Lung cancer medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Saarah T. Alkhairy M.D

Overview

The therapy for lung cancer consists of surgery, radiation therapy, chemotherapy, and targeted therapy.

Medical Therapy

The therapy for lung cancer consists of surgery, radiation therapy, chemotherapy, and targeted therapy.

The table below summarizes the treatment for each stage of lung cancer for those who either refuse or unable to tolerate surgery.

Stage Treatment
I Radiation therapy AND consider chemotherapy for high risk stage IB
II (T2a, N0 OR T3, N0) Consider chemotherapy for high risk stage II AND radiation therapy
II (T1a, N1 OR T1b, N1 OR T2a, N1 OR T2b, N1) Chemoradiation
III Chemoradiation

The algorithm below demonstrates a treatment protocol for stage I patients that can tolerate surgery [1].


The algorithm below demonstrates a treatment protocol for stage II without invasion patients that can tolerate surgery [2].


The algorithm below demonstrates a treatment protocol for stage II with invasion that can tolerate surgery [3].


The algorithm below demonstrates a treatment protocol for stage III without invasion that can tolerate surgery [4][5].

The algorithm below demonstrates a treatment protocol for stage III with invasion that can tolerate surgery [6][7].

The treatment of stage 4 lung cancers are treated with chemotherapy if the Eastern Cooperative Oncology Group (ECOG) Performance Scale is between 0 or 2. If the performance score is 3 or 4, the supportive care is recommended[8].

The Eastern Cooperative Oncology Group (ECOG) Performance Scale is the following[9]:

  • 0 - fully active
  • 1 - self-care activities but unable to do hard physical work
  • 2 - self-care activities but unable to do any work
  • 3 - unable to do any self-care activities or any work
  • 4 - fully disabled

Surgery

To view the surgery of lung cancer, click here

Radiation Therapy

Radiation therapy can be given with either one of two methods:

  • External Beam Radiation Therapy (EBRT)
  • This is more commonly used
  • The body receives radiation from an outside machine
  • The radiation is given in a series of sessions for about 8 weeks
  • Internal Radiation Therapy (brachytherapy)
  • This therapy involves placing a radioactive object in or near the tumor
  • This can shrink a tumor that blocks the airway
  • Possible side effects include the following:
  • Dry, sore, painful skin
  • Hair loss
  • Swelling of the lungs or esophagus
  • Fatigue
  • Loss of appetite

Chemotherapy for Non Small Cell Lung Cancer

Chemotherapy Regimens for Neoadjuvant and Adjuvant Therapy

  • Cisplatin 50 mg/m2 days 1 and 8 AND vinorelbine 25 mg/m2 days 1, 8, 15, 22, every 28 days for 4 cycles[10]
  • Cisplatin 100 mg/m2 day 1 AND vinorelbine 30 mg/m2 days 1, 8, 15, 22, every 28 days for 4 cycles
  • Cisplatin 75-80 mg/m2 day 1 AND vinorelbine 25-30 mg/m2 days 1 + 8, every 21 days for 4 cycles
  • Cisplatin 100 mg/m2 day 1 AND etoposide 100 mg/m2 days 1-3, every 28 days for 4 cycles
  • Cisplatin 80 mg/m2 days 1, 22, 43, 64 AND vinblastine 4 mg/m2 days 1, 8, 15, 22, 29 then every 2 wks after day 43, every 21 days for 4 cycles
  • Cisplatin 75 mg/m2 day 1 AND gemcitabine 1250 mg/m2 days 1, 8, every 21 days for 4 cycles
  • Cisplatin 75 mg/m2 day 1 AND docetaxel 75 mg/m2 day 1, every 21 days for 4 cycles
  • Cisplatin 75 mg/m2 day 1 AND pemetrexed 500 mg/m2 day 1 for nonsquamous (without specific histologic subtype), every 21 days for 4 cycles

Chemotherapy Regimens for Patients with Comorbidities or Patients Not Able to Tolerate Cisplatin[11]

  • Paclitaxel 200 mg/m2 day 1, carboplatin AUC 6 day 1, every 21 days

Concurrent Chemotherapy and Radiation Therapy Regimens

  • Cisplatin 50 mg/m2 on days 1, 8, 29, and 36 AND etoposide 50 mg/m2 days 1-5, 29-33 WITH concurrent thoracic radiation therapy[12]
  • Cisplatin 100 mg/m2 days 1 and 29 AND vinblastine 5 mg/m2/weekly x 5 WITH concurrent thoracic radiation therapy
  • Carboplatin AUC 5 on day 1 AND pemetrexed 500 mg/m2 on day 1 every 21 days for 4 cycles WITH concurrent thoracic radiation therapy
  • Cisplatin 75 mg/m2 on day 1 AND pemetrexed 500 mg/m2 on day 1 every 21 days for 3 cycles WITH concurrent thoracic radiation therapy

Sequential Chemotherapy and Radiation Therapy Regimens

  • Cisplatin 100 mg/m2 on days 1 and 29 AND vinblastine 5 mg/m2/weekly on days 1, 8, 15, 22, and 29 FOLLOWED by radiation therapy [13]
  • Paclitaxel 200 mg/m2 over 3 hours on day 1 AND carboplatin AUC 6 over 60 minutes on day 1 every 3 weeks for 2 cycles FOLLOWED by thoracic radiation therapy

Concurrent Chemotherapy and Radiation Therapy Followed by Chemotherapy

  • Paclitaxel 45-50 mg/m2 weekly AND carboplatin AUC 2 WITH concurrent thoracic radiation therapy FOLLOWED by 2 cycles of paclitaxel 200 mg/m2 and carboplatin AUC 6 [14]
  • Cisplatin 50 mg/m2 on days 1, 8, 29, and 36 AND etoposide 50 mg/m2 days 1-5, 29-33 WITH concurrent thoracic radiation therapy FOLLOWED by cisplatin 50 mg/m2 and etoposide 50 mg/m2 x 2

Chemotherapy for Non Small Cell Lung Cancer

Chemotherapy as Primary or Adjuvant Therapy[15]

LIMITED STAGE (MAXIMUM of 4-6 cycles):

  • Cisplatin 60 mg/m2 day 1 AND etoposide 120 mg/m2 days 1, 2, 31
  • Cisplatin 80 mg/m2 day 1 AND etoposide 100 mg/m2 days 1, 2, 32
  • Carboplatin AUC 5-6 day 1 AND etoposide 100 mg/m2 days 1, 2, 33

EXTENSIVE STAGE (MAXIMUM of 4-6 cycles):

  • Cisplatin 75 mg/m2 day 1 AND etoposide 100 mg/m2 days 1, 2, 3
  • Cisplatin 80 mg/m2 day 1 AND etoposide 80 mg/m2 days 1, 2, 3
  • Cisplatin 25 mg/m2 days 1, 2, 3 AND etoposide 100 mg/m2 days 1, 2, 3
  • Carboplatin AUC 5-6 day 1 AND etoposide 100 mg/m2 days 1, 2, 3
  • Cisplatin 60 mg/m2 day 1 AND irinotecan 60 mg/m2 days 1, 8, 15
  • Cisplatin 30 mg/m2 AND irinotecan 65 mg/m2 days 1, 89
  • Carboplatin AUC 5 day 1 and irinotecan 50 mg/m2 days 1, 8, 15

Subsequent Chemotherapy (Relapse < 2-3 Months)

Subsequent Chemotherapy (Relapse > 2-3 Months up to 6 Months)

Subsequent Chemotherapy (Relapse > 6 Months)

  • Original regimen[18]

Targeted Therapy

Targeted therapy treats selected lung cancers or is combined with chemotherapy. It is less likely to harm normal cells compared to chemotherapy.

The table below summarizes the targeted therapy drug, mechanism of action, and their common side effects[19]:

Drug Mechanism of Action Common Side Effects
Afatinib Blocks the signals from EGFRs to prevent cell growth Diarrhea, skin problems, mouth sores, and lack of appetite
Bevacizumab Stops the growth of new blood vessels Diarrhea, high blood pressure, headache, fatigue, and mouth sores
Cetuximab Attaches to EGFRs to prevent cell growth Skin rash, fatigue, and weakness
Crizotinib Block the signals from ALKs to prevent cell growth Lack of appetite, nausea, vomiting, diarrhea, visual defects, and flu-like symptoms
Erlotinib hydrocholoride Blocks the signals from EGFRs to prevent cell growth Skin rash on face, neck, or trench within the first 2 weeks of treatment, diarrhea, fatigue, lack of appetite, and nausea

References

  1. ↑ http://www.nccn.org/patients/guidelines/nscl/#56/z
  2. ↑ http://www.nccn.org/patients/guidelines/nscl/#58/z
  3. ↑ http://www.nccn.org/patients/guidelines/nscl/#61/z
  4. ↑ http://www.nccn.org/patients/guidelines/nscl/#63/z
  5. ↑ http://www.nccn.org/patients/guidelines/nscl/#64/z
  6. ↑ http://www.nccn.org/patients/guidelines/nscl/#66/z
  7. ↑ http://www.nccn.org/patients/guidelines/nscl/#67/z
  8. ↑ http://www.nccn.org/patients/guidelines/nscl/#72/z
  9. ↑ http://www.nccn.org/patients/guidelines/nscl/#71/z
  10. ↑ http://www.nccn.org/professionals/physician_gls/PDF/nscl.pdf
  11. ↑ http://www.nccn.org/professionals/physician_gls/PDF/nscl.pdf
  12. ↑ http://www.nccn.org/professionals/physician_gls/PDF/nscl.pdf
  13. ↑ http://www.nccn.org/professionals/physician_gls/PDF/nscl.pdf
  14. ↑ http://www.nccn.org/professionals/physician_gls/PDF/nscl.pdf
  15. ↑ http://www.nccn.org/professionals/physician_gls/PDF/sclc.pdf
  16. ↑ http://www.nccn.org/professionals/physician_gls/PDF/sclc.pdf
  17. ↑ http://www.nccn.org/professionals/physician_gls/PDF/sclc.pdf
  18. ↑ http://www.nccn.org/professionals/physician_gls/PDF/sclc.pdf
  19. ↑ http://www.nccn.org/patients/guidelines/nscl/#51/z

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