Lung Cancer treatment
Having diagnosed the lung cancer, a multidisciplinary team evaluates each case on an individual basis so they may prepare a course of treatment that offers the best chance of curing the patient.
The team comprises all of the healthcare professionals directly involved in the diagnostic and therapeutic process, such as pulmonologists, radiologists, nuclear medicine specialists, pathologists, radiotherapists, oncologists, thoracic surgeons and nursing staff.
Once the team reach a collective decision, the doctor in charge will inform the patient and explain the treatment.
The type of treatment is determined according to the following factors:
- Patient characteristics: age, other diseases that complicate particular treatments and their functional status.
- Type of tumour.
- Current stage of the disease (TNM).
There are several types of therapeutic approach to lung cancer that can be carried out individually or in combination depending on the degree of extension and biological characteristics of the tumour:
- Surgical treatment
- Non-surgical treatment: chemotherapy and radiotherapy
- New therapies
- Palliative treatment
Surgical procedures aim to completely eliminate all tumour cells and cure the disease. The location and size of the tumour determine the extent of surgery required. Depending on the case, surgery is complemented with chemotherapy and/or radiotherapy.
Surgery offers the best chance of cure and is indicated for patients with early stage lung cancer who have good overall health. Around 30% of patients with lung cancer can benefit from surgical treatment.
After selecting this approach, the type of surgery to be carried out is assessed:
Lobectomy. Surgical procedure involving removal of the lobe of the lung containing the tumour. The right lung is divided into three lobes (upper, middle and lower), while the left comprises two lobes (upper and lower). A lobectomy, accompanied by removal of the lymph nodes, is the standard treatment for early stage lung cancer.
Pneumonectomy. Surgery to remove an entire lung. This operation is performed on tumours located in the bronchi, the lung’s main airways, or when the tumour affects more than one lobe.
Segmentectomy. Each lobe is in turn composed of several segments. When the tumour is small and located in a peripheral area of the lung, then just the affected segment can be removed and the rest of the lobe preserved. Segmentectomies are carried out in patients with benign or low malignancy tumours, in cases of lung metastasis due to a cancer originating in another organ, or in those patients who would not tolerate a broader lung resection given their overall condition.
Atypical sublobar resection. This involves removing a portion of the affected lung lobe. As with segmentectomies, they are carried out in patients with benign or low malignancy tumours, in cases of lung metastasis due to a cancer originating in another organ, or in those patients who would not tolerate a broader lung resection given their overall condition. not tolerate a broader lung resection given their overall condition.
For all of the surgical procedures described above the thoracic surgeon will select the best incision and approach. The different options available are:
- Thoracotomy. A 15–20 cm incision is made in the chest between two ribs and then a retractor placed between them to open a space through which the resection can be performed.
- Minimally invasive surgery with video-assisted thoracoscopy. This is a closed surgical procedure that consists of 1 or 2 small incisions through which are inserted a camera to look inside the thorax and the instruments required to complete the surgical procedure without having to place a retractor between the ribs.
Whenever possible, surgery is performed using a video-assisted thoracoscope because of its benefits for the patient: less postoperative pain, a quicker recovery and a more aesthetic outcome.
que sigui possible, es realitza el procediment quirúrgic per videotoracoscopia, pels seus beneficis en el pacient: menys dolor en el postoperatori i recuperació més ràpida, a més de millors resultats estètics.
As with any other surgery, that of lung cancer involves risks and complications. Some of the most common are:
- Accumulation of air between the lung and the chest wall (pleural cavity) that can cause a collapse of the lung (tension pneumothorax)
- Bleeding (haemorrhage)
- Tube opening between a bronchiole and the pleural cavity that leads to the filtration of air or fluid into the surgical area (broncho-pleural fistula)
- Accumulation of pus in the chest cavity (empyema)
There may be other risks, depending on the state of health of the individual. It is important to consult the medical team of any doubts before this procedure.
In lung cancer surgery, as in the majority of surgical operations, there can be, with more or less frequency, complications and adverse effects that may alter the quality of life of the patient.
The most important is the control of the patient’s pain, for which the doctor will prescribe a series of drugs. If the pain does not abate, it must be mentioned to the healthcare team.
Another of the frequent complications in this type of surgery is the accumulation of fluids inside the chest. To prevent this happening, the surgeon inserts a small drainage tube at the level of the wound, which is withdrawn after a few days.
After the removal of part or all of the lung, some patients experience some difficulty in breathing. It is a sensation that normally disappears with time. It is possible that the patient may need oxygen after the surgery, but this is usually stopped before being discharged from hospital.
Despite patients being bedridden, they should be able to move about within their possibilities, and little by little to walk in order to recover their strength.
It is also advised to learn deep breathing exercises and techniques in order to cough, to improve lung expansion, and help prevent post-operative pneumonia.
Chemotherapy is the treatment most commonly applied to lung cancer. It is generally administered intravenously, but in some cases it may be taken orally.
Chemotherapy inhibits the growth of cells in the process of division. It affects both tumour and healthy cells which is what causes the symptoms associated with the treatment, known as adverse effects or side effects.
Chemotherapy may be administered as a two-drug combination or a monotherapy (one drug). Some of the most used medications include platinum-based compounds (cisplatin and carboplatin), antifolates (pemetrexed), taxanes (paclitaxel and docetaxel), vinorelbine, gemcitabine and etoposide.
The number of cycles depends on the characteristics and staging of each tumour, but patients generally receive 4–6 treatment cycles. Different tests are conducted throughout the treatment to evaluate its effectiveness.
Radiation therapy or radiotherapy uses high-energy X-rays to destroy cancer cells. It has many applications in lung cancer and can be administered alone or in combination with chemotherapy in order to reduce the size of the tumour prior to surgery, eliminate remaining cancer cells after surgery or to treat lung cancer that has spread to other parts of the body outside the lungs, such as the brain or bones.
Non-small cell lung cancer:
- Chemotherapy performed after surgery (stages II–III) is also known as adjuvant treatment and it serves to decrease the risk of the tumour reappearing over time.
- For tumours located in the chest (stages IIIA–IIIB), chemotherapy is administered in combination with radiotherapy in order to increase the tumour’s sensitivity and eliminate it to a greater extent.
- In advanced stages (stage IV), chemotherapy plays a key role as it decreases the size of the tumour, reduces the growth rate and alleviates the symptoms associated with the disease, such as pain, choking, tiredness or loss of appetite. In such cases chemotherapy is not expected to eradicate the tumour completely.
Small cell lung cancer:
- For this type of tumour, chemotherapy is essential in order to detain its rapid growth.
- The most used agents are a combination of a platinum-based compound (cisplatin or carboplatin) and etoposide.
- Radiotherapy is also very important when treating this cancer, both to control the disease in the chest and in the brain.
- When the cancer is in a regional stage (intrathoracic), radiotherapy is administered in parallel with chemotherapy, whereas in more advanced or extrathoracic stages it is administered after chemotherapy.
- Radiotherapy is applied to the brain (whole-brain radiotherapy) to prevent the appearance of brain metastases.
Depending on the specific type of chemotherapy administered, each treatment will cause different side effects. It is very important that your doctor tells you about them before starting treatment.
Some of the symptoms that may appear are: tiredness (asthenia), changes in dietary preferences, nausea, vomiting, hair loss, inflammation of the mouth’s mucous membrane, fever, constipation/diarrhoea, abdominal and muscular pain, hives and nail lesions. If in doubt you should talk with your doctor.
Radiotherapy can be associated with skin irritation, inflammation of the oesophageal mucous membrane (oesophagitis, difficulty swallowing), tiredness and pneumonitis (i.e., inflammation of lung tissue which usually appears months after completing treatment).
- Radiofrequency ablation. This technique attempts to destroy the tumour by placing a catheter inside the lung. It is indicated for small volume tumours which cannot be resected through surgery.
- Stereotactic radiosurgery (SRS). A type of radiotherapy that precisely directs high-energy X-rays to very small areas of the body. It is indicated to treat brain metastases and small lung tumours.
- Bronchial endoprosthesis. A metal spring (stent) is placed inside the bronchus to dilate the airway in cases where an endobronchial tumour is obstructing the passage of air.
Lung cancer treatment has witnessed some very significant advances in recent years with the incorporation of new biological drugs aimed at specific targets within tumour cells. Examples include medicines that focus on the epidermal growth factor receptor (EGFR), the anaplastic lymphoma kinase receptor (ALK) or the vascular endothelium growth factor (VEGF).
In contrast to most chemotherapies, several of these treatments are administered orally and are better tolerated by patients. To discover if you can be treated with one of these biological treatments, a molecular study is performed on a tumour sample to determine whether you are likely to respond to treatment.
Immunotherapy is a new treatment strategy that has proven to be effective in lung cancer. It involves the intravenous administration of a biological therapy that enhances the immune system’s own capacity to recognise and destroy the tumour.
There are currently several clinical studies into immunotherapy underway, which could, in the future, be used to treat lung cancer.
Cancer is associated with a wide range of physical problems but it also entails emotional ones. Lung cancer treatment must focus on all of these aspects.
Various studies have shown that palliative treatment not only improves the quality of life in patients with advanced lung cancer but it can also help them live longer.
Palliative care helps alleviate physical symptoms, such as pain, while also addressing the emotional and spiritual anxiety felt by patients and their families.