Treatment

Depending on the type and stage of your cancer, your medical oncologist may recommend chemotherapy:

• Before surgery to shrink your tumor so it’s easier to remove
• After surgery to kill any remaining cancer cells and improve your chances of a cure 
• Along with other treatments, if surgery isn’t an option for you

Lung cancer chemotherapy is generally given every three to four weeks in cycles, either in pill form or through an intravenous (IV) line in the hand or arm or a port in the chest.

Your SCCA team will talk with you about the specific medicines we recommend for you, how you’ll receive them, your treatment schedule and what to expect. We’ll also explain how to take the best possible care of yourself during treatment and after, and we’ll connect you with medical and support resources throughout SCCA.

One of the major changes in lung cancer treatment recently is the introduction of immunotherapies. These medicines harness your immune system to fight your cancer. They may be used alone or with chemotherapy or, in clinical trials, with other treatments.

Most lung cancer immunotherapy relies on medicines called checkpoint inhibitors. SCCA doctors and researchers are exploring additional types of immunotherapy for lung cancer.

Proton therapy offers:

• Less radiation to your heart, lung, and esophagus
• Potentially fewer side effects in some patients from radiation treatment, including lower rates of pneumonitis and esophagitis (less inflammation of the lungs and esophagus) compared to conventional radiation 
• Similar efficacy at killing cancer cells as other forms of radiation

Advantages of proton therapy over X-ray radiation 

Too much radiation to the healthy tissue surrounding the tumor can increase the risk of side effects. This is a major concern when it comes to radiation treatment for lung cancer because the cancer may be close to your heart, healthy lung, and other critical organs. The unique properties of protons allow proton radiation to better conform to your cancer, reducing excess radiation to the healthy tissues and organs around it.

A large clinical trial in lung cancer treatment recently showed that a patient’s survival after lung cancer treatment is closely related to the amount of radiation the patient’s heart received, and the amount of esophagus toxicity (swallowing difficulty) patients developed during radiation treatment (trial RTOG 0617). Proton therapy can decrease the radiation dose to the heart and the esophagus, as well as normal lung.

In the figure below, a proton therapy radiation plan is shown on the right, and a plan with conventional radiation is shown on the left. With proton radiation, there is less radiation to the normal lung, heart, and rest of the body, compared with conventional radiation.

Types of lung and thoracic cancers

Below is a list of lung and thoracic cancers that can benefit from proton therapy. Our radiation oncologists use other forms of radiation to treat cancers, so they will provide you with an expert recommendation for your consideration. 

• Non-small cell lung cancer
• Select small cell lung cancer 
• Malignant mesothelioma
• Mediastinal tumors
  • Thymoma
  • Sarcoma
• Select recurrent lung and metastatic cancer

Are you a candidate for proton therapy?

You should consider proton therapy if you:

• Have lung cancer that has not spread outside your chest, especially along with one of the following:
  • Have limited or poor pulmonary function
  • Have a heart condition
  • Had prior radiation therapy

Many people with lung cancer have radiation therapy alone or along with other treatments. It is painless and noninvasive, and each treatment lasts only minutes. 

Radiation therapy may be used:

• To cure lung cancer, either alone or with surgery, chemotherapy or immunotherapy 
• To relieve symptoms of advanced lung cancer, such as pain or trouble breathing

Different types of radiation treatments are used for different situations. A few examples of the types used for lung cancer are:

• Intensity-modulated image-guided radiotherapy (IMRT/IGRT)
• Radiosurgery
• Proton therapy

IMRT/IGRT

In this form of radiation treatment, doctors use computed tomography (CT) to scan your tumor and create beams of radiation that closely conform to the tumor’s shape. The beams vary in shape and intensity to deliver a higher dose of radiation to the tumor and lower doses to nearby healthy tissue. 

Learn more about IMRT/IGRT and other forms of external-beam radiation therapy (EBRT).

Radiosurgery

Radiosurgery is an advanced form of highly focused, high-dose radiation therapy that can kill tumors in fewer treatments than conventional radiation treatment — typically one to five sessions rather than daily sessions for several weeks. It has a greater than 95 percent chance of killing small lung tumors.

There are many names for this type of treatment, including:

• Stereotactic body radiation therapy (SBRT)
• Stereotactic ablative body radiotherapy (SABR) 
• CyberKnife, a brand name

Proton therapy 

Proton therapy is an advanced therapy and an important alternative to conventional radiation for many types of cancer (and some noncancerous tumors).
 
Lung cancer is frequently located close to critical structures. The advantage of using protons to treat this cancer is that doctors can target high doses of radiation at the cancer with the goal of minimizing radiation to healthy tissues. This may reduce side effects. SCCA Proton Therapy Center is the only facility in a seven-state region to offer this treatment.

SCCA patients have surgery at University of Washington Medical Center (UWMC) with thoracic surgeons who are among the best in the country. Surgeons at UWMC do more lung operations than anywhere else in the Pacific Northwest. They also help diagnose and stage lung cancer and relieve symptoms of advanced disease.

Our surgeons have some of the most extensive experience in the world taking on the most complex cases, including patients who might be told elsewhere that they cannot have surgery or surgery is too risky.

• For early-stage non-small cell lung cancer, surgery to remove the cancer may be an option. When it is an option, it provides the best chance for a cure. 
• For small cell lung cancer, doctors rarely use surgery because by the time the disease is found it has often spread too far for surgery to be effective.

Any surgery your team recommends will depend on the type and stage of your disease, your general health and your lung function. Your surgeon will probably remove lymph nodes too to check them for signs of cancer. 

Common surgical procedures for lung cancer

These surgeries are typically used to treat lung cancer.

• Lobectomy — removing a whole lobe (section) of the lung. This is the most common lung cancer surgery.
• Wedge resection or segmentectomy — removing part of a lobe of the lung. This is the second most common lung cancer surgery. It may be used for several reasons, including if you have compromised lung function, are too sick to undergo lobectomy or strongly prefer to preserve lung function.
• Pneumonectomy — removing the entire lung on the side of your body with the tumor. You may need this surgery due to the size or location of your cancer, although most experts look for ways to spare the lung using advanced surgical procedures.

Video-assisted thoracic surgery

Minimally invasive surgery called video-assisted thoracic surgery (VATS) may be an option if you have early-stage lung cancer. 

Classically, surgeons make a 6- to 10-inch incision, cutting larger portions of muscles and spreading ribs to reach the tumor.

With VATS, surgeons make three to four small incisions about an inch long, cut less muscle and entirely avoid spreading ribs. They operate by inserting a camera through one incision and surgical instruments through the others.

People who have VATS may have less pain and a quicker recovery of function and quality life after leaving the hospital.

Advanced surgical and endoscopic procedures

Sometimes lung cancer is difficult to remove surgically because it involves the main air passages, major blood vessels, the rib cage or other important structures in the chest.

Procedures performed at UWMC for complex or advanced lung cancers include:

• Sleeve resection — used for cancer in the large airways (trachea or bronchi). The cancerous section of the airway is removed, and the remaining sections are sewn together.
• Carinal pneumonectomy — to remove the lung and the lower part of the trachea, where it branches toward that lung. The remaining trachea and lung airway are sewn together.
• Vascular reconstruction — to rebuild the pulmonary artery when the tumor involves this blood vessel as well as the airways. The goal is to remove the cancer entirely and save the lung, potentially avoiding a pneumonectomy.
• Chest-wall resection and reconstruction — to remove a tumor in the chest wall and reconstruct the chest.
• Stenting – to place a tube inside the airway to help open it, allowing patients to breathe easier.
• Tumor debulking – to remove a tumor piece by piece from inside the airway, allowing patients to breathe easier.

Targeted therapies are newer cancer treatments that work more selectively than standard chemotherapy. These medicines are used most often in people with advanced and recurrent lung cancer and are effective in patients with specific changes in their tumor genes. 

The current standard of care is to test for changes in the genes EGFR, ALK, ROS1 and BRAF, which we can do using UW-OncoPlex, a diagnostic tool developed by researchers at UW Medicine. Treatments are being developed to target other genetic changes as well.

For lung cancer, targeted therapies called small molecules are used to block specific growth-factor receptors involved in cancer cell proliferation (growth and division of cancer cells). Examples include erlotinib (Tarceva), gefitinib (Iressa), crizotinib (Xalkori), alectinib (Alecensa) and others.

At SCCA, patients have access to newer targeted therapies in clinical studies that aren’t available otherwise. This is a very active area of research.