Treatment of lung cancer

Modern evidence-based medicine relies on strict scientific reasoning when determining lung cancer treatment protocols. The attending physician’s choice is based on the tumor’s morphological characteristics, its spread, the presence or absence of metastases, and the patient’s overall condition.

It is well known that the small cell variant of lung cancer responds better to chemotherapy, while the non-small cell variant often requires surgery or a combination of treatments, depending on the stage and extent of the disease.

In addition to surgical treatment, various radiation therapy programs can be used in combination with chemotherapy. Patients and their families facing emotional and psychological challenges can benefit from the support of psycho-oncologists.

Lung cancer treatment methods at different stages

To summarize, the treatment approach for lung cancer depends on its stage:

• Stage 0: When the tumor has not invaded the deeper layers of the mucosa, surgery is usually sufficient. Radiation therapy and chemotherapy are not required.
• Stage 1: Surgery is typically the main treatment. If the risk of recurrence is high, adjuvant chemotherapy or radiation therapy may be recommended. The operation may involve removing a lung lobe or a smaller portion, along with some mediastinal lymph nodes.
• Stage 2: Before surgery, the doctor may prescribe neoadjuvant chemotherapy or radiation therapy to shrink the tumor. The operation may involve removing part of the lung or, in some cases, the entire lung. After surgery, chemotherapy is always administered, and sometimes radiation therapy is added.
• Stage 3: Treatment usually starts with chemotherapy and radiation therapy. If the tumor is operable and the patient’s condition allows, surgery may be performed. If surgery is not possible, chemotherapy and radiation therapy remain the primary treatments.
• Stage 4 (Non-Small Cell Lung Cancer): Palliative and symptomatic therapy is the main approach to improve quality of life.

Lung cancer treatment at stages 1 and 2

The standard treatment for stage 1-2 lung cancer typically includes surgery and radiation therapy.

The extent of surgical intervention depends on the tumor’s stage and location.

• Advantages: Surgery offers a potential for a complete cure.
• Disadvantages: The procedure is invasive and carries a high risk of postoperative complications.

In some cases, standard surgery is not feasible due to:

• Decompensated heart or respiratory failure.
• The proximity of the tumor to the heart, aorta, major blood vessels, or nerve plexuses.
• Drug intolerance, among other factors.

For such patients, stereotactic radiosurgery (CyberKnife therapy) is an alternative, delivering high-precision radiation to the tumor with minimal impact on healthy tissues. This method is often combined with intensity-modulated radiation therapy (IMRT).

Advantages of Modern Radiotherapy Methods

• Minimal damage to surrounding healthy tissue.
• The ability to increase radiation doses to a therapeutically effective level.

To enhance the effects of radiosurgery and radiation therapy, chemotherapy may also be used, depending on the case.

For small cell lung cancer, radiation therapy is typically combined with chemotherapy drugs such as thiophosphamide and 5-fluorouracil.

Prognosis:

• Stage 0-1 squamous cell lung cancer has a favorable prognosis, with most patients achieving long-term remission.
• Stage 2 lung cancer prognosis depends on the tumor type and individual response to treatment.

Lung Cancer Treatment at Stages 3 and 4

For stage 3 lung cancer, when cancer has spread to regional lymph nodes, treatment usually involves a combination of radiation therapy and chemotherapy.

In addition, symptomatic treatment is provided as needed, such as:

• Pleural effusion management (draining fluid from the pleural cavity).
• Hemostatic agents to control bleeding.

For stage 4 lung cancer, when metastases have spread to distant organs, treatment strategies remain similar, focusing on symptom relief and slowing disease progression.

When metastases from other organs are detected in the lungs, treatment is determined based on the primary cancer and the extent of lung involvement.

Prognosis:

• Patients with metastatic tumors have a lower chance of remission than those with early-stage disease.
• Those with locally advanced squamous cell carcinoma have a moderately optimistic outlook.
• Even at stage 4, about 10% of patients can achieve disease stabilization with appropriate treatment, depending on the cancer type.

When should lung cancer treatment begin?

Timely treatment significantly increases survival chances.

Main Treatment Methods for Early-Stage Lung Cancer:

1. Surgery:
   • Tumor removal with nearby tissues (up to 2 cm) and affected lymph nodes.
   • Types of surgery:
     • Wedge resection – Removal of the tumor and adjacent tissue.
     • Lobectomy – Removal of one lung lobe.
     • Bilobectomy – Removal of two lung lobes.
2. Chemotherapy:
   • Used after surgery to prevent recurrence.
3. Radiation therapy:
   • Used post-surgery to lower recurrence risk.

Surgical vs. non-surgical treatment approaches

• NSCLC is generally more responsive to surgery than SCLC. Depending on the tumor’s size and location, the surgeon may remove only the tumor with a margin of healthy tissue or the entire lung. Surgery is often followed by adjuvant chemotherapy or radiation therapy to eliminate remaining cancer cells and reduce the risk of recurrence.
• Minimally invasive procedures are increasingly used, where a thoracoscope (a flexible, lighted camera) is inserted through a small incision in the chest.
• Radiofrequency ablation (RFA) is another option for NSCLC. A thin needle is inserted into the tumor, and an electric current is used to destroy cancer cells.
• SCLC is often inoperable, requiring alternative treatments such as chemotherapy and radiation therapy.

Main treatment methods

The choice of treatment depends on:

• Tumor location and spread.
• The type of lung cancer.
• The patient’s overall health condition.

The leading treatment approaches include:

1. Surgery – The primary treatment method.
2. Radiation therapy – Often combined with surgery or chemotherapy.
3. Chemotherapy – Used alone or alongside other treatments.
4. Hormonal and immunotherapy – Increasingly used in advanced cases.

Complex treatment involving a combination of surgery, radiotherapy, chemotherapy, and immunotherapy is becoming more common for late-stage lung cancer.

Photodynamic Therapy for Lung Cancer

A promising new approach is photodynamic therapy (PDT), which uses light, oxygen, and a photosensitizing drug to destroy tumors.

How It Works:

1. A photosensitizer drug is injected into the patient’s body.
2. The drug selectively binds to cancer cells.
3. When exposed to a low-intensity laser, the oxygen in the tumor transforms into a toxic form, killing cancer cells without thermal damage.

Indications for PDT:

• Early-stage lung cancer (tumors in the trachea, bronchi, or esophagus).
• Inoperable tumors (cases where surgery is too risky or not possible).

PDT can also be combined with chemotherapy and radiotherapy for enhanced results.

Contraindications:

• Hereditary or acquired porphyria.
• Increased skin photosensitivity.
• Severe liver or kidney disease.

Possible Complications:

• Increased skin sensitivity to light (managed by avoiding direct sunlight post-treatment).
• Decreased PDT effectiveness if:
  • Oxygen supply to the tumor is low.
  • The photosensitizer concentration is insufficient.
  • Tumor blood supply is poor.

The primary treatment for lung cancer is surgery. The extent of surgical intervention is determined by the tumor’s location, size, presence or absence of metastases, and the overall function of internal organs.

Surgical treatment involves removing a specific area of the lung, one or more lobes, or the entire lung. Typically, at least a portion of lung tissue is removed, along with the lymph nodes.

Surgical options:

• Wedge resection – removal of the primary tumor and surrounding tissue.
• Segmental resection – removal of the affected segment of the lung.
• Lobectomy – removal of one lobe of the lung.
• Bilobectomy – removal of two lobes of the lung.
• Pneumonectomy – removal of the entire lung.

If the tumor has spread to neighboring organs, partial removal (resection) of these organs may be necessary. In cases where the tumor is located near the trachea, tracheal resection may be performed. Such procedures are considered combined surgeries. Palliative surgery may also be performed in cases where curative treatment is not possible.

Chemotherapy

Chemotherapy is often used as an adjunct treatment for lung cancer. However, it can also be the primary treatment method if surgery and radiation therapy are contraindicated.

The effectiveness of chemotherapy depends on the tumor’s sensitivity to the drugs used. Different types of lung cancer respond differently to drug therapy:

• Small cell lung cancer (SCLC) – chemotherapy is the primary treatment, with an effectiveness rate of up to 80%. It is often combined with radiation therapy, either simultaneously or sequentially.
• Non-small cell lung cancer (NSCLC) – chemotherapy is used when surgery and radiation therapy are not viable options.

Targeted therapy

Recently, targeted therapy has emerged as a promising treatment for NSCLC. It involves small molecules or monoclonal antibodies designed to block specific targets, such as epidermal growth factor receptors (EGFR) and angiogenesis (formation of new blood vessels in tumors).

Targeted therapy is usually used as a second- or third-line treatment for certain types of lung cancer that express specific receptors. In many cases, chemotherapy and targeted therapy not only reduce tumor size and prevent metastasis but also improve quality of life and, in some cases, lead to long-term remission or recovery.

The clinic offers both neoadjuvant chemotherapy (before surgery) and adjuvant chemotherapy (after surgery) in hospital oncology centers and outpatient day hospitals.

The choice of chemotherapy regimen is based on the patient’s exact diagnosis, tumor histology, and disease stage, following internationally recognized treatment protocols that have been proven effective in clinical trials.

New-generation drugs are used to maximize effectiveness while minimizing toxicity. Supportive therapy is provided to reduce side effects on blood cells and internal organs.

In some cases, infusion pumps are used for the continuous administration of chemotherapy drugs, or port systems are implanted for easier drug delivery.

For cases of neoplastic pleurisy (pleural carcinomatosis), palliative surgical procedures such as thoracocentesis (fluid drainage) and pleurodesis (sealing of the pleural cavity) can be performed.

The following targeted drugs are used for lung cancer treatment:

• Angiogenesis inhibitors – Prevent the formation of new blood vessels that nourish tumors.
• EGFR inhibitors – Block epidermal growth factor receptor (EGFR), a protein that normally regulates cell division but becomes overactive in cancer cells, promoting uncontrolled growth.
• ALK inhibitors – Target mutations in the ALK (anaplastic lymphoma kinase) gene, which are more common in non-smokers or light smokers.
• BRAF inhibitors – Block mutations in the BRAF gene, which drive unchecked cell proliferation.

Radiation therapy

Radiation therapy is effective for both NSCLC and SCLC. It can be used for different purposes:

• Before surgery (neoadjuvant radiation therapy) – shrinks the tumor, making surgical removal easier and better tolerated.
• After surgery (adjuvant radiation therapy) – destroys any remaining cancer cells, reducing the risk of recurrence.
• As a palliative treatment – alleviates symptoms such as pain and bleeding in advanced cancer stages.

In some cases, chemoradiotherapy (a combination of chemotherapy and radiation therapy) is used for greater effectiveness.

Treatment for cancer of the pleura

The treatment of neoplastic pleurisy (cancerous pleural effusion) typically begins with pleurocentesis, a procedure that drains excess fluid from the pleural cavity. This immediately relieves symptoms such as shortness of breath and chest pain, significantly improving the patient’s quality of life.

A fluid analysis performed after pleurocentesis helps determine the exact cause of pleural effusion. Further imaging studies, including X-rays, CT scans, and ultrasound, provide a detailed assessment of disease progression.

However, in some cases, fluid may reaccumulate within a short period. If fluid returns within a month of thoracentesis, the doctor may place an intrapleural port system—a small titanium device with a silicone membrane implanted under the skin and connected to the pleural cavity. This allows for easy fluid drainage without repeated invasive procedures.

Additionally, chemotherapy drugs can be administered through this system. Intrapleural chemotherapy can help reduce pleural effusion, especially in patients with mesothelioma, lung cancer, and breast cancer.

If needed, videothoracoscopy may be performed, allowing doctors to examine the pleural cavity using a small camera inserted through a chest wall incision. This procedure enables targeted biopsy of suspicious tissue, which is crucial for an accurate diagnosis.

Systemic chemotherapy not only treats the cancer but, in some cases, also helps resolve pleural effusion.

Pleurodesis

If chemotherapy is not an option, pleurodesis may be performed. This procedure involves introducing special agents into the pleural cavity to fuse the pleural layers together, preventing further fluid buildup. Some agents also have localized anti-cancer effects.

Additionally, immunotherapy can be used alongside pleurodesis. This may include LAK (lymphokine-activated killer) cells, recombinant interleukin-2, or a combination of both. The oncologist determines the most suitable immunotherapy approach based on factors such as fluid accumulation rate, overall health, and prior treatments.

Pleurocentesis is performed by experienced specialists using the Pleurocan device (USA) under ultrasound guidance, ensuring maximum safety, speed, and precision.

Treatment at stage 4 lung cancer with metastases

In stage 4 lung cancer, when the disease has spread extensively, treatment focuses on palliative (symptomatic) care rather than a cure. Palliative treatment aims to relieve suffering, prolong life, and improve quality of life.

Patients receive:

• Adequate pain management
• Oxygen therapy
• Detoxification treatments
• Palliative surgeries if necessary (e.g., tracheostomy, thoracocentesis, pleurodesis)
• Management of cancer pneumonia with anti-inflammatory treatment
• Hemostatic therapy in case of pulmonary hemorrhage

Palliative surgery

Palliative surgery may be considered for:

• Extensive tumor invasion into the chest wall
• Tumor breakdown (necrosis)
• Blockage of the trachea or major bronchi
• Atelectasis (lung collapse)
• Risk of severe pulmonary hemorrhage

However, surgery is generally avoided in cases of advanced lung cancer, severe respiratory failure, or heart failure.

Modern intensive treatment protocols are used to:

• Reduce tumor mass and slow its progression
• Remove accumulated fluid in body cavities
• Provide multi-component therapy to support vital organs (heart, liver, kidneys, lungs)
• Manage side effects and enhance overall well-being

Every effort is made to improve patients’ comfort, quality of life, and symptom relief in advanced-stage lung cancer.

Recovery after lung cancer in elderly patients

Post-treatment recovery is a crucial aspect of cancer care.

Regular follow-ups are necessary to detect tumor recurrence or metastases early. These examinations typically include:

• Patient interviews and physical examinations
• Laboratory tests (blood and urine)
• Chest X-rays
• Lung function tests

If recurrence is suspected, additional diagnostic tests are performed.

Rehabilitation is also essential, especially for elderly patients, due to age-related physiological changes. Rehabilitation is divided into:

• General rehabilitation, which includes medication, controlled physical activity, and dietary adjustments.
• Specialized rehabilitation, which may involve aerosol therapy, positive pressure ventilation, breathing exercises, oxygen therapy, airway drainage, and pain management.

These rehabilitation measures help patients recover more efficiently after treatment.

Prevention

Lung cancer prevention focuses on reducing exposure to risk factors and early detection.

Primary prevention

This involves measures to eliminate or reduce exposure to carcinogenic factors, including:

• Reducing air pollution
• Preventing occupational hazards
• Avoiding tobacco smoking

Secondary prevention

This involves systematic screening of the population to detect and treat precancerous conditions or early-stage lung cancer. Early diagnosis and timely treatment significantly improve outcomes.

Final thoughts

Lung cancer treatment is evolving rapidly, with precision medicine, targeted therapies, and immunotherapy showing promising results. While early detection significantly improves survival, even advanced-stage patients can benefit from new treatment strategies that improve quality of life and prolong survival.

Every lung cancer patient has unique circumstances, and a tailored approach combining various therapies offers the best possible outcome.