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Non-Small Cell Lung Cancer Treatment (PDQ®)
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General Information About Non-Small Cell Lung Cancer
Key Points:
Non-small cell lung cancer is a disease in which malignant
(cancer) cells form in the tissues of the lung.
The lungs are a pair of cone-shaped breathing organs in the chest. The lungs bring oxygen into the body as you breathe in. They release carbon dioxide, a waste product of the body’s cells, as you breathe out. Each
lung has sections called lobes. The left lung has two
lobes. The right lung is
slightly larger and has three lobes. Two
tubes called bronchi lead from the
trachea (windpipe) to the right and
left lungs. The bronchi are sometimes also involved in lung cancer. Tiny air sacs called alveoli and small tubes called
bronchioles make up the inside of
the lungs.
Respiratory anatomy; drawing shows right lung with upper, middle, and lower lobes; left lung with upper and lower lobes; and the trachea, bronchi, lymph nodes, and diaphragm. Inset shows bronchioles, alveoli, artery, and vein.
A thin membrane called the
pleura covers the outside of each lung and lines the inside wall of the chest cavity. This creates a sac called the pleural cavity.
The pleural cavity normally contains a small amount of fluid that helps the lungs move smoothly in the chest when you breathe.
There are two main types of lung cancer: non-small cell lung cancer and
small cell lung cancer. (See the
PDQ summary on Small Cell Lung Cancer
Treatment for more information.)
There are several types of non-small cell lung cancer.
Each type of non-small cell lung cancer has different kinds of cancer cells. The cancer
cells of each type grow and spread in different ways. The types of non-small
cell lung cancer are named for the kinds of cells found in the cancer and how
the cells look under a microscope:
Other less common types of non-small cell lung cancer are: pleomorphic, carcinoid tumor, salivary gland carcinoma, and unclassified carcinoma.
Smoking can increase the risk of developing non-small cell lung cancer.
Smoking cigarettes or cigars is the most common cause of lung cancer. The more years a person smokes, the greater the risk. If a person has stopped smoking, the risk becomes lower as the years pass, but is never completely gone.
Anything that increases a person's chance of developing a disease is called a risk factor. Risk factors for lung cancer include the following:
- Smoking cigarettes or cigars, now or in the past.
- Being exposed to second-hand smoke.
- Being treated with radiation therapy to the breast or chest.
- Being exposed to asbestos, radon, chromium, arsenic, soot, or tar.
- Living where there is air pollution.
When smoking is combined with other risk factors, the risk of developing lung cancer is increased.
Possible signs of non-small cell lung cancer include a cough that doesn't go away and shortness of breath.
Sometimes lung cancer does not cause any symptoms and is found during a routine chest x-ray. Symptoms may be caused by lung cancer or by other conditions. A doctor should be consulted if any of the following problems occur:
- A cough that doesn’t go away.
- Trouble breathing.
- Chest discomfort.
- Wheezing.
- Streaks of blood in sputum (mucus coughed up from the lungs).
- Hoarseness.
- Loss of appetite.
- Weight loss for no known reason.
- Feeling very tired.
Tests that examine the lungs are used to detect (find), diagnose, and stage non-small cell lung cancer.
Tests and procedures to detect, diagnose, and stage non-small cell lung cancer are often done at the same time. The following tests and procedures may be used:
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Physical exam and history: An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits, including smoking, and past jobs, illnesses, and treatments will also be taken.
- Chest x-ray: An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.
Chest x-ray; shows patient standing with back to the x-ray machine. X-rays are used to take pictures of organs and bones of the chest. X-rays pass through the patient onto film.
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CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, such as the chest, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.
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PET scan (positron emission tomography scan): A procedure to find malignant tumor cells in the body. A small amount of radioactive glucose (sugar) is injected into a vein. The PET scanner rotates around the body and makes a picture of where glucose is being used in the body. Malignant tumor cells show up brighter in the picture because they are more active and take up more glucose than normal cells do.
PET (positron emission tomography) scan; drawing shows patient lying on table that slides through the PET machine.
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Sputum cytology: A procedure in which a pathologist views a sample of sputum (mucus coughed up from the lungs) under a microscope, to check for cancer cells.
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Fine-needle aspiration biopsy of the lung: The removal of part of a lump, suspicious tissue, or fluid from the lung, using a thin needle. A CT scan, ultrasound, or other imaging procedure is used to locate the abnormal tissue or fluid in the lung. A small incision may be made in the skin where the biopsy needle is inserted into the abnormal tissue or fluid. A sample is removed with the needle and sent to the laboratory. A pathologist then views the sample under a microscope to look for cancer cells. A chest x-ray is done after the procedure to make sure no air is leaking from the lung.
Lung biopsy; drawing shows a patient lying on a table that slides through the computed tomography (CT) machine with an x-ray picture of a cross-section of the lung on a monitor above the patient. Drawing also shows a doctor using the x-ray picture to help place the biopsy needle through the chest wall and into the area of abnormal lung tissue. Inset shows a side view of the chest cavity and lungs with the biopsy needle inserted into the area of abnormal tissue.
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Bronchoscopy: A procedure to look inside the trachea and large airways in the lung for abnormal areas. A bronchoscope (a thin, lighted tube) is inserted through the nose or mouth into the trachea and lungs. Tissue samples may be taken for biopsy.
Bronchoscopy; drawing shows a bronchoscope inserted through the mouth, trachea, and bronchus into the lung; lymph nodes along trachea and bronchi; and cancer in one lung. Inset shows patient lying on a table having a bronchoscopy.
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Thoracoscopy: A surgical procedure to look at the organs inside the chest to check for abnormal areas. An incision (cut) is made between two ribs, and a thoracoscope (a thin, lighted tube) is inserted into the chest. Tissue samples and lymph nodes may be removed for biopsy. This procedure may be used to remove parts of the esophagus or lung. If certain tissues, organs, or lymph nodes can’t be reached, a thoracotomy may be done. In this procedure, a larger incision is made between the ribs and the chest is opened.
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Thoracentesis: The removal of fluid from the space between the lining of the chest and the lung, using a needle. A pathologist views the fluid under a microscope to look for cancer cells.
Certain factors affect prognosis (chance of recovery) and treatment options.
The prognosis (chance of recovery) and treatment options depend on the following:
- The stage of the cancer (the size of the tumor and whether it is
in the lung only or has spread to other places in the body).
- The type of lung
cancer.
- Whether there are symptoms such as coughing or trouble breathing.
- The patient’s general health.
For most patients with non-small cell lung cancer, current
treatments do not cure the cancer.
If lung cancer is found, taking part in one of the many clinical
trials being done to improve treatment should be considered. Clinical trials
are taking place in most parts of the country for patients with all stages of
non-small cell lung cancer. Information about ongoing clinical trials is
available from the NCI Web site.
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Stages of Non-Small Cell Lung Cancer
Key Points:
After lung cancer has been diagnosed, tests are done to
find out if cancer cells have spread within the lungs or to other parts of the
body.
The process used to find out if cancer has spread within the lungs or to other parts
of the body is called staging. The information gathered from the
staging process determines the stage of the disease. It is
important to know the stage in order to plan treatment. Some of the tests used to diagnose non-small cell lung cancer are also used to stage the disease. (See the General Information section.) Other tests and procedures
that may be used in the staging process include the following:
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Laboratory tests: Medical procedures that test samples of tissue, blood, urine, or other substances in the body. These tests help to diagnose disease, plan and check treatment, or monitor the disease over time.
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Chest x-ray: An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.
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MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body, such as the brain. This procedure is also called nuclear magnetic resonance imaging (NMRI).
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Endoscopic ultrasound (EUS): A procedure in which an endoscope (a thin, lighted tube) is inserted into the body. The endoscope is used to bounce high-energy sound waves (ultrasound) off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram. This procedure is also called endosonography. EUS may be used to guide fine needle aspiration biopsy of the lung, lymph nodes, or other areas.
Endoscopic ultrasound-guided fine-needle aspiration biopsy; drawing shows an endoscope with an ultrasound probe and biopsy needle inserted through the mouth and into the esophagus. Drawing also shows lymph nodes near the esophagus and cancer in one lung. Inset shows the ultrasound probe locating the lymph nodes with cancer and the biopsy needle removing tissue from one of the lymph nodes near the esophagus.
- Lymph node
biopsy: The
removal of all or part of a lymph node. A pathologist views the tissue under a microscope to look for cancer cells.
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Mediastinoscopy: A surgical procedure to look at the organs, tissues, and lymph nodes between the lungs for abnormal areas. An incision (cut) is made at the top of the breastbone and an endoscope (a thin, lighted tube) is inserted into the chest. Tissue and lymph node samples may be taken for biopsy.
Mediastinoscopy; shows mediastinoscope with light and lens inserted into
the chest through an incision above the breastbone. Drawing shows right
and left lungs, trachea, and lymph nodes. Inset shows anterior
mediastinotomy (Chamberlain procedure) with incision beside the
breastbone.
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Anterior
mediastinotomy: A surgical procedure to look at the organs and tissues between the lungs and between the breastbone and spine for abnormal areas. An incision (cut) is made next to the breastbone and an endoscope (a thin, lighted tube) is inserted into the chest. Tissue and lymph node samples may be taken for biopsy. This is also called the Chamberlain procedure.
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Bone scan: A procedure to check if there are rapidly dividing cells, such as cancer cells, in the bone. A very small amount of radioactive material is injected into a vein and travels through the bloodstream. The radioactive material collects in the bones and is detected by a scanner.
The following stages are used for non-small cell lung
cancer:
Occult (hidden) stage
In the occult (hidden) stage, cancer cells are found in sputum
(mucus coughed up from the lungs), but no tumor can be found in the lung by
imaging or bronchoscopy, or the
primary tumor is too small to be
checked.
Stage 0 (Carcinoma in Situ)
In stage 0, abnormal cells are found in the innermost lining of the lung. These abnormal cells may become cancer and spread into nearby normal tissue. Stage 0 is also called carcinoma in situ.
Stage I
Two-panel drawing of stage I non-small cell lung cancer; first panel shows stage IA with cancer in one lung; the trachea, lungs, lymph nodes, right main bronchus, bronchioles, and diaphragm are also shown; second panel shows stage IB with cancer in the left lung and near the left main bronchus. The inset shows a close-up of the lung, chest wall, and pleura with cancer spreading from the lung into the innermost layer of the pleura.
In stage I, cancer has formed. Stage I is divided into stages IA and IB:
Stage II
Two-panel drawing of stage II non-small cell lung cancer; first panel shows stage IIA with cancer in one lung and cancer in several nearby lymph nodes on the same side of the chest; the right main bronchus is also shown; second panel shows stage IIB with cancer in the chest wall, the diaphragm, the pleura between the lungs, and in the left main bronchus; the trachea, carina, and bronchioles are also shown; One inset shows a close up of cancer spreading from the lung into the pleura and chest wall; another inset shows a close up of cancer spreading from the lung into the pericardium (membrane around the heart).
Stage II is divided into stages IIA and IIB:
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Stage IIA: The tumor is 3 centimeters or smaller and cancer has spread to nearby lymph nodes on the same side of the chest as the tumor.
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Stage IIB:
-
Cancer has spread to nearby lymph nodes on the same side of the chest as the tumor and one or more of the following is true:
- The tumor is larger than 3 centimeters.
- Cancer has spread to the main bronchus of the lung and is 2 centimeters or more from the carina (where the trachea joins the bronchi).
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Cancer has spread to the innermost layer of the membrane that covers the lungs.
- The tumor partly blocks the bronchus or bronchioles and part of the lung has collapsed or developed pneumonitis (inflammation of the lung).
or
- Cancer has not spread to lymph nodes and one or more of the following is true:
- The tumor may be any size and cancer has spread to the chest wall, or the diaphragm, or the pleura between the lungs, or membranes surrounding the heart.
- Cancer has spread to the main bronchus of the lung and is no more than 2 centimeters from the carina (where the trachea meets the bronchi), but has not spread to the trachea.
- Cancer blocks the bronchus or bronchioles and the whole lung has collapsed or developed pneumonitis (inflammation of the lung).
Stage IIIA
Stage IIIA non-small cell lung cancer; drawing shows cancer in the lymph nodes, the left main bronchus, pleura, diaphragm, and chest wall. One inset shows a close up of cancer spreading from the lung into the pleura and chest wall; another inset shows a close up of cancer spreading from the lung into the pericardium (membrane around the heart).
In stage IIIA, cancer has spread to lymph nodes on the same side of the chest as the tumor. Also:
Stage IIIB
Stage IIIB non-small cell lung cancer; drawing shows cancer in the lymph nodes above the collarbone or lymph nodes in the opposite side of the chest from the cancer; also shows cancer in the trachea, left main bronchus, esophagus, sternum, diaphragm, inferior vena cava, aorta, heart, and chest wall. One inset shows a close-up of cancer spreading from the lung into the pleura and chest wall; another inset shows a close-up of cancer spreading from the lung into the pericardium (membrane around the heart) and the heart.
In stage IIIB, the tumor may be any size and has spread:
- To lymph nodes above the collarbone or in the opposite side of the chest from the tumor; and/or
- To any of the following:
Stage IV
Stage IV non-small cell lung cancer; drawing shows parts of the body where cancer may spread from the lung where it started, including another lobe of the same lung, the other lung, the brain, lymph nodes, adrenal gland, liver, kidney, and bone; inset shows close-up of cancer spreading through the blood and lymph to other parts of the body.
In stage IV, cancer
may have spread to lymph nodes and has spread to another lobe of the lungs or to other parts of the body, such as the brain, liver, adrenal glands, kidneys, or bone.
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Recurrent Non-Small Cell Lung Cancer
Recurrent non-small cell
lung cancer is cancer that has recurred (come back) after it has been treated.
The cancer may come back in the brain, lung, or other parts of the body.
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Treatment Option Overview
Key Points:
There are different types of treatment for patients with non-small cell lung cancer.
Different types of treatments are available for patients with non-small cell lung cancer. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. Before starting treatment, patients may want to think about taking part in a clinical trial. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment.
Clinical trials are taking place in many parts of the country. Information about ongoing clinical trials is available from the NCI Web site. Choosing the most appropriate cancer treatment is a decision that ideally involves the patient, family, and health care team.
Six types of standard treatment are used:
Surgery
Four types of surgery are used:
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Wedge resection:
Surgery to remove a triangle-shaped slice of tissue. Wedge resection is used to remove a tumor and a small amount of normal tissue around it. When a slightly larger amount of tissue is taken, it is called a segmental resection.
Wedge resection of the lung; shows trachea and lungs with cancer in a lung lobe. The removed lung tissue with the cancer and small amount of healthy tissue around it is shown next to the lung lobe it was removed from.
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Lobectomy:
Surgery to remove a whole lobe (section) of the lung.
Lobectomy; drawing shows lobes of both lungs, trachea, bronchi, bronchioles, and lymph nodes. Cancer is shown in one lobe. The removed lobe is shown next to the lung it was removed from.
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Pneumonectomy:
Surgery to remove one whole lung.
Pneumonectomy; shows trachea and lungs with cancer in one lung. The removed lung with the cancer is shown.
- Sleeve resection: Surgery to remove part of the bronchus.
Radiation therapy
Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer.
Radiosurgery is a method of delivering radiation directly to the tumor with little damage to healthy tissue. It does not involve surgery and may be used to treat certain tumors in patients who cannot have surgery.
The way the radiation therapy is given depends on the type and stage of the cancer being treated.
Chemotherapy
Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the spinal column, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). The way the chemotherapy is given depends on the type and stage of the cancer being treated.
Laser therapy
Laser therapy is a
cancer treatment that uses a laser beam (a narrow beam of intense light) to kill cancer cells.
Photodynamic therapy (PDT)
Photodynamic therapy
(PDT) is a cancer treatment that uses a drug and a certain type of laser light to kill cancer cells. A drug that is not active until it is exposed to light is injected into a vein. The drug collects more in cancer cells than in normal cells. Fiberoptic tubes are then used to deliver the laser light to the cancer cells, where the drug becomes active and kills the cells. Photodynamic therapy causes little damage to healthy tissue. It is used mainly to treat tumors on or just under the skin or in the lining of internal organs.
Watchful waiting
Watchful waiting is closely monitoring a patient’s condition without giving any treatment until symptoms appear or change. This may be done in certain rare cases of non-small cell lung cancer.
New types of treatment and prevention are being tested in
clinical trials. These include the following:
Chemoprevention
Chemoprevention is the
use of drugs, vitamins, or other substances to reduce the risk of developing cancer or to reduce the risk cancer will recur (come back).
Biologic therapy
Biologic therapy is a treatment that uses the patient's immune system to fight cancer. Substances made by the body or made in a laboratory are used to boost, direct, or restore the body's natural defenses against cancer. This type of cancer treatment is also called biotherapy or immunotherapy.
New combinations
New combinations of treatments are being studied in clinical
trials.
This summary section refers to specific treatments under study in
clinical trials, but it may not mention every new treatment being studied.
Information about ongoing clinical trials is available from the
NCI Web site.
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Treatment Options by Stage
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Occult Non-Small Cell Lung Cancer
Treatment of occult non-small cell lung cancer depends on where the cancer has spread. It can usually be cured by surgery.
Check for clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with occult non-small cell lung cancer.
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Stage 0 (Carcinoma in Situ)
Treatment of stage 0 may include the
following:
Check for clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with stage 0 non-small cell lung cancer.
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Stage I Non-Small Cell Lung Cancer
Treatment of stage I non-small cell lung
cancer may include the following:
This summary section refers to specific treatments under study in
clinical trials, but it may not mention every new treatment being studied.
Information about ongoing clinical trials is available from the
NCI Web site.
Check for clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with stage I non-small cell lung cancer.
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Stage II Non-Small Cell Lung Cancer
Treatment of stage II non-small cell lung
cancer may include the following:
This summary section refers to specific treatments under study in
clinical trials, but it may not mention every new treatment being studied.
Information about ongoing clinical trials is available from the
NCI Web site.
Check for clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with stage II non-small cell lung cancer.
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Stage IIIA and Stage IIIB Non-Small Cell Lung Cancer
Treatment of stage IIIA non-small cell
lung cancer may include the following:
Treatment of stage IIIB non-small cell
lung cancer may include the following:
This summary section refers to specific treatments under study in
clinical trials, but it may not mention every new treatment being studied.
Information about ongoing clinical trials is available from the
NCI Web site.
Check for clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with stage III non-small cell lung cancer.
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Stage IV Non-Small Cell Lung Cancer
Treatment of
stage IV non-small cell lung cancer
may include the following:
This summary section refers to specific treatments under study in
clinical trials, but it may not mention every new treatment being studied.
Information about ongoing clinical trials is available from the
NCI Web site.
Check for clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with stage IV non-small cell lung cancer.
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Treatment Options for Recurrent Non-Small Cell Lung Cancer
Treatment of recurrent
non-small cell lung cancer may include
the following:
This summary section refers to specific treatments under study in
clinical trials, but it may not mention every new treatment being studied. Information about ongoing clinical trials is available from the
NCI Web site.
Check for clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with recurrent non-small cell lung cancer.
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Changes to This Summary (11/29/2007)
The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.
Editorial changes were made and images were added to this summary.
This information is provided from the PDQ® database in collaboration with the NCI.
