What are the treatment options for lung cancer?

Treatment Options for Lung Cancer

Treatment for lung cancer is determined by histologic type (non-small cell vs. small cell), stage, and operability, with surgical resection being the standard for early-stage disease and multimodality therapy for advanced disease.

Non-Small Cell Lung Cancer (NSCLC)

Early-Stage Disease (Stage I-II)

Surgical resection with ipsilateral mediastinal lymph node dissection is the standard treatment for operable stage I (T1-2N0) and stage II (T1-2N1, T3N0) NSCLC 1, 2.

• Lobectomy or pneumonectomy with lymph node dissection forms the foundation of surgical treatment 2.
• Pneumonectomy carries higher surgical risk but may offer better outcomes for centrally located tumors 2.
• In elderly patients or those with respiratory dysfunction, conservative resection techniques (segmentectomy or wedge resection) should be performed 1, 2.
• Surgical candidacy requires: VO2 max ≥15 ml/kg/min, good performance status, absence of cardiovascular disease, and no nodal involvement at mediastinoscopy 1.
• Severe vascular disease must be treated prior to lung surgery 1.

Postoperative radiotherapy is NOT indicated for completely resected stage I and II N0-N1 tumors 1, 2.

Radiotherapy as Alternative for Early-Stage Disease

For patients with medical contraindications to surgery or who refuse surgery, curative external-beam radiotherapy with classical fractionation is the alternative treatment 1.

• Deliver total dose >60 Gy to the tumor mass if respiratory function permits and severe complications can be avoided 1.
• For peripheral stage IA tumors, radiotherapy to the primary tumor volume alone (not including mediastinum) can be considered 1.

Locally Advanced Disease (Stage IIIA)

For unresectable stage IIIA NSCLC, the standard treatment is short-term induction chemotherapy containing cisplatin plus at least one other drug, combined with external-beam radiotherapy at optimal dose with classical fractionation 1, 2.

• For resectable stage IIIA tumors, complete excision with extensive lymph node dissection is an option 1, 2.
• Multidisciplinary consultation is the standard in this rapidly changing treatment area 1, 2.
• Neoadjuvant chemotherapy can be given to patients with stage IB, II, and IIIA tumors, though survival benefit remains uncertain 1.
• The treated volume should include all macroscopic tumor with a 1.5-2 cm safety margin 1.

Metastatic Disease (Stage IV)

Platinum-based doublet chemotherapy (cisplatin combined with vinorelbine, gemcitabine, or taxane) prolongs survival, improves quality of life, and controls symptoms in patients with good performance status 2.

• For solitary brain metastasis with resectable primary tumor, surgical resection and/or radiotherapy may be beneficial, with 5-year survival rates of approximately 10-20% 2.
• For solitary adrenal metastasis with resectable lung tumor, surgical resection has resulted in long-term survival in select cases 2.

Chemotherapy-Naive Advanced NSCLC

Docetaxel 75 mg/m² IV over 1 hour immediately followed by cisplatin 75 mg/m² over 30-60 minutes every 3 weeks is indicated for chemotherapy-naive patients with unresectable, locally advanced or metastatic NSCLC 3.

Previously Treated Advanced NSCLC

For NSCLC after failure of prior platinum-based chemotherapy, docetaxel 75 mg/m² IV over 1 hour every 3 weeks is the recommended dose 3.

• A dose of 100 mg/m² is associated with increased hematologic toxicity, infection, and treatment-related mortality and should be avoided 3.
• Do not administer docetaxel to patients with neutrophil counts <1500 cells/mm³ 3.
• Avoid docetaxel in patients with bilirubin >ULN or AST/ALT >1.5× ULN with alkaline phosphatase >2.5× ULN 3.

Adjuvant and Neoadjuvant Therapy Considerations

The efficacy of adjuvant chemotherapy has not been clearly demonstrated; it should only be performed in the setting of randomized clinical trials 1.

• New radiotherapy techniques for stage III tumors should be evaluated in randomized clinical trials 1.

Follow-Up Care

Spiral chest CT with or without contrast is recommended every 6-12 months after surgery for 2 years, then annually 2.

• Response assessment after 2-3 cycles of chemotherapy should be performed by repeating initial radiographic tests 2.
• Measurement and reporting must follow RECIST 1.1 criteria 2.

Critical Pitfalls to Avoid

• Age alone is not an absolute contraindication for surgical resection in carefully selected patients 2.
• Do not perform adjuvant radiotherapy for completely resected stage I-II N0-N1 disease, as it provides no benefit 1, 2.
• Avoid routine chemotherapy or radiochemotherapy in stage IIIA patients when complete excision is uncertain; these patients should be enrolled in clinical trials 1.
• Surgical mortality should be <6% for pneumonectomy and <2% for lobectomy 2.