoms should gradually pass as your lungs recover from the effects of the treatment.