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Lung Cancer Treatment

What Is the Goal of Treatment?

The goal of cancer treatment can be different for different individuals. If there is a chance of curing your cancer, you will be offered treatments to eliminate the cancer. These are called curative treatments.  If your cancer cannot be cured, then you will be given treatments to help you feel more comfortable and manage your symptoms. These are called palliative treatments.

Local vs. Systemic Treatments

Local treatments are directed at a specific part of the body such as the lungs. A local treatment is given when the cancer is limited to one area. Radiation and surgery are both local treatments. Systemic treatments affect your whole body. They are given when cancer is found in several parts of the body or to reduce the chance of cancer coming back. Chemotherapy and targeted therapy are two kinds of systemic treatment.

Your treatment team will consider several factors when choosing treatments that will fight your cancer most effectively. They will consider your overall health, age, and personal circumstances. They will also consider the unique features of your particular cancer including the cancer type, tumour location, biomarker testing, and whether it has spread to other parts of your body.

Your treatment team should also consider your wishes for your treatment. You are an important part of your lung cancer treatment team, so don’t be afraid to ask questions about your treatment or to discuss other available treatment options.  You and your treatment team work together to make shared decisions that are best for you. Optimal decisions take into account evidence-based information about available options, the treatment team’s knowledge and experience, and your values and preferences.

Need one-on-one advice? Talk to a Certified Respiratory Educator through our Lung Health Line. We’re available Monday – Friday, 9:00 a.m. to 4:00 p.m. EST. Chat live at lunghealth.ca, email us, or call us toll-free at 1-888-344-LUNG (5864).

Treatment Pathways

Regardless of your location, Lung cancer treatment follows a structured pathway, ensuring patients receive comprehensive and coordinated care. Treatment pathways provide a standardized approach to managing lung cancer. They use evidence-based best practices which helps ensure all patients receive the most effective and most up-to-date treatments.

Treatment pathways are used to try to improve patient outcomes. They also help guide decision making by health care providers and their patients and facilitate coordination of care between multidisciplinary care team members.

The first step is to diagnose the type and stage of lung cancer through various tests and procedures including imaging and biopsies. This requires that various specialists are consulted including thoracic surgeons (who can determine whether the cancer is operable), oncologists, radiologists, pathologists, and other specialists. These health care team members work together to develop an individualized treatment plan which considers the patient’s unique needs.

Patients will then receive treatments based on the stage and characteristics of their cancer. This may include surgery, radiation, chemotherapy, targeted therapy, or immunotherapy. The treatments will be delivered in a specific order and additional testing may be performed to evaluate how well the treatments are working.

After treatment, patients will be followed and monitored.

When cancer is not curable, patients will receive supportive care through to end-of-life.

Lung Cancer Treatment Options

This treatment option depends on the size and location of the tumour. Your tumour may be resectable, meaning it can be completely removed with surgery, or unresectable, meaning it cannot be completely removed with surgery.

The two commonly used approaches are thoracotomy and minimally invasive surgery. Thoracotomy involves making an incision on the side of the chest and dividing some of the chest wall muscles to access the lung. Minimally invasive surgery, on the other hand, uses small incisions and special instruments, including a camera, to perform the surgery. This method is also known as thoracoscopy or video-assisted thoracoscopic surgery (VATS) and can be done with the help of a surgical robot. The choice of approach depends on factors such as the location, size, and stage of the tumor, as well as the surgeon’s expertise.

During surgery, all or part of the tumor as well as a portion of healthy tissue is removed. Surgery is done under a general anesthetic, and you will stay in the hospital for a few days following the surgery.

Surgery is most used for non-small cell cancer, or for small cell lung cancer if it is found at an early stage. There are several types of surgical procedures that can be done such as:

  1. Wedge resection- the removal of a small, wedge-shaped part of the lung tissue surrounding the tumor.
  2. Segmental resection or segmentectomy- the removal (resection) of the one of the five lobes of the lung affected by lung cancer.
  3. Lobectomy- the removal (resection) of the one of the five lobes of the lung affected by lung cancer.
  4. Pneumonectomy- the removal (resection) of the one of the five lobes of the lung affected by lung cancer.

Sometimes lymph nodes in the chest will be removed as well.

It takes time to recover after surgery. Side effects can include pain or discomfort and the collection of air or fluid in the chest. You can also expect some shortness of breath right after your surgery. These side effects are temporary and can be managed. You will likely need to perform coughing and breathing exercises several times a day.

Radiation therapy uses intense beams of energy to kill cancer cells. Many people with lung cancer receive radiation therapy. Radiation therapy may be given before surgery to shrink tumors (induction or neoadjuvant therapy) or after surgery to help destroy cancer cells that may remain in your body (adjuvant therapy). Radiation therapy may be used if your cancer can’t be surgically removed – either because of your overall health, your level of heart or lung function, or how close the cancer is to your vital organs. When radiation is combined with chemotherapy, this is called chemoradiation.

Radiation therapy treatments are given at a cancer centre that has the radiation equipment. They are provided on a daily basis (for the duration of the treatment course). Most people live at home during the treatment and travel to the clinic each day. Those who live too far away from the cancer centre for daily commuting may have to seek accommodation near the cancer centre for the duration of their treatment regimen. Some cancer centres have accommodations available. The length of your radiation therapy treatment can vary. For large tumours or those that have spread to the lymph nodes, radiation therapy can take place in daily doses that span several weeks.

Since radiation damages the cells in its path – healthy cells as well as tumour cells – there are some side effects. Fatigue and shortness of breath are the most common. Remember to talk to your cancer care team about any side effects you experience, as they can often be managed.

External beam radiation treatment uses a large machine to direct an external beam of radiation directly at the tumor. Treatment times are short and painless, though you’ll be required to lay down and be very still. Some types of external radiation therapy include 3D conformal radiation therapy, intensity-modulated radiation therapy, and stereotactic body radiotherapy.

Stereotactic body radiotherapy is an option for those with small lung cancers. This form of radiation aims many beams of radiation from different angles at the lung cancer. Stereotactic body radiotherapy treatment is typically completed in one or a few treatments. In certain cases, it may be used in place of surgery for small tumors.

Internal beam radiation or brachytherapy is provided by placing the radioactive material (i.e., seeds, needles, or catheters) directly into or near the tumor. This technique uses internal radiation. It may be done during surgery. It can be used to shrink tumours in your airway, which can relieve symptoms.

Chemotherapy is the use of anticancer drugs which destroy cancer cells. Chemotherapy may be given for different reasons. You may have chemotherapy before surgery to shrink tumors (induction or neoadjuvant therapy) or after surgery to help destroy cancer cells that may remain in your body (adjuvant therapy). You may also receive chemotherapy as the main treatment if the cancer cannot be removed with surgery.

Chemotherapy may be given as an injection or an oral therapy, depending on the actual drug that is required. Chemotherapy interferes with the ability of the cancer cells to grow and spread, but it can also damage your healthy cells as well. Healthy cells recover over time, but you can experience a range of side effects. You may experience nausea, vomiting, loss of appetite, fatigue, lung problems, hair loss, and increased risk of infection, to name a few.

Chemotherapy by injection is usually given at the cancer centre. There are a variety of protocols for various drugs and you may have to travel to the cancer centre at various time intervals depending on the drug you are receiving.

More and more oral chemotherapy drugs are becoming available. Being able to take your medication on your own at home can mean less visits to your cancer centre and can save you time and energy, but it means that you will have to monitor and manage your own symptoms. It is important to talk with the cancer care team about when you should call the cancer centre if you are experiencing changes in your side effects.

Your immune system defends your body from infection and disease. When things are working properly, your body will sense threats and get rid of them. However, your body’s immune system can’t always recognize cancer cells as a threat. To your immune system, they may just look like normal cells.

Immunotherapy is medicine that stimulates your own immune system to recognize and destroy cancer cells. It can be given alone or with other treatments like chemotherapy. Immunotherapy may be given by needle into a vein (IV), or as a pill or capsule you swallow.

The most commonly used immunotherapy for lung cancer is a treatment called immune checkpoint inhibitors (ICIs). The body produces proteins that prevent the immune system from destroying its own cells. ICIs work by blocking these proteins, allowing the body’s T-cells to attack cancer cells.

Like chemotherapy, the goals of immunotherapy treatment vary depending on personal factors. You may be prescribed immunotherapy to stop or slow growth of your cancer, or to control symptoms.

Immunotherapy is often well tolerated, but there are some side effects that you should know about. The most common are fatigue, skin reactions, and flu-like symptoms. Other possible side effects include muscle pain, shortness of breath, leg swelling, sinus congestion, headaches, weight gain, diarrhea, hormone changes, and cough. Remember to talk to your cancer care team about any side effects you experience, as they can often be managed.

Targeted therapies are treatments that are personalized to the specific biomarkers for your cancer.

Targeted therapies work to exploit a particular weakness of your cancer. By identifying the unique molecular features of your cancer, doctors can use therapies that have a better chance of working. Additionally, targeted therapies may have fewer or less intense side effects when compared to general treatments like chemotherapy.

Previously, targeted therapies were only available for non-small cell lung cancer, but now, some forms of small cell lung cancer may qualify for targeted therapies.

It’s important to ask about biomarker testing and targeted therapies to ensure you are receiving the best available treatment for your cancer.

Some of the more common biomarkers and their targeted lung cancer therapies include:

Biomarker

Targeted therapies

Epidermal growth factor receptor (EGFR) mutations

First generation: erlotinib, gefitinib,

Second generation: afatinib, dactomitinib,

Third generation: osimertinib, amivantamab

Anaplastic lymphoma kinase (ALK) mutations

First generation: crizotinib,

Second generation: alectinib, brigatinib, lorlatinib, alectinib

ROS1 mutations

crizotinib and entrectinib

KRAS G12C mutation

sotorasib

BRAF mutations

dabrafenib and trametinib

Neurotrophic tyrosine receptor kinase (NTRK) mutations

larotrectinib and entrectinib, sometimes larotrectinib monotherapy

MET exon 14 skipping mutations

capmatinib and tepotinib

RET gene fusions

selpercatinib and pralsetinib

For small cell lung cancer:

Mutation

Targeted therapies

PD-1 and PD-L1 immune checkpoints

immune checkpoint inhibitors (ICIs)

CD56 surface marker

Lorvotuzumab (in trials, not yet approved)

BCL-2 overexpression

Venetoclax (in trials, not yet approved for SCLC)

 

You may be offered an opportunity to participate in a clinical trial as part of your treatment plan. A clinical trial is a carefully controlled research study that determines how well a treatment works and how safe it is. A clinical trial may be performed for a new treatment, or for an existing treatment that’s being used in a new way.

If you are thinking about participating in a clinical trial, it’s a good idea to discuss this carefully with your doctor. Your doctor must make sure that you understand what’s involved in participating in the trial, how your safety will be protected, and what the potential risks are. This is all part of informed consent.

Once you have discussed the opportunity with your doctor, consider talking it over with your family and others in your support system. Participating in a clinical trial can involve some travel, tests and occasional hospital stays, and you may need more support and assistance.

The choice to participate in a clinical trial or not is yours. You don’t have to participate if you don’t want to.

Potential Benefits

Potential Drawbacks

●       A clinical trial could help you gain early access to a treatment you wouldn’t otherwise be able to access

●       A clinical trial could help you access medications you wouldn’t be able to afford

●       It gives you access to a wider care team

●       It’s a chance to help others and improve the way cancer is treated

●       Depending on the trial, you may not get to access new treatment. This is a possibility because many cancer clinical trials are designed to compare new treatments to more established/approved treatments.

●       The side effects of new treatments may not be as well known

●       New treatments may not be as effective as established treatments.

There are many steps that a treatment has to go through before it gets to the clinical trial stage. This includes extensive laboratory tests using cells, tissue samples, and animals.

Before the trial begins, the person or organization testing the treatment must apply to Health Canada. Health Canada’s scientists will review the application to make sure:

  • Drugs are used in the right way for the patients being studied
  • Any risks in using the drug are lowered as much as possible
  • The best interests of the people taking part in the trial have been considered
  • The goals of the trial can be met

There are very strict rules in place for clinical trials in Canada. All trials must:

  • Protect the health of the people in the trial
  • Be well designed and conducted by trained professionals
  • Be monitored and side effects reported
  • Be reviewed by a Research Ethics Board

Finding clinical trials for lung cancer

The Canadian Partnership Against Cancer maintains a searchable database of ongoing clinical trials. You can filter by location and create email alerts for any new trials that begin in your area. Your Oncologist can also help you find clinical trials.

Boost Your Results By Quitting Smoking!

It’s never “too late” to quit smoking. In fact, if you smoke, getting you the help you need to quit is an important part of your treatment plan. There is evidence that continuing to smoke could make your treatments less effective, and increase your risk of experiencing treatment complications, especially when it comes to surgery.

Quitting isn’t always easy, but we can help. You can get non-judgemental, one-on-one guidance from Certified Smoking Cessation Counselor through our Lung Health Line. We’re available Monday – Friday, 8:30 a.m. to 4:30 p.m. EST. Chat live at lunghealth.ca, email us, or call us toll-free at 1-888-344-LUNG (5864).

Managing Side Effects of Lung Cancer Treatment

Cancer treatments typically have side effects such as fatigue, hair loss or nausea. However, treatments may affect each person differently. It is hard to predict exactly what your experience with side effects will be. The important thing to remember is that side effects can be managed effectively.

Talk with your cancer care team about what you are experiencing and seek their advice about managing the side effects. Below are tips for managing a few of the most common ones individuals experience. Some you can manage yourself while others will need the assistance of the health care team members.

Lung cancer can cause bleeding in the airway and cause you to cough up blood (called hemoptysis). Sometimes bleeding can become severe. Treatments are available to control bleeding. It’s important to talk to your health care team about this symptom.

Everyone who has cancer pain will feel it differently. Only you know how much pain you are feeling and how it affects you. Getting relief from pain is important because it can interfere with getting a good sleep, eating well, enjoying your time with family and friends, and doing your work or hobbies. You do not have to accept pain as a normal part of living with cancer.

Pain will feel different when it comes from different parts of your body.

Bone pain can be felt as a deep throbbing pain that can be sharp at times. It may get worse as you move around.

Neuropathic pain is from damage to your nerves. This pain can feel like burning, or shooting pain or like ‘pins and needles’. It can hurt when things touch your skin (i.e., clothing, water, wind).

Visceral pain is from the organs inside your body. It can be dull, deep or squeezing pain. Sometimes it is hard to tell where it is coming from.

If you are taking medication regularly for pain, you may experience breakthrough pain between doses. This can happen suddenly.

Discuss your pain experience with your doctor and the health care team. There are different medications for different types of pain. Sometimes it takes some adjusting to find the right dose and time to take your medications. Your doctor may prescribe more than one type of pain medication. It is important to work together to find the right plan for your situation.

Lung cancer can cause fluid to accumulate in the space that surrounds the affected lung in the chest cavity (pleural space). This accumulation of fluid can result in shortness of breath and pain. Treatments are available to drain this fluid from your chest and reduce the risk that the pleural effusion will occur again.

Anemia is caused by a low level of healthy red blood cells. Cancer and its treatment can decrease the amount of red blood cells and the hemoglobin level in the blood. Symptoms can include:

  • Fatigue
  • Pale skin, especially noticeable around the lips and nail beds
  • Dizziness
  • Weakness
  • Shortness of breath
  • Low blood pressure
  • Feeling cold
  • Headache
  • Difficulty concentrating

Constipation is when the stool is hard and difficult to pass. It can be caused by chemotherapy and radiation, as well as some pain relievers or anti-nausea drugs. Treatments are available, including medication and lifestyle changes. Symptoms can include:

  • Bloating or feeling full
  • Cramping or pain
  • Gas
  • Loss of appetite
  • No regular bowel movement for two or more days
  • Straining to have a bowel movement

Diarrhea is the frequent passing of loose, watery stool and can be caused by cancer treatment. Symptoms of diarrhea can include:

  • Gas
  • Cramping
  • Bloating
  • Weight loss
  • Rectal pain or bleeding
  • Dehydration

Difficulty breathing is feeling like you can’t get enough air. This can be caused by a tumour blocking, narrowing or putting pressure on an airway, radiation therapy to the lungs or lung surgery. This is something you can speak to your health care team about. Symptoms can include:

  • Trouble catching your breath
  • Working hard to breathe
  • Fast breathing, fast heartbeat, or both
  • Wheezing
  • Coughing

Some types of cancer treatments can make it harder to swallow. Symptoms can include:

  • Feeling like food is stuck in the throat
  • Difficulty starting to swallow
  • Trouble moving food from the mouth to the throat
  • Food getting stuck in the cheeks
  • Coughing, choking or gagging when swallowing

Disseminated intravascular coagulation (DIC) is a condition with two stages. In stage one, overactive clotting causes blood clots in the bloodstream. These clots block small blood vessels in organs or limbs. In stage two, blood clotting factors are low, which can cause excessive bleeding. DIC can be caused by tumours in the lung. Symptoms can include:

  • Bleeding and bruising easily
  • Shortness of breath
  • Pain or swelling in the arms and legs
  • Jaundice, which includes yellow skin and whites of the eyes
  • Low blood pressure
  • Low blood oxygen level
  • Bleeding at an intravenous site or in the gums, skin, muscles, digestive tract or abdominal cavity

Chemotherapy or radiation can cause hair loss. Some biological therapies can dry or thin hair. Hair loss is a common side effect of chemotherapy, but not all drugs cause hair loss. In most cases, hair loss is temporary. Radiation can cause hair loss in the area where the radiation was given. The amount of hair loss and whether it will grow back depends on the dose of radiation. Hair loss often begins two to three weeks after chemotherapy or radiation starts.

Hypercalcemia is when too much calcium is in the blood. It develops when the bones release too much calcium or the kidneys cannot get rid of enough calcium. It can be caused by advanced stages of lung cancer. Symptoms can include:

  • Nausea and vomiting
  • Loss of appetite
  • Constipation
  • Muscle weakness
  • Increased thirst
  • Frequent urination
  • Dark yellow urine
  • Little or no sweating
  • Confusion and difficulty concentrating
  • Bone pain or bone fracture

Cancer treatment lowers the number of white blood cells in the body, which play a major role in defending the body against viruses and bacteria. This can lead to infections. With lung cancer, recurring bronchitis or pneumonia may occur.

Symptoms of infection can vary, depending on what part of the body is affected. Having a fever is the most common sign of infection. But sometimes you can have an infection without a fever. Symptoms can include:

  • Chills or shivering
  • Unusual sweating
  • Redness, heat, swelling or discomfort from a wound, surgical cut or area around an intravenous line or vascular access device site
  • Sore throat
  • Cough, which may produce phlegm
  • Shortness of breath or rapid breathing
  • Diarrhea
  • Vomiting
  • Weakness
  • Sinus pain

Cancer treatment can affect the way food tastes or make you not feel like eating. Symptoms can include:

  • Feeling like food tastes “funny”
  • Being put off by certain food odours
  • Not liking a food that was once a favourite
  • Eating only one or two types of foods
  • Feeling full sooner than expected

Low blood cell counts happen when bone marrow doesn’t produce the normal number of blood cells. Chemotherapy and radiation can affect the bone marrow and cause low blood cell counts. A low red blood cell count is called anemia. Symptoms can include:

  • Fatigue
  • Pale skin or lips
  • Increased heart rate
  • Tiring easily with exertion
  • Dizziness

A low white blood cell count is called neutropenia or leukopenia. It puts you at greater risk of infection.

Platelets are made in the bone marrow and help the blood to clot. Chemotherapy, biological therapies or other drugs can cause platelet levels to drop. Symptoms can include:

  • Easy bruising
  • Bleeding from the nose, gums or mouth
  • Tiny red spots on the skin
  • Blood in the urine
  • Dark or black bowel movements

Nausea and vomiting are common side effects of cancer treatment and often occur together. Causes include chemotherapy and radiation or pain medication. There are treatments available that can relieve symptoms.

Radiation pneumonitis is inflammation of the lung caused by radiation to the chest. It most commonly develops one to three months after treatment. Radiation pneumonitis is more likely to happen with high doses of radiation or when a large area of the lung is treated. Some chemotherapy drugs can also increase the risk of developing radiation pneumonitis if given along with radiation therapy. Symptoms can include:

  • Cough
  • Chest congestion or pain
  • Shortness of breath

Cancer treatments can alter your usual sleep patterns. Sleep problems can be caused by anxiety and depression, or by symptoms of cancer, or side effects of treatment, such as pain, nausea or shortness of breath. You may have trouble falling asleep or staying asleep, not feel refreshed after sleep or you may sleep too much. This can impact your quality of life, so it’s important to speak to your health care team if you are experiencing sleep disturbances.

A sore mouth and throat can be side effects of chemotherapy and radiation. Sores and inflammation can develop in the mouth, back of the throat and the lips.

The superior vena cava is the large vein that carries blood from the head, neck, arms and chest to the heart. Superior vena cava syndrome is a group of symptoms that occur when there is pressure on the superior vena cava or it is partially blocked and blood can’t flow back to the heart properly. Superior vena cava syndromes is common in lung cancer and lymphomas. This causes more pressure in the veins and face, which leads to a buildup of fluid or swelling. Symptoms can include:

  • Shortness of breath, especially when bending over or lying down
  • Feeling of fullness in the head
  • Swelling in the face, neck, upper body or arms
  • Hoarseness
  • Chest pain
  • Bluish colour on the lips and skin

Syndrome of inappropriate antidiuretic hormone develops when there is too much antidiuretic hormone (ADH) in the body. ADH helps regulate the balance of fluids in the body by decreasing the amount of urine the body makes and increasing the amount of water the kidneys take up. Too much ADH leads to water retention, electrolyte imbalances and a low level of sodium in the blood. This syndrome can be caused by lung cancer or by some cancer treatments or pain medications. Symptoms can include:

  • Fatigue
  • Headache
  • Nausea and vomiting
  • Muscle cramps
  • Lethargy
  • Agitation
  • Confusion
  • Delirium
  • Disorientation
  • Hallucinations

Clinical trials

You may be offered an opportunity to participate in a clinical trial as part of your treatment plan. This decision is one to talk carefully about with your doctor. Your doctor must make sure that you understand what’s involved in participating in the trial, how your safety will be protected, and what the potential risks are. This is part of an important concept called informed consent.

Once you have discussed the opportunity with your doctor, consider talking it over with your family and others in your support system. Participating in a clinical trial can involve some travel, tests and occasional hospital stays, and you may need more support and assistance from those you can count on.

What is a clinical trial?

A clinical trial is a carefully controlled research study that determines how well a treatment works and how safe it is. A clinical trial may be performed for a brand new treatment, or for an existing treatment that’s being used in a new way.

What are some of the potential benefits?
A clinical trial could help you gain early access to a treatment that you wouldn’t otherwise be able to access (or afford). It also gives you access to a wider care team.

What about the drawbacks?

Depending on the trial, you may not get to access new treatment. This is a possibility because many cancer clinical trials are designed to compare new treatments to more established/approved treatments. Another drawback is side effects. In newer treatments, the side effects may not be as well known. It’s important to communicate with your clinical trial investigators about any side effects you experience.

What happens before a clinical trial?

There are many steps that a treatment has to go through before it gets to the clinical trial stage. This includes extensive laboratory tests using cells, tissue samples, and animals.

Before the trial begins, the person or organization testing the treatment must apply to Health Canada. Health Canada’s scientists will review the application to make sure:

  • Drugs are used in the right way for the patients being studied
  • Any risks in using the drug are lowered as much as possible
  • The best interests of the people taking part in the trial have been considered
  • The goals of the trial can be met

There are very strict rules in place for clinical trials in Canada. All trials must:

  • Protect the health of the people in the trial
  • Be well designed and conducted by trained professionals
  • Be monitored and side effects reported
  • Be reviewed by a Research Ethics Board

Source: Clinical Trials and Drug Safety, Health Canada.

Finding clinical trials for lung cancer

The Canadian Partnership Against Cancer maintains a searchable database of ongoing clinical trials. You can filter by location, and create email alerts for any new trials that begin in your area.

Lung Cancer Screening

Lung Cancer Screening

“Screening” means checking for cancer before symptoms develop, even if you feel healthy. Screening can help detect cancer in its earliest stages.

Middle aged man hugs his adult son. He looks supported.

Diagnosis and Staging

Being diagnosed with lung cancer is often life-changing, and emotional distress is common. Understanding the steps and procedures can help you feel more in control, prepare you to advocate for yourself during your treatment.

Navigating Your Lung Cancer Care

The cancer care system can seem overwhelming at first, but we’re here to help you navigate it in a way that makes you feel empowered and supported. 

An elderly man comforts his wife

Living with Lung Cancer

The questions we list here are the top coping questions reported by people with lung cancer. Our answers provide some basic information, but we encourage you to discuss any concerns or questions with your oncologist and other members of your cancer care team.