Management

Treatment options are determined by the histological cell type, the stage of cancer at diagnosis, patient performance status and the patient’s wishes. Socioeconomic deprivation, depression, comorbidities and late diagnosis all result in lung cancer being difficult to treat. Treatments include surgery, chemotherapy and radiotherapy.

Over the past 10 years, surgical techniques have trended towards minimal invasiveness. This offers comparable or sometimes better results in terms of patient outcome than the classical, more invasive procedures. Video-assisted thoracic surgery (VATS) is a form of keyhole surgery on the lung; its use in the management of patients with lung cancer was initially met with much scepticism. However, VATS-guided excisions and lobectomies have become established in the management of patients with early-stage lung cancer. VATS has an important role in patients with significant comorbidities and borderline pulmonary function, since recovery is usually quicker than after thoracotomy. Consequently, more patients with lung cancer are able to have operations. In addition, in order to improve the prognosis, adjuvant (post-operative) or neo-adjuvant (pre-operative) chemotherapy and/or radiotherapy may be useful (this is known as multimodal therapy).

Significant advances have also been made in chemotherapy. It is now recognised that patients with different subtypes of lung cancer respond differently to treatments and it is possible to tailor treatment according to the tumour subtype. For example, patients with advanced adenocarcinoma of the lung will benefit from pemetrexed plus platinum, while those with squamous cell carcinoma of the lung will benefit from gemcitabine plus platinum.

Recent advances in understanding the biology of lung cancer have resulted in newer targeted therapies, such as the tyrosine kinase inhibitors (erlotinib or gefitinib), which are known to be particularly beneficial in patients with advanced lung cancers that harbour a mutation in the epidermal growth factor receptor. Oral tyrosine kinase inhibitors are now licensed for the first-line treatment of patients with advanced lung cancer. In genetically selected patients with advanced lung cancer, these oral agents have been shown to be superior to conventional chemotherapy. In 2012, the European Medicines Agency approved the oral agent crizotinib for patients with advanced lung cancer and this may be preferred to standard chemotherapy when the lung cancer is shown to have an EML4-ALK fusion gene.

Radiotherapy techniques for lung cancer are also continuing to evolve. Modern radiotherapy employs techniques to spare surrounding tissues from the damage-enabling higher radiation doses applied to the cancer. The advent of stereotactic radiotherapy has allowed patients with poor lung function, who previously may not have received treatment, to receive radiotherapy.

Interventional bronchoscopic techniques are useful in the palliative care of patients with cancers that obstruct major airways.

See the entire Lung Cancer Chapter