NCCN Lung Cancer Treatment Guidelines IV Cancer Treatment Guidelines for Patients Advanced Cancer...

Lung CancerTreatment Guidelines for Patients

Version IV/ February 2008

Current Cancer Treatment Guidelines for Patients

Advanced Cancer and Palliative Care Treatment Guidelines for Patients(English and Spanish)

Bladder Cancer Treatment Guidelines for Patients (English and Spanish)

Breast Cancer Treatment Guidelines for Patients (English and Spanish)

Cancer Pain Treatment Guidelines for Patients (English and Spanish)

Cancer-Related Fatigue and Anemia Treatment Guidelines for Patients(English and Spanish)

Colon and Rectal Cancer Treatment Guidelines for Patients (English and Spanish)

Distress Treatment Guidelines for Patients (English and Spanish)

Fever and Neutropenia Treatment Guidelines for Patients with Cancer(English and Spanish)

Lung Cancer Treatment Guidelines for Patients (English and Spanish)

Melanoma Cancer Treatment Guidelines for Patients (English and Spanish)

Nausea and Vomiting Treatment Guidelines for Patients with Cancer(English and Spanish)

Non-Hodgkin’s Lymphoma Treatment Guidelines for Patients (English and Spanish)

Ovarian Cancer Treatment Guidelines for Patients (English and Spanish)

Prostate Cancer Treatment Guidelines for Patients (English and Spanish)

The mutual goal of the National Comprehensive Cancer Network® (NCCN®) andthe American Cancer Society (ACS) partnership is to provide patients and thegeneral public with state-of-the-art cancer treatment information in an easy-to-understand language. This information, based on the NCCN’s Clinical PracticeGuidelines, is meant to help you when you talk with your doctor about treatmentoptions that are best for you. These guidelines do not replace the expertise andclinical judgment of your doctor.

Lung CancerTreatment Guidelines for Patients

Version IV/ February 2008

NCCN Clinical Practice Guidelines were developed by a diverse panel of experts.The guidelines are a statement of consensus of its authors regarding the scientificevidence and their views of currently accepted approaches to treatment. TheNCCN guidelines are updated as new information becomes available. The PatientInformation version is updated accordingly and is available on-line through theAmerican Cancer Society and NCCN Web sites. To be sure you have the most up-to-date version of the guidelines, check the Web sites of the ACS (www.cancer.org)or NCCN (www.nccn.org). You may also call the NCCN at 1-888-909-NCCN or theACS at 1-800-ACS-2345 for the most recent information.

©2008 by the American Cancer Society (ACS) and the National ComprehensiveCancer Network (NCCN). All rights reserved. The information herein may not bereprinted in any form for commercial purposes without the expressed writtenpermission of the ACS. Single copies of each page may be reproduced for personaland non-commercial uses by the reader.

Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5Making decisions about lung cancer treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5About the lungs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6Types of lung cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7Tests and exams for the diagnosis of lung cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7Lung cancer staging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11Types of treatment for lung cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14Complementary and alternative medicines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19About clinical trials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19Other things to consider during and after treatment . . . . . . . . . . . . . . . . . . . . . . . . .20Work-up (evaluation) and treatment guidelines . . . . . . . . . . .23

Decision trees for non-small cell lung cancer:Initial work-up and staging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24Evaluation of stages I and II . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26Treatment of stages I, II, and IIIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28Evaluation of stages IIB and IIIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32Treatment of stages IIB and IIIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34Evaluation of stages IIIA and IIIB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38Treatment of stage IIIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40Treatment of stage IIIB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44Evaluation and treatment of stage IIIB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46Treatment of stage IIIB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48Treatment of stage IV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50Follow-up and treatment of stage IV and recurrent cancer . . . . . . . . . . . . . . . .52Treatment of stage IV and recurrent cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56Treatment of stage IV with disease progression . . . . . . . . . . . . . . . . . . . . . . . . . . .58Treatment of second primary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60Decision trees for small cell lung cancer:Initial work-up and staging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .64Limited stage work-up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66Treatment for limited stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68Work-up and treatment for extensive stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70Adjuvant treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72Treatment of recurrent disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .76

City of Hope

Dana-Farber/Brigham and Women’s Cancer Center Massachusetts General Hospital Cancer Center

Duke Comprehensive Cancer Center

Fox Chase Cancer Center

Huntsman Cancer Institute at the University of Utah

Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance

Arthur G. James Cancer Hospital and Richard J. Solove ResearchInstitute at The Ohio State University

The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins

Robert H. Lurie Comprehensive Cancer Center of Northwestern University

Memorial Sloan-Kettering Cancer Center

H. Lee Moffitt Cancer Center & Research Institute

Roswell Park Cancer Institute

Siteman Cancer Center at Barnes-Jewish Hospital andWashington University School of Medicine

St. Jude Children’s Research Hospital/University of Tennessee Cancer Institute

Stanford Comprehensive Cancer Center

University of Alabama at Birmingham Comprehensive Cancer Center

UCSF Helen Diller Family Comprehensive Cancer Center

University of Michigan Comprehensive Cancer Center

UNMC/Eppley Cancer Center at The Nebraska Medical Center

The University of Texas M.D. Anderson Cancer Center

Vanderbilt-Ingram Cancer Center

Member Institutions

Introduction

With this booklet, patients have access toinformation on the way lung cancer is treatedat the nation’s leading cancer centers.Originally developed for cancer specialists bythe National Comprehensive Cancer Network(NCCN), these treatment guidelines havenow been translated for the lay public by theAmerican Cancer Society (ACS).

Since 1995, doctors have looked to theNCCN for guidance on the highest quality,most effective advice on treating cancer. Formore than 90 years, the public has relied onthe American Cancer Society for informationabout cancer. The Society’s books andbrochures provide comprehensive, current,and understandable information to hundredsof thousands of patients, their families, andfriends. This collaboration between the NCCNand ACS provides an authoritative andunderstandable source of cancer treatmentinformation for the public.

These patient guidelines will help youbetter understand your cancer treatmentoptions. We urge you to discuss them withyour doctor. Here are some questions youmight want to ask:

• What type of lung cancer do I have? • Has my cancer spread? • What is the stage of my cancer and

what does that mean? • What are my treatment choices? • What treatment do you suggest and why? • What should I do to get ready for

treatment, minimize side effects oftreatment, and hasten my recovery?

• What is the goal of this treatment? • What risks or side effects are there to

the treatment you suggest? • When will I be able to return to my

normal activities? • What are the chances of my cancer

recurring (coming back) with the treatment options we have discussed?

• What rehabilitation and support servicesare available to me and my family?

• Is this the right time to discuss my livingwill or advance directives?

In addition to these questions, be sure towrite down some of your own. For instance,you might want more information so that youcan plan your work schedule. Or, you may wantto ask if you qualify for any clinical trials.

Making decisions aboutlung cancer treatment

Although lung cancer is a very seriousdisease, it can be treated by a team of healthcare professionals. This team may include asurgeon, radiation oncologist, medical oncol-ogist, lung specialist, oncology nurse, andsocial worker.

But not all people with lung cancer shouldhave the same treatment. Doctors must con-sider each patient’s specific medical situation.These guidelines are intended to help youunderstand the treatment options availableto people with lung cancer so that you andyour doctors can work together to identifywhich treatment best meets your medicaland personal needs.

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On the following pages, you will find flowcharts that doctors call Decision Trees. Theyshow how you and your doctor can use infor-mation about the type, location, and extentof the lung cancer to arrive at the choices youneed to make about your treatment. Here youwill also find background information on lungcancer with explanations of cancer stage,work-up, and treatment – all terms used in theflow charts.

About the lungs

Most cancers are named after the part of thebody where the cancer first starts. Lungcancer begins in the lungs. Other cancers canspread (metastasize) to the lungs, but thesecancers are named according to where theyfirst developed. For example, breast cancercan spread to the lungs, but it is calledmetastatic breast cancer, not lung cancer.These guidelines only address cancers thatstart in the lungs.

The lungs are 2 sponge-like organs in thechest. They bring air into (inhale) the bodyand push it out (exhale), taking in oxygen andgetting rid of carbon dioxide gas, a wasteproduct. The right lung has 3 sections, calledlobes. The left lung has 2 lobes. It is smallerbecause the heart takes up more room onthat side of the body. The lining around thelungs, called the pleura, helps protect thelungs and allows them to move when youbreathe. The trachea (windpipe) brings airdown into the lungs. It divides into tubescalled bronchi, which divide into smallerbranches called bronchioles. At the end of

these small branches are tiny air sacs knownas alveoli. Most lung cancers start in the lin-ing of the bronchi, but they can also begin inother areas such as the trachea, bronchioles,or alveoli.

Lymphatic vessels are like veins but carrylymph instead of blood. Lymph is a clear fluidthat contains tissue waste products andimmune system cells. Lymphatic vessels ofthe lungs lead to nearby lymph nodes insidethe chest. These nodes are located aroundthe bronchi and in the mediastinum (the areabetween the 2 lungs). Cancer cells may enterlymph vessels and spread out to reach lymphnodes. Lymph nodes are small, bean-shapedcollections of immune system cells that areimportant in fighting infections. When lungcancer cells reach the lymph nodes, they can

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Trachea

Bronchus

Lung Lung

Hilar lymphnodes

Lower mediastinallymph nodes

Uppermediastinal

lymph nodes

Supraclavicular(collarbone)

lymph nodes

Subcarinal lymph nodes

Bronchiallymphnodes

The lungs and nearby lymph nodes

continue to grow. If cancer cells have multi-plied in the lymph nodes, they are more likelyto have spread to other organs of the bodytoo. One of the most important decisionsabout lung cancer treatment is based onwhether the cancer has spread to the nearbylymph nodes in the mediastinum. The names,location, and importance of lymph nodes nearthe lungs are explained in the section on stag-ing of lung cancer (see Lung Cancer Stagingon page 11) and are shown in the diagram onthe previous page.

Types of lung cancer

The lungs are made up of many kinds of cellsthat have different functions. The type of lungcancer depends on which cell type is affected.There are 2 major types of lung cancer. Thefirst type is non-small cell lung cancer, orNSCLC. This term refers to a group of cancersthat are categorized based on their similartreatment and outcomes. The other type issmall cell lung cancer, or SCLC, which has adifferent prognosis and is treated very differ-ently from NSCLC. Very rarely, lung cancershave features of both types—they are calledmixed small cell/large cell cancer or combinedsmall cell and non-small cell lung cancer.

Non-small cell lung cancer Non-small cell lung cancer (NSCLC) is the mostcommon type of lung cancer, accounting for85% to 90% of lung cancers. There are 3 sub-types within this group which differ in size,shape, and chemical make-up when lookedat under a microscope:

• squamous cell carcinoma (carcinomais another word for cancer)

• adenocarcinoma (including bronchioloalveolar carcinoma)

• large cell undifferentiated carcinoma.

The subtypes of NSCLC, however, have thesame treatment options.

Small cell lung cancer Small cell lung cancer (SCLC) accounts for10% to 15% of all lung cancers. Other namesfor small cell lung cancer are oat cell carci-noma, small cell undifferentiated carcinoma,and poorly differentiated neuroendocrinecarcinoma.

Other types of lung cancerThere are other rare types of lung cancer thatare not covered in this booklet. For example,malignant mesothelioma, a type of cancer thatdevelops from cells of the pleura, is treateddifferently from SCLC and NSCLC. Also,cancer that spreads to the lungs (metastaticcancer) but started in other organs (such asthe breast, pancreas, kidney, or skin) is notcovered. Treatment for metastatic cancer tothe lungs depends on where it started. Forinformation on these cancers, refer to otherNCCN and/or ACS booklets.

Tests and exams for thediagnosis of lung cancer

If there is a reason to suspect you may havelung cancer, your doctor will use one or moremethods to find out if the disease is reallypresent. If these tests find lung cancer, more

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tests will be done to find out how far thecancer has spread.

Medical history and physical examYour doctor will ask you a series of questionsabout your health in general, any other con-ditions or disease you might have and aboutyour symptoms and risk factors. This iscalled “taking your medical history.” Althoughmost lung cancers do not cause symptomsuntil they have spread, some of the most fre-quent symptoms are caused by the cancergrowing in the lungs and its spread to nearbytissues. You should tell your doctor about anyof these symptoms right away:

• A cough that does not go away • Chest pain, often made worse by

deep breathing • Shoulder pain with numbness in

some fingers; with (or without) adroopy eyelid

• Hoarseness • Weight loss and loss of appetite • Bloody or rust-colored sputum

(spit or phlegm) • Shortness of breath • Fever without a known reason • Infections that keep coming back,

such as bronchitis and pneumonia • New wheezing • Headaches, dizziness; change in vision

or speech • Seizures

These problems are often caused by someother condition, but if lung cancer is found,prompt treatment could help you live longerand relieve symptoms. In many cases, lungcancer may have spread to distant organs

before it causes any symptoms. Symptomscaused by cancer that has spread to otherorgans include:

• Bone pain • Weakness or numbness of the arms

or legs• Dizziness • Yellow coloring of the skin and eyes

(jaundice) • Lumps near the surface of the body,

caused by cancer spreading to the skinor to lymph nodes (often in the neck orabove the collarbone)

• Clusters of symptoms (called paraneo-plastic syndromes) caused by thecancer that can point to a possiblelung cancer

The medical history and physical examare the first steps towards finding outwhether a lung cancer is present and findingout how far it may have spread. Informationabout problems other than lung cancer suchas bronchitis, emphysema, or heart diseasewill help doctors decide what treatmentoptions are best for you.

Performance statusBecause the side effects of chemotherapy canbe severe, recommendations for chemotherapyare often based on a patient’s overall generalhealth. This is called a patient’s performancestatus. NCCN doctors use precise definitionsof “good health” or “poor health,” based on theEastern Cooperative Oncology Group (ECOG)Performance Scale. The ECOG PerformanceScale ranks the health of people with canceron a scale of 0 to 4. A rank of 0 means that thepatient has no symptoms and is able to do

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the same things he or she could do beforebeing diagnosed with cancer. At the otherend of the scale, a rank of 4 means that thepatient cannot take care of his or her dailyself-care activities (such as feeding, bathing,dressing, or going to the bathroom) and can-not get out of bed. A rank of 3 means that thepatient can do some self-care activities, butspends more than half of his or her wakinghours in bed because of feeling too sick orweak. In the Decision Trees presented here,an EGOG performance scale ranking of 0-2is good health, while a ranking of 3 or 4 ispoor health.

Imaging testsThese tests use x-rays, magnetic fields, orradioactive substances to create pictures ofthe inside of the body to look at the extent orspread of the cancer.

Computed tomography Computed tomography, or a CT scan, is an x-ray test that produces detailed cross-sectionalpictures of your body. Instead of taking onepicture, as does a usual chest x-ray, a CTscanner takes many pictures as it rotatesaround you. A computer then combines thesepictures into an image of a slice of your body.The machine will take pictures of multipleslices of the part of your body that is beingstudied.

Often after the first set of pictures is taken,you will get an intravenous (IV) injection of aradio-contrast agent or dye, which helps tobetter outline structures in your body. Asecond set of pictures is then taken. Somepeople get hives or, rarely, a few people canhave more serious allergic reactions like

trouble breathing and low blood pressure. Besure to tell the doctor if you have ever had areaction to any contrast material used for a test.

The CT scan can give precise informationabout the size, shape, and position of a tumorand can help find enlarged lymph nodes thatmight contain cancer. CT scans are more sen-sitive than a routine chest x-ray in findingearly lung cancers.

Magnetic resonance imaging Magnetic resonance imaging (MRI) scans useradio waves and strong magnets instead of x-rays to take pictures. The energy from theradio waves is absorbed and then released ina pattern formed by the type of tissue and bycertain diseases. A computer translates thepattern of radio waves given off by the tissuesinto very detailed cross-sectional images ofparts of the body. A contrast material mightbe injected just as with CT scans. These imagesare useful in finding lung cancer that hasspread to the brain or spinal cord.

Radionuclide bone scanThis procedure helps show if a cancer hasspread to bones. You will get an injection ofradioactive material (usually technetiumdiphosphonate). The amount of radioactivityused is very low and causes no long-termeffects. The radioactive substance is attractedto diseased bone cells throughout the entireskeleton. Areas of diseased bone will be seenon the bone scan image as dense, gray to blackareas, called “hot spots.” These areas maysuggest the presence of metastatic cancer, butarthritis, infection, or other bone diseasescan also cause a similar pattern.

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Positron emission tomography Positron emission tomography (PET) scansuse a form of sugar (glucose) that contains aradioactive atom. A small amount of the radio-active material is injected into your arm.Because of the high amount of energy thatlung cancer cells use, areas of cancer in thebody absorb large amounts of the radioactivesugar. Then you are put into the PET machinewhere a special camera can detect theradioactivity. Newer devices combine PETscans and CT scans.

Procedures used to diagnose andcheck for spread of lung cancerDepending on the results of the imaging tests,one or more of the following procedures maybe used to collect samples and check themfor cancer cells. A pathologist, a doctor whospecializes in laboratory tests to diagnosediseases such as cancer, will examine the cellsusing a microscope. If you have any questionsabout your pathology results or any diagnostictests, do not hesitate to ask your doctor. Youcan get a second opinion of your pathologyreport, called a pathology review, by havingyour tissue specimen sent to a consultingpathologist at an NCCN center or other labo-ratory recommended by your doctor.

Sputum cytologyA sample of phlegm (mucus you cough up fromthe lungs) is checked to see if cancer cells arepresent.

Fine needle biopsyA thin needle can be guided between the ribsinto the area of concern while the lungs are

being viewed with fluoroscopy ( fluoroscopyis like an x-ray, but the image is looked at ona screen rather than on film). CT scans canalso be used to direct needle placement. Oncedoctors are certain the needle tip is withinthe target area, a biopsy (sample) is removedand sent to the laboratory. A thin needle canalso be inserted through the wall of the tracheausing a bronchoscope in order to samplenearby lymph nodes. This procedure, calledtranstracheal fine needle aspiration, is oftenused to take samples of subcarinal lymphnodes (around the point where the windpipebranches into the left and right bronchi) andmediastinal lymph nodes (along the windpipeand the major bronchial tube areas).

Bone marrow biopsyA bone marrow biopsy is done to look for lungcancer cells that may have spread to bonemarrow. A needle is used to remove a smallpiece of bone and a sample of bone marrow,usually from the back of the hip bone. A bonemarrow biopsy is only done for some patientswith small cell lung cancer (SCLC).

BronchoscopyBronchoscopy can help find tumors and takesamples of tissue or fluids to see if cancer cellsare present. A lighted, flexible tube called abronchoscope is passed through the mouthinto the bronchi. After a lung cancer has beendiagnosed, bronchoscopy is used to thoroughlycheck the lining of other airways in the lungs.If another cancer is found that is not close tothe first one, surgery may not be able toremove all of the cancerous tissue.

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MediastinoscopyFor a mediastinoscopy a hollow, lighted tubeis inserted under the breastbone (sternum),through a small cut in the base of the neck.Special instruments operated through thistube can be used to take a tissue sample fromthe mediastinal lymph nodes (along the wind-pipe and the major bronchial tube areas).

ThoracentesisThoracentesis is done to check whether fluidaround the lungs is caused by cancer that hasspread to the pleural membranes (the delicatemembranes that cover the lungs) or causedby a non-cancerous condition, such as heartfailure or an infection. A needle is placedbetween the ribs to drain the fluid, which ischecked under a microscope to look forcancer cells. If fluid collects around the lungs,it can keep the lungs from filling with air, sothoracentesis can help improve the patient’sbreathing.

ThoracoscopyA thoracoscopy procedure uses a thin, lightedtube connected to a video camera and monitorto look at the space between the lungs andthe chest wall. This allows the doctor to seetumors on the surface of the lungs. The doctorcan also take a biopsy of any areas that looksuspicious.

Blood testsWhen cancer spreads to the liver and bones,it may cause certain chemical abnormalitiesin the blood. Certain blood tests are oftendone to see if the lung cancer has spread to

these areas. These tests include a completeblood count (CBC) and blood chemistry. ACBC determines whether the patient’s bloodhas the correct number of various cell types.Doctors repeat this test regularly in patientstreated with chemotherapy, because thesedrugs temporarily affect blood-forming cellsof the bone marrow. To find these changes,doctors perform blood chemistry tests.

Lung cancer staging

Staging is the process of finding out how farthe cancer has spread. This is very important,because your treatment and the outlook foryour recovery and chances of cure depend onthe stage of your cancer. For example, somestages of lung cancer may be best treated withsurgery, while others are best treated withcombinations of chemotherapy and radiationtherapy. There are different staging systemsfor small cell and non-small cell lung cancer.

Your treatment and prognosis (the outlookfor chances of survival) depend, to a largeextent, on your cancer’s stage and cell type.Tests such as MRI, CT scans, bone marrowbiopsy, mediastinoscopy, and blood tests areused to stage the cancer.

Be sure to ask your doctor to explain yourstage in a way you understand. Once youknow your stage, you will know which DecisionTrees in this booklet apply to you. Reviewingthese Decision Trees can help you and yourdoctor decide which treatments are bestsuited for you.

Staging of non-small cell lung cancerThe system most often used to describe thegrowth and spread of non-small cell lungcancer (NSCLC) is the TNM staging system,also known as the American Joint Committeeon Cancer (AJCC) system. In TNM staging,information about the tumor, nearby lymphnodes, and distant organ metastases is com-bined and a stage is assigned to that specificgrouping. The grouped stages are describedusing Roman numerals from I to IV.

In TNM staging T stands for tumor (itssize and how far it has spread within the lungand to nearby organs), N stands for spread tolymph nodes, and M is for metastasis (spreadto distant organs).

T categories for non-small cell lung cancerT categories are based on the lung cancer’ssize, its spread and location within the lungs,and its spread to nearby tissues.

Tis: Cancer is found only in the layer ofcells lining the air passages. It has not spreadinto other lung tissues. This stage is alsoknown as carcinoma in situ.

T1: The cancer is no larger than 3 centi-meters (slightly less than 11⁄4 inches), has notspread to the visceral pleura (membranesthat surround the lungs), and does not affectthe main branches of the bronchi.

T2: The cancer has one or more of thefollowing features:

• It is larger than 3 cm across. • It has grown into a main bronchus but

is not closer than 2 cm (about 3⁄4 inch)from the point where the trachea(windpipe) branches into the left andright main bronchi.

• It has spread to the membranes thatsurround the lungs.

• The cancer may partially block the air-ways, but this has not caused theentire lung to collapse or developpneumonia.

T3: The tumor is any size and has one ormore of the following features:

• It has spread to the chest wall, thediaphragm (breathing muscle that separates the chest from the abdomen),the mediastinal pleura (membranessurrounding the space between the 2 lungs), or parietal pericardium (membranes of the sac surroundingthe heart).

• It has grown into a main bronchus, andit is closer than 2 cm (about 3⁄4 inch)from the point where the trachea(windpipe) branches into the left andright main bronchi, but has not growninto this area.

• It has grown into the airways enoughto cause one lung to entirely collapse orto cause pneumonia of the entire lung.

T4: The cancer has one or more of thefollowing features:

• It has spread to any of the following:the mediastinum (space behind thechest bone and in front of the heart),the heart, the trachea (windpipe), theesophagus (tube connecting the throatto the stomach), the backbone, or thepoint where the windpipe branchesinto the left and right main bronchi.

• Two or more separate tumors are present in the same lobe of a lung.

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• There is a malignant pleural effusion(fluid containing cancer cells in thespace surrounding the lung).

N categories for non-small cell lung cancerThe N category depends on which, if any, ofthe lymph nodes near the lungs are affectedby the cancer.

N0: The cancer has not spread to lymphnodes.

N1: The cancer has spread to lymph nodeswithin the lung, or the hilar lymph nodes(located around the area where the bronchusenters the lung). Metastases affect lymph nodesonly on the same side as the cancerous lung.

N2: The cancer has spread to subcarinallymph nodes (around the point where thewindpipe branches into the left and right

bronchi) or to lymph nodes in the mediastinum(space behind the chest bone and in front ofthe heart). Affected lymph nodes are on thesame side of the lung with the tumor.

N3: The cancer has spread to lymph nodesnear the collarbone on either side, and/or tohilar or mediastinal lymph nodes on the sideopposite the lung with the tumor.

M categories for non-small cell lung cancerThe M category describes whether the cancerhas spread to any distant tissues and organs.

M0: No distant cancer spread. M1: Cancer has spread to one or more dis-

tant sites. Sites considered distant include otherlobes of the lungs, lymph nodes further thanthose mentioned in N stages, and other organsor tissues such as the liver, bones, or brain.

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Table 1. Stage grouping for non-small cell lung cancer

Overall Stage T category N category M category

Stage 0 Tis (In situ) N0 M0

Stage IA T1 N0 M0

Stage IB T2 N0 M0

Stage IIA T1 N1 M0

Stage IIB T2 N1 M0T3 N0 M0

Stage IIIA T1 N2 M0T2 N2 M0T3 N1 M0T3 N2 M0

Stage IIIB Any T N3 M0T4 Any N M0

Stage IV Any T Any N M1

Stage grouping for non-small cell lung cancerOnce the T, N, and M categories have beenassigned, this information is combined (stagegrouping) to assign an overall stage of 0, I, II,III, or IV (see Table 1). Various T and N cate-gories are combined into stages. The stagesidentify tumor types that have a similar prog-nosis and are treated in a similar way. As notedin the table, a tumor that has metastasized todistant areas (M1) is considered Stage IV,regardless of the tumor’s size or if the lymphnodes are involved. Patients with lower stagecancers have a more favorable outlook forsurvival (that is, patients with Stage I diseasetend to live longer than those with Stage IVdisease).

Staging of small cell lung cancerAlthough small cell lung cancer can be stagedlike NSCLC, most doctors have found that amuch simpler 2-stage system works betterchoosing treatment. This system divides SCLCinto “limited stage” and “extensive stage.”

• Limited stage means that the cancer isonly in one lung and in lymph nodeson the same side of the chest.

• Extensive stage means that the cancerhas spread outside the other lung andto other parts of the body such as thelymph nodes on the other side of thechest, or to distant organs; or there ismalignant fluid surrounding the lung.

Types of treatment forlung cancer

There is a lot for you to think about whenchoosing the best way to treat or manageyour cancer. There may be more than onetreatment to choose from. Planning lungcancer treatment is very complex. A team ofcancer care professionals should be availableto discuss all of the options. Combinations ofchemotherapy, radiation therapy, targetedtherapy, or surgery may be of greater valuethan any single treatment alone. You may feelthat you need to decide on a treatmentquickly. But give yourself time to understandyour options. Talk with your doctor. Look atthe list of questions on page 5 to get someideas. Then add your own.

You may want to get a second opinion.Your doctor should not mind if you want todo this. In fact, some insurance companiesrequire a second opinion. If your first doctorhas done tests, the results can be sent to thesecond doctor so that you will not have tohave them done again. Before making anyplans check your health insurance company’spolicy about second opinions.

The treatment options for lung cancer aresurgery, radiation therapy, chemotherapy, andtargeted therapy either alone or in combina-tion, depending on the stage of the tumor.

SurgeryDepending on the type and stage of the cancer,surgery may be used to remove the tumor andsome of the lung tissue around it. If a lobe(section) of the lung is removed, the surgery iscalled a lobectomy. If the entire lung is removed,

14

the surgery is called a pneumonectomy.These operations are done with the patientasleep under general anesthesia. A hospital stayof about 1 week is usually needed. Becausethe surgeon has to cut or spread the ribs toget to the lungs, the patient will have somepain after the surgery. There are many waysto control pain. (See the ACS/NCCN CancerPain Treatment Guidelines for Patients formore information on pain management.)

People who do not have any other lungproblems (other than the cancer) can oftenreturn to their normal activities after a lobeor even an entire lung is removed. However, ifthey also have diseases such as emphysemaor chronic bronchitis (common among heavysmokers), they may find that their shortnessof breath gets worse. For people who can’thave surgery because they are in poor generalhealth, have other medical problems, orbecause the cancer is widespread, other typesof therapy ( for example, radiation therapy,chemotherapy, and supportive care) can begiven to relieve symptoms.

Surgery may be the first step in treating yourlung cancer. Or, surgery may be consideredafter chemotherapy and radiation therapy. Ineither case, your initial work-up before begin-ning any treatment should include evaluationby a surgeon.

Chemotherapy Chemotherapy refers to the use of drugs tokill cancer cells. Usually the drugs are giveninto a vein or by mouth. Once the drugs enterthe bloodstream, they reach all parts of thebody. Often several drugs are given at the sametime. Depending on the type and stage of lungcancer, chemotherapy may be given as the

main treatment or in addition to surgery and/or radiation therapy. When it is used withsurgery, chemotherapy is called adjuvanttherapy. It is added to surgery to reduce therisk that the cancer will recur (come back) orspread outside the lung.

Doctors who prescribe these drugs (calledmedical oncologists) most often use a combi-nation of medicines that have proven to bemore effective than a single drug. Doctorsgive chemotherapy in cycles, with each cycleof treatment followed by a recovery period.Chemotherapy cycles generally last about 21to 28 days, and initial treatment typicallyinvolves 4 to 6 cycles. Chemotherapy is notrecommended for patients in poor health(performance status 3–4). Advanced age isnot a barrier, as long as the patient is not inpoor health.

All chemotherapy agents have side effects.Temporary side effects might include loss ofappetite, nausea and vomiting, mouth sores,and hair loss. Chemotherapy can damage thecells of the bone marrow that make blood,causing a decrease in white blood cells thatcan increase a patient’s risk of infection; ashortage of blood platelets that can causebleeding or bruising after minor cuts orinjuries; and a decrease in red blood cells(low blood hemoglobin levels) that can lead tofatigue. (For more information see the ACS/NCCN Cancer-Related Fatigue and AnemiaTreatment Guidelines for Patients).

Things can be done to prevent or lessenthese side effects. For example, there are sev-eral drugs that can prevent or reduce nauseaand vomiting (see the ACS/NCCN Nausea andVomiting Treatment Guidelines for Patientswith Cancer). A group of drugs called growth

15

factors can help bone marrow recover afterchemotherapy and shorten the period of timethat a person’s blood counts are low.

Patients can also have long-term effectsfrom cancer drugs such as premature meno-pause, infertility, or heart or lung damage.

Your doctor or nurse will discuss possibleside effects and what can be done to reducethem, with you and your family before youstart treatment. Once treatment is started,your doctor and nurse will expect you to tellthem about any side effects that you have.

Non-small cell lung cancerThe drug combinations most frequently usedfor initial chemotherapy (also called first-linetherapy) for NSCLC are cisplatin combinedwith one of the following:

• Docetaxel• Etoposide • Gemcitabine • Vinblastine• Vinorelbine

Some patients cannot tolerate cisplatintherapy. If this is the case, the patient maybe given other drugs, including carboplatincombined with either gemcitabine, paclitaxel,or docetaxel. Docetaxel can also be combinedwith gemcitabine.

For some patients, bevacizumab, a drugthat blocks the growth of blood vessels thatfeed the cancer, can be combined withchemotherapy drugs. After chemotherapy,bevacizumab may be continued until thecancer progresses.

First-line chemotherapy for advanced ormetastatic NSCLC includes cisplatin or carbo-platin combined with any of the following drugs:

• Docetaxel• Etoposide• Gemcitabine • Irinotecan• Paclitaxel• Vinblastine• Vinorelbine

Patients who cannot tolerate combinationchemotherapy, can have single-agent chemo-therapy (that is, using just one drug). However,chemotherapy is not recommended forpatients in poor general health (performancestatus 3–4).

Chemotherapy or targeted therapy usedfor second-line therapy (medicines used ifthe cancer continues to grow during or afterinitial chemotherapy) for NSCLC includes allthe drugs listed before, and also:

• Docetaxel alone • Erlotinib alone• Pemetrexed alone

Small cell lung cancerThe drug combinations most frequently usedfor initial chemotherapy for limited stagesmall cell lung cancer are:

• Cisplatin and etoposide • Carboplatin and etoposide

The drug combinations most frequentlyused for initial chemotherapy for extensivestage small cell lung cancer are:

• Cisplatin and etoposide • Carboplatin and etoposide • Cisplatin and irinotecan

Chemotherapy drugs used if the small celllung cancer comes back within 6 months ofinitial treatment include:

16

• Topotecan• Irinotecan• Paclitaxel• Docetaxel• Gemcitabine• Oral etoposide• Cyclophosphamide, doxorubicin, and

vincristine (CAV)• Vinorelbine• Ifosfamide

For relapses more than 6 months after theinitial treatment, the original chemotherapycan be repeated.

Targeted therapyIn the past few years, lung cancer researchhas focused on drugs that are specificallytargeted at cancer cells and interfere withtheir ability to grow. For example, erlotinib(Tarceva®) has been recently approved by theFood and Drug Administration (FDA) to beused in NSCLC patients who are no longerresponding to chemotherapy (this is usuallydetermined after 1 or 2 different chemother-apy combinations have been tried). Tarcevais taken by mouth. Common side effects thisdrug include skin rash and diarrhea.

Bevacizumab (Avastin®) is another tar-geted therapy that has been most commonlyused to treat colon cancer but has also beenrecently approved by the Food and DrugAdministration (FDA) as a treatment forNSCLC. Bevacizumab can cause bleeding,which means it cannot be used in patientswho are coughing up blood, whose cancerhas spread to the brain, or who are on bloodthinners (anticoagulation therapy). Patients

with squamous cell cancer also cannot use itbecause it leads to bleeding from this type oflung cancer. Other rare but serious sideeffects include blood clots and high bloodpressure. Bevacizumab is given intravenously(IV) every 3 weeks with chemotherapy.

Radiation therapyRadiation therapy uses high-energy rays (suchas x-rays) to kill or shrink cancer cells. Theradiation may be given from outside the body(external radiation) or from radioactive mate-rials placed directly in the tumor (internal orimplant radiation, also called brachytherapy).External radiation is the type most often usedto treat lung cancer.

Combination therapyLung cancer is often initially treated with acombination of different therapies; that is,the combination of surgery with chemother-apy, or radiation therapy, or both, giveneither before or after the surgery.Chemotherapy and radiation therapy can becombined in several different ways. This iscalled chemoradiation. For example, thechemotherapy can be given at the same timeas the radiation therapy. And sometimesmore chemotherapy will be given after thecombined therapy. In other situations, thechemotherapy and radiation therapy aregiven in sequence. Typically chemotherapy isgiven before radiation therapy, but sometimesthe radiation therapy may come first. The Tand N status of the tumor (see the stagingsection on page 11) are used to determinewhether chemoradiation therapy is needed.

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Palliative and supportive careMost of these guidelines identify ways to curesome people with lung cancer or to help oth-ers live longer by removing or destroying lungcancer cells. But it is also important to realizethat controlling symptoms and helping youcontinue to do the things you want and needto do is another key goal. Don’t hesitate todiscuss your symptoms or how you are feelingwith your cancer care team. There are effec-tive and safe ways to treat pain, most othersymptoms of lung cancer, and most of the sideeffects caused by lung cancer treatments.Treatment to help relieve symptoms is some-times called palliative care, or supportive care.

Pain is a significant concern for patientswith lung cancer. If the cancer grows aroundcertain nerves it may cause severe pain. It isimportant that patients tell their doctors rightaway if they have pain. For most patients,treatment with morphine or other opioidswill reduce the pain considerably. Opioids areprescription medicines and the strongest painrelievers available. For more information onmanaging cancer pain, look at the ACS Website, www.cancer.org, or call 1-800-ACS-2345and request a copy of the NCCN Cancer PainTreatment Guidelines for Patients.

In addition to the general supportive caremeasures for any type of advanced cancer,you may also benefit from specific ways torelieve some symptoms of lung cancer thatare relatively rare with other cancers. Forexample, some small cell lung cancers maysecrete a hormone (called antidiuretic hor-mone). The pituitary gland normally makessmall amounts of this hormone, but largeamounts produced by a cancer may causefluid to collect in the body. Limiting how

much fluid you take in may help. Drug ther-apy with demeclocycline also helps. Otherhormone-like substances produced by lungcancer cells can cause high levels of thehormones produced by the adrenal glands.These hormones cause a condition knownas Cushing’s syndrome. Patients with thisproblem may notice weight gain (especiallyaround the chest and abdomen), fat depositsbehind the neck and shoulders, fatigue, easybruising, depression and/or moodiness, andweakened bones. This condition may betreated with a drug called ketoconazole.Other hormone-like substances that may beproduced by NSCLC can affect blood calciumlevels, leading to muscle weakness and othernervous system problems. Intravenous fluidsand medicines can help relieve some of thesesymptoms.

Sometimes patients may be given cancertreatment that is intended to reduce or preventsymptoms but is not expected to cure thecancer. This palliative care may include radi-ation or chemotherapy treatments that relievesymptoms by shrinking the tumor. Some otherpalliative treatments for lung cancer includelaser surgery and photodynamic therapy.

Laser surgery can vaporize the part of atumor that is blocking an airway and inter-fering with breathing. But it does not destroyall of the cancer.

Photodynamic therapy uses a drug whichis only attracted to cancer cells. The drug isinjected into a vein in an inactive form. It isthen activated by shining a certain color lighton it. Beams of laser light can be aimedthrough a bronchoscope and activate thedrug there to help destroy the part of a tumorthat is blocking an air passage. Patients must

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avoid sunlight for a time to avoid side effectsto the skin.

Complementary andalternative medicines

Complementary and alternative medicinesare different kinds of health care practicesand products that are not part of your usualmedical treatment. They may include herbs,special supplements, acupuncture, massage,and a host of other types of treatment. Youmay hear about different treatments fromyour family and friends. People may offer allsorts of suggestions, such as vitamins, herbs,stress reduction, and more, as a treatment foryour cancer or to help you feel better.

The American Cancer Society definescomplementary medicine or methods asthose that are used along with your regularmedical care. If these treatments are carefullymanaged, they may add to your comfort andwell-being. Some of these methods have beentested, while others have not. Some haveshown possible benefit, while others have notproven helpful. Some of these treatmentshave harmful effects too.

Alternative medicines are defined as thosethat are used instead of regular medical care.Some of them have been proven harmful, butare still promoted as “cures.” If you choosethese alternatives, it is important to know thateven the methods that do not cause harmmay reduce your chance of fighting yourcancer by delaying or replacing regularcancer treatment.

There is a great deal of interest today incomplementary and alternative treatments

for cancer. Many are being studied to find outif they are helpful to people with cancer.

Before changing your treatment or addingany of these methods, it is best to discussthis openly with your doctor or nurse. Somemethods can be safely used along with stan-dard medical treatment. Others, however, caninterfere with standard treatment or causeserious side effects. That is why it’s importantto talk with your doctor. More informationabout complementary and alternative meth-ods of cancer treatment is available throughthe American Cancer Society’s toll-free num-ber at 1-800-ACS-2345 or on our Web site atwww.cancer.org.

About clinical trials

All drugs used to treat cancer or other diseasesmust undergo clinical trials in order to deter-mine their safety and effectiveness before theFood and Drug Administration (FDA) canapprove them for use. Treatments used inclinical trials are often found to have realbenefits. Researchers conduct studies of newtreatments to answer the following questions:

• Is the treatment helpful?• How does this new type of treatment

work?• Does it work better than other

treatments already available? • What side effects does the treatment

cause? • Do the benefits outweigh the risks,

including side effects? • Which patients will the treatment

most likely help?

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During cancer treatment, the doctor maysuggest taking part in a clinical trial.Scientists conduct clinical trials only whenthey believe that the treatment being studiedmay be better than other treatments.

All patients in a clinical trial are closelywatched by a team of experts to monitor theirprogress very carefully. The study is done tofind out if the new treatment will work betterthan the standard treatment and if the sideeffects are worse or less. The new treatmentmay have some side effects, which the doctorwill discuss with you before the clinical trialis started.

Deciding to enter a clinical trialTaking part in any clinical trial is completelyvoluntary. Doctors and nurses explain thestudy in detail and provide a consent form toread and sign. This form states that thepatient understands the risks and wants toparticipate. Even after signing the form andthe trial begins, the patient may leave thestudy at any time, for any reason.

Taking part in the study will not keepanyone from getting other medical care theymay need. You should always check with yourhealth insurance company to find out whetherit will cover the costs of taking part in a clin-ical trial.

Participating in a clinical trial evaluatingnew, improved methods for treating cancermay help the patient directly, and it may helpother people with cancer in the future. Forthese reasons, members of the NationalComprehensive Cancer Network and theAmerican Cancer Society encourage partici-pation in clinical trials.

How can I find out more aboutclinical trials that might be rightfor me?The American Cancer Society offers a clinicaltrials matching service that will help you finda clinical trials that is right for you. You canreach this service at 1-800-303-5691 or throughthe Web site http://clinicaltrials.cancer.org.Based on the information you give about yourcancer type, stage, and previous treatments,this service compiles a list of clinical trialsthat match your medical needs. The servicewill also ask where you live and whether youare willing to travel so that it can look for atreatment center you can get to.

You can also get a list of current clinicaltrials by calling the National CancerInstitute’s Cancer Information Service tollfree at 1-800-4-CANCER (1-800-422-6237) orby visiting the NCI clinical trials Web site atwww.cancer.gov/clinical_trials/.

More information about clinical trials isavailable through the American CancerSociety’s toll-free number at 1-800-ACS-2345or on our Web site at www.cancer.org.

Other things to considerduring and after treatment

During and after treatment for your lungcancer, you may be able to speed up yourrecovery and improve your quality of life bytaking an active role. Learn about the benefitsand disadvantages of each of your treatmentoptions and ask questions if there is anythingyou do not understand. Learn about and lookout for side effects of treatment and report

20

these promptly to your cancer care team sothat they can take steps to reduce them.

Remember that your body is as unique asyour personality and your fingerprints.Although understanding your cancer’s stageand learning about your treatment optionscan help predict the health problems you mayface, no one can say precisely how you willrespond to cancer or its treatment.

You may have special strengths such as ahistory of excellent nutrition and physicalactivity, a strong family support system, or adeep faith, and these strengths may make adifference in how you respond to cancertreatment. There are also experienced pro-fessionals in mental health services, socialwork services, and pastoral services who mayassist you and your family in coping withyour illness.

You can also help in your own recoveryfrom cancer by making healthy lifestylechoices. If you use tobacco, stop now. Quittingwill improve your overall health, and the fullreturn of your sense of smell may help youenjoy a healthy diet during recovery. If youuse alcohol, limit how much you drink.Have no more than 1 or 2 drinks per day.

Good nutrition can help you get better aftertreatment. Eat a nutritious and balanceddiet, with plenty of fruits, vegetables, andwhole grain foods. If you are having nutritionproblems, ask your cancer care team if youmay benefit from talking with a dietician.

If you are being treated for cancer, beaware of the battle that is going on in yourbody. Radiation therapy and chemotherapyadd to the fatigue caused by the disease itself.To help you with the fatigue, plan your dailyactivities around when you feel your best. Getplenty of sleep at night. Don’t be afraid to askothers for help. And ask your cancer careteam about a daily exercise program to helpyou feel better.

A cancer diagnosis and its treatment is amajor life challenge that has an impact on youand everyone who cares for you. Before youget to the point where you feel overwhelmed,consider attending a meeting of a local sup-port group. If you need assistance in otherways, contact your hospital’s social servicedepartment or the American Cancer Society.

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22

NOTES

23

Work-up (evaluation) andtreatment guidelines

Decision treesThe Decision Trees (or flow charts) on the following pages represent differentstages of lung cancer. Each one shows you step-by-step how you and your doctorcan arrive at the choices you need to make about your treatment.

Keep in mind, this information is not meant to be used without the expertise ofyour own doctor who is familiar with your situation, medical history, and per-sonal preferences. You may want to review this booklet together with your doctor,who can show you which of the Decision Trees apply to you. We’ve left some blankspaces in the Decision Tree section for you or your doctor to add notes about thetreatments. You might also use this space to write down some questions to askyour doctors about the treatments.

Participating in a clinical trial is an option for patients at any stage of lungcancer. Taking part in a study does not prevent you from getting other medicalcare you may need.

The NCCN guidelines are updated as new significant data become available. Toensure you have the most recent version, consult the Web sites of the ACS(www.cancer.org) or NCCN (www.nccn.org). You may also call the NCCN at 1-888-909-NCCN or the ACS at 1-800-ACS-2345 for the most recent information onthese guidelines. If you have questions about your cancer or cancer treatment,please call the ACS any day at any time at 1-800-ACS-2345.

Non-small cell lung cancer: Initialwork-up and stagingThis Decision Tree begins when you have justbeen diagnosed with non-small cell lungcancer. This diagnosis is based on the resultsof a biopsy (a small piece of tissue that hasbeen removed from the tumor) or cytology(examination of cell samples, such as cells insputum, cells in the fluid that has collectedaround the lungs, or cells that have beenscraped from the lining of the airways).

The next step after diagnosis is a series ofexaminations and tests that doctors call theinitial work-up. The medical history andphysical exam focus on symptoms that maysuggest spread outside the lung. Your doctoralso reviews your overall health and discusses

the results of your biopsy. Your biopsy tissuemay also be sent for another pathologist toreview so that you can be sure of the diagnosis.You then have a group of tests that are usedto find the extent of the cancer. For example,a chest CT scan can show the tumor’s sizeand location and also allows the doctor tolook at the lymph nodes in the chest. If theselymph nodes are enlarged, they may containcancer cells that have spread from the lungtumor. The CT scan also includes views ofyour liver and adrenal glands, because lungcancers may spread to these areas. A varietyof blood tests are done to see how well yourliver and kidneys are working and to make sureyour blood cell counts are not too low. Lowblood cell counts or problems with internal

24

Treatment Guidelines for Patients

Initial work-up (evaluation)Diagnosis

• Medical history and physical examto assess general health and cancersymptoms

• Pathology review

• CT scan of chest, upper abdomen,and adrenal glands

• Blood cell counts

• Blood chemistry tests

• Counseling on smoking cessation

Patient has non-smallcell lung cancer basedon test results (biopsyor cytology of mainlung tumor or of ametastatic site)

25

organs could mean that you are especially atrisk for problems and side effects of certainlung cancer treatments, so these tests mustbe done before your treatment begins. Otherblood test results can suggest a cancer hasspread outside the lung. Depending on yourmedical history, symptoms, and physical examresults, extra testing of your heart, lungs,kidneys, or other organs may be needed to seeif you are likely to have serious problems fromcertain lung cancer treatments. If you smoketobacco, your doctor will ask that you quitand will talk with you about ways to do this.

The results of your initial evaluation areused to determine the clinical stage (T, N, and

M status) of your cancer. These results deter-mine which of the Decision Trees are mostrelevant to your treatment. If you have anyquestions about your clinical stage afterchecking the information on pages 11–14 askyour doctor.

Based on your clinical stage, the guidelinesrecommend that you have other tests to learnmore about whether your cancer has spread.These tests may include other imaging studies(MRI scans, bone scans) or procedures to gettissue samples from your lungs, lymph nodes,or other organs. Your stage may change afterbiopsies and surgery.

©2008 by the National Comprehensive Cancer Network (NCCN) and theAmerican Cancer Society (ACS). All rights reserved. The information hereinmay not be reproduced in any form for commercial purposes without theexpressed written permission of the NCCN and the ACS. Single copies of eachpage may be reproduced for personal and non-commercial uses by the reader.

Non-small cell lung cancer: Initial work-up and staging

Clinical stage Additional work-up and treatment

Determine clinical stagebased on initial work-up

Depends on clinical stage

Non-small cell lung cancer:Evaluation of stages I and II Stage I and some stage II cancers are gener-ally small tumors and may have spread tolymph nodes within the lung. For moredetailed information on staging, see pages11–14.

If your initial clinical stage is T1 or T2, andN0 or N1, the guidelines recommend sometests and scans to see if surgery is a goodtreatment option. Pulmonary function tests

measure how well the lungs take in andexhale air and how efficiently they transferoxygen into the blood. Bronchoscopy looksfor cancer in other parts of the lungs or toget tissue for biopsy and diagnosis.Mediastinoscopy checks whether cancer hasspread to mediastinal lymph nodes. The PETscan also shows spread to mediastinal lymphnodes, as well as spread anywhere else in thebody. MRI of the brain is needed if stage IInonsquamous cell cancer is present because

26


Work-up and resultsClinical stage andtumor location

• Pulmonary function tests ifnot previously done

• Bronchoscopy to look foradditional tumors

• Mediastinoscopy to look forspread of cancer to lymphnodes in the chest

• PET scan

• Brain MRI (only if stage IInonsquamous cell cancer)

Stage I(T1–T2, N0)Located in the outer part of the lungs

OR

Located in the center of thelungs near large airways

OR

Stage II(T1–T2, N1)

this type of cancer more frequently spreadsto the brain.

If there is no cancer in the mediastinalnodes and the cancer can be removed withsurgery, treatment is discussed on theDecision Tree on page 28.

If there is no cancer in the mediastinalnodes or no distant spread but surgery can’t

be done because of other medical conditions,radiation therapy is an option that may curethe cancer.

If cancer is found in the mediastinalnodes, the cancer is stage III, and surgerymay or may not be a good option. See theDecision Trees beginning on page 40 that fityour T and N categories.

27

Non-small cell lung cancer: Evaluation of stages I and II


TreatmentFindings

See the Decision Tree fortreatment for NSCLC stagesI, II, and IIIA (page 28)

Potentially curativeradiation therapy

See the Decision Trees for treatmentfor NSCLC stage IIIA and IIIB whichbegin on page 40

No cancer in mediastinallymph nodes

Operable

Medicallyinoperable

Mediastinal lymphnodes contain cancer

Non-small cell lung cancer:Treatment of stages I, II, and IIIA If the initial test results show the cancer has notspread, exploratory surgery is recommendedto remove the cancer and look at the areaaround the tumor. The surgeon tries to com-pletely remove the cancer whenever possible,

since this offers the best chance for a cure.The surgical margin (the edge of the tissueremoved by the surgeon) is checked under themicroscope for cancer cells. If cancer cells arepresent at the edge (positive surgical margin),it is likely that some cancer cells may havebeen left behind. This can happen even when

28


Initial treatment Surgical stage

Stage IAT1, N0

Stage IBT2, N0

Stage IIIAT1–T2, N2(Cancer in lymph nodesfound at surgery)

Stage IIA, IIBT1–T2, N1

Surgery to cut out tumorand search for spread

Surgery toremovemediastinallymph nodes

the surgeon removes all cancer that was visibleduring surgery. In this case, your doctor willrecommend more treatment. A negative sur-gical margin is usually a sign that no cancerwas left behind in the area the tumor was

removed from. A negative surgical margin doesnot mean a cure is a sure thing, because cancercells may have spread to other areas of thebody before surgery.

29

Non-small cell lung cancer: Treatment of stages I, II, and IIIA


Adjuvant (additional) therapy Findings

Tumor removed – no cancerat edges of specimen

Lung tumor removed – butcancer at edges of specimen

Tumor removed – no cancerat edges of specimen



Lung tumor removed – nocancer at edges of specimen



Observe, OR chemotherapy in selected patients

Surgery to remove remaining cancer with or withoutchemotherapy, OR chemoradiation* with or withoutadditional chemotherapy, OR radiation therapy alone

Surgery to remove remaining cancer with chemotherapy,OR chemoradiation* with additional chemotherapy

More surgery to remove remaining cancer with chemotherapy,OR chemoradiation* with additional chemotherapy

Chemotherapy with mediastinal radiation therapy

Chemoradiation* with additional chemotherapy

Chemotherapy if no adverse factors present (see page 31)

Chemotherapy, OR chemoradiation* with additionalchemotherapy if adverse factors present

Observe, OR chemotherapy in selected patients

* Chemoradiation = either chemotherapy given togetherwith radiation therapy at the same time, or chemotherapyand radiation therapy given one after the other

After surgery has completely removed thetumors, if no cancer was found at the edges ofthe specimens, patients with T1, N0 and manypatients with T2, N0 tumors will be watchedcarefully.

Patients with tumor cells that look verydifferent from normal cells, or patients withtumors that have grown into nearby bloodvessels, or have very narrow surgical marginsare considered to be high risk and shouldconsider chemotherapy.

Chemotherapy is a systemic therapy thatcan kill cancer cells that have spread beyondthe lung. Chemotherapy is strongly recom-mended for larger tumors.This is becauselarger tumor size is associated with a greaterrisk of spread beyond the lung. For example,

there is disagreement about the use ofchemotherapy for T2, N0 tumors, but it isrecommended for T1/T2, N1/N2 tumors.

Radiation therapy and surgery are knownas “local” therapies, because they do notattempt to treat cancer that has spread outsidethe lung. Additional local therapy is neededfollowing surgery whenever the margins oredges of the removed tissue are found tocontain cancer.

The radiation may also be combined withchemotherapy in different ways. This iscalled chemoradiation. For example, chemo-therapy can be given at the same time as theradiation therapy, or chemotherapy and radi-ation therapy can be given one after theother. Sometimes additional chemotherapy

30


NOTES

is added after the chemoradiation therapy,and this is referred to as chemoradiationwith additional chemotherapy,

In one instance, radiation therapy is anoption even when the tumor margins arenegative. If the tumor has spread to lymphnodes near the lung, the treatment depends onwhether certain adverse factors are presentor not. Adverse factors are:

• the lymph nodes in the mediastinumcannot be evaluated as needed

• the cancer has grown outside thelymph nodes

• there are many lymph nodes involvedwith cancer

• the margins may be very close to theedge of the cancer

If no adverse factors are present and thesurgical margins are not involved with cancer,then only chemotherapy is recommended. Ifthere are adverse factors, there is a higherrisk that the surgery did not remove all of thetumor. In this case chemotherapy alone, orchemoradiation followed by additionalchemotherapy may be advised.

If cancer is found in the lymph nodes dur-ing surgery (T1,T2, N2) the cancerous nodesshould be removed along with the tumor. Ifthere is no cancer at the edge of the tumorspecimen, chemotherapy with radiation to themediastinum is recommended. If cancer isfound at the specimen edge, chemoradiationfollowed by additional chemotherapy may besuggested.

31

NOTES

Non-small cell lung cancer: Treatment of stages I, II, and IIIA(continued)

Non-small cell lung cancer:Evaluation of stages IIB and IIIA This Decision Tree is for patients with tumorsthat invade the chest wall, either in the superiorsulcus (upper part of the lung) or elsewhere;or tumors invading the main bronchus nearthe trachea. Lymph nodes near the tumor mayor may not have cancer cells (N0 or N1). Thesecancers are larger than those in the previousDecision Tree. This means your doctor will

need to make an extensive evaluation beforetreatment can be started to make sure thecancer hasn’t spread to mediastinal lymphnodes or distant sites in the body.

Bronchoscopy is done to check for moretumors in other areas of the lungs.Mediastinoscopy is recommended to find outif cancer has spread to the mediastinal lymphnodes. MRI of the brain and, for superiorsulcus tumors, the spine, is done to look for

32


Additional work-up (evaluation)Clinical stage

• Bronchoscopy

• Mediastinoscopy, to check for cancer in mediastinal lymph nodes

• Brain MRI

• MRI scan of spine to include uppermost part ofthe chest cavity for tumors in the uppermostpart of the chest (superior sulcus)

• PET scan

• Pulmonary function tests, if not previously done

Stage IIB(T3, N0)

OR

Stage IIIA(T3, N1)

spread to these tissues. A PET scan is alsodone to look for spread. Finally, if not alreadydone, pulmonary function tests are recom-mended to measure how well the lungs takein and exhale air and how efficiently theytransfer oxygen into the blood.

This Decision Tree refers you to otherswith more specific details depending on thefindings the additional tests. If it is found thatthe cancer has spread to distant areas, thecancer is reclassified as M1, and you shouldsee the Decision Tree on page 50.

33

Non-small cell lung cancer: Evaluation of stages IIB and IIIA


Findings Treatment

Cancer is in the uppermostpart of the chest (superiorsulcus) and has not spreadoutside the chest

Cancer is growing into thechest wall, but has notspread outside the chest

Cancer is growing into themain breathing tubes or intothe mediastinum, but hasnot spread outside the chest

Cancer has spread to distantsites outside the chest

See treatment for superiorsulcus tumor (page 34)

See treatment for chestwall tumor (page 36)

See treatment for cancerin main breathing tubesor mediastinum (page 36)

See treatment for Stage IVlung cancer (page 50)

Non-small cell lung cancer:Treatment of stages IIB and IIIA Tumors in the very top part of the lung, calledsuperior sulcus tumors, often grow into nervesand other tissues in that area. This makes itdifficult to remove them completely with sur-gery. If the surgeon thinks the tumor can be

completely removed (it is resectable), therecommendation is first to give chemotherapywith radiation to shrink the tumor, followedby surgery and more chemotherapy.

If the tumor cannot be removed with surgery(it is unresectable), then chemotherapy with afull dose of radiation therapy is recommended.

34


Clinical assessmentStage and site of tumor

Stage IIB and IIIA withsuperior sulcus tumor(T3–T4, N0–N1)

Tumor can becompletelyremovedwith surgery

Tumor cannotbe completelyremoved withsurgery

Tumor maypossibly becompletelyremovedwith surgery

Sometimes in cases where the chance ofremoval is uncertain, chemotherapy is givenwith radiation therapy, followed by surgeryand then more chemotherapy if the tumor

becomes resectable. If the tumor still cannotbe removed, then radiation therapy is recom-mended as the primary therapy followed bychemotherapy.

35

Non-small cell lung cancer: Treatment of stages IIB and IIIA


Adjuvant(additional)treatment

Initial treament

Re-evaluate

Surgery andchemotherapy

Surgery andchemotherapy

Complete radiationtherapy with additionalchemotherapy

Tumor can becompletelyremovedwith surgery

Tumor cannotbe completelyremoved withsurgery

Chemoradiation*

Chemoradiation*

Chemoradiation*


Non-small cell lung cancer:Treatment of stages IIB and IIIA(continued) Tumors growing into the chest wall, into mainbreathing tubes near the trachea, or into themediastinum may be treated with surgery first

(which is preferred). Other options includechemotherapy alone, chemotherapy togetherwith radiation therapy, or radiation therapyalone; all of these options are followed bysurgery.

36


Surgery (preferred)

OR

Chemotherapy, then surgery

OR

Chemoradiation*, then surgery

OR

Radiation, then surgery

Stage IIB and IIIAwith chest wallinvolvement(T3, N0–N1)

OR

Main breathing tubesor mediastinum (center of the chest)involvement (T3, N0–N1)

Initial treamentStage and site of tumor

If, after surgery, the specimen margins(edges) are free of cancer, more chemotherapyis recommended. If the edges of the specimencontain cancer, then either further surgery andchemotherapy or chemoradiation followed

by more chemotherapy is recommended. If alarge amount of tumor remains after surgery,the radiation therapy is typically given beforethe chemotherapy.

37


Non-small cell lung cancer: Treatment of stages IIB and IIIA(continued)

Lung tumor removed –no cancer at edges ofspecimen

Lung tumor removed –but cancer at edges ofspecimen

Surgery to remove remainingcancer, and chemotherapy

OR

Chemoradiation* and additionalchemotherapy

Chemotherapy

Adjuvant (additional)treatment

Findings


Non-small cell lung cancer:Evaluation of stages IIIA and IIIB This Decision Tree is for evaluating patientswith stage IIIA cancers that appear to havespread to mediastinal lymph nodes (N2), aswell as those with stage IIIB cancers with alarge tumor (T4), but minimal lymph nodespread (N0–N1). The stage IIIA patients shouldhave bronchoscopy and biopsy of mediastinal

lymph nodes, either by mediastinoscopy orfine needle aspiration. PET scan and MRI ofthe brain are done to look for spread to distantareas. If not previously done, pulmonary func-tion tests are recommended to measure howwell the lungs take in and exhale air and howefficiently they transfer oxygen into the blood.

The patient with a stage IIIB tumor shouldalso have bronchoscopy, mediastinoscopy,

38


Work-upStage

Stage IIIA(T1–T3, N2)

Stage IIIB(T4, N0–N1)

• Bronchoscopy

• Mediastinoscopy or biopsy oflymph nodes with fine needlethrough trachea or esophagus

• PET scan

• Brain MRI

• Pulmonary function tests, ifnot previously done

• Bronchoscopy

• Mediastinoscopy

• PET scan

• Brain MRI

• Pulmonary function tests, ifnot previously done

• MRI of spine if cancer appearsto be invading there

PET scan, MRI of the brain, and pulmonaryfunction tests, if not already done. Because alarge T4 tumor can invade the spine, an MRIof the spine may be recommended.

Further treatment, as outlined on theDecision Tree, depends on the findings ofthese tests.

39


Mediastinal biopsy results/possibilityof complete surgical removal

No cancer found in lymph nodes

Cancer found in lymph nodes onthe same side of chest as tumor

Cancer found in lymph nodes onthe other side of chest from tumor

Cancer has spread outside the chest

Cancer has spread outside the chest

The cancer, including a seperatetumor, can be completelyremoved with surgery

The cancer cannot be completelyremoved with surgery – there is nopleural effusion (fluid in the chest)

The cancer cannot be completelyremoved with surgery – there is apleural effusion (fluid in the chest)

The main cancer, but not a seperate tumor, can be completely removed with surgery

Treatment

See the Decision Tree for NSCLCstage IIIA treatment (page 40)

See the Decision Tree forNSCLC stage IIIB evaluationand treatment (page 46)

See the Decision Tree for NSCLCstage IV treatment (page 50)

See the Decision Tree for NSCLCstage IIIB treatment (page 44)

See the Decision Tree for NSCLCstage IIIB treatment (page 48)


Non-small cell lung cancer: Evaluation of stages IIIA and IIIB

Non-small cell lung cancer:Treatment of stage IIIA Three different stages are described here. Thefirst one is T1–T3 with no cancer cells foundin the biopsy of the mediastinal lymph nodes

(N0). Surgery with removal of the mediastinalnodes is recommended.

• If the tumor is completely removableand the mediastinal lymph nodes donot contain cancer, then further treatment is as described on page 28.

40


Surgery

Initial treatment FindingsStage and results ofmediastinal biopsy

• Brain MRI

• PET scan, if notpreviously done

• Brain MRI

• PET scan, if notpreviously done

Stage IIIA (T3),Cancer found innodes on sameside of chest (N2)

Stage IIIA (T1–T2),Cancer found innodes on sameside of chest (N2)

Stage IIIA (T1–T3)

Completely removable

Not completely removable

No evidence ofdistant spread

The cancer has spreadto distant sites

No evidence ofdistant spread

The cancer has spreadto distant sites

• If cancer is found in mediastinal lymphnodes (N2) and the surgical margins donot contain cancer, chemotherapy alone

or chemoradiation with additionalchemotherapy can be given.

41

Non-small cell lung cancer: Treatment of stage IIIA

Adjuvant (additional) treatment

Remove tumorsand mediastinallymph nodes

See the Decision Trees onpages 28 or 32 to treatfor appropriate stage

Chemotherapy

OR

Chemoradiation* and additional chemotherapy

Chemoradiation* andadditional chemotherapy

Surgery with or withoutchemotherapy, and with orwithout radiation therapy(if not previously given)

Radiation (if not givenpreviously) with orwithout chemotherapy

If excellent response,consider surgery

Treat according to stage(radiation therapy andchemotherapy)



Chemotherapy together withfull-dose radiation therapy

Chemotherapy together withfull-dose radiation therapy

OR

Short course of chemotherapywith or without radiationtherapy

N0–N1

N2

No cancer atedges of specimen

Cancer at edgesof specimen

Cancer doesn’t grow

Cancer grows



42

• If the margins do contain cancer cellschemoradiation with additionalchemotherapy is recommended.

• If the original tumor couldn’t beremoved, the tumor should be treatedaccording to the stage as described inearlier Decision Trees.

The next group is those patients with T1and T2 tumors with cancer found in themediastinal lymph nodes on the same side asthe tumor (N2). If the brain MRI and PET scanshow that the cancer has not spread, thereare 2 options: chemotherapy with a full doseof radiation therapy, or a short course ofchemotherapy with (or without) radiation


NOTES

can be given to determine if surgery is possi-ble. If the disease has not progressed duringthis treatment, surgery with or withoutchemotherapy and with or without radiation(if not given before) is an option

The final patient group is those with T3tumors with cancer cells found in the medi-

astinal lymph nodes on the same side as thetumor (N2). If the scans show no evidence ofspread to distant areas or organs, patients canbe initially treated with chemotherapy with afull course of radiation therapy. If there is anexcellent response, surgery can be consideredin rare cases.

43

Non-small cell lung cancer: Treatment of stage IIIA (continued)

NOTES

Non-small cell lung cancer:Treatment of stage IIIB This Decision Tree describes the treatment forpatients with separate tumor nodules or verylarge tumors (T4) that have spread into struc-tures within the chest, but have little spreadto lymph nodes (N0, N1). While not having thecancer spread to mediastinal lymph nodes isgood news, the extent of tumor growth maystill make it difficult or impossible for a surgeonto completely remove the tumor.

Whenever possible, the surgeon tries toremove the tumor and any satellite tumors(separate tumors spread within the same lobeof the lung). If this is successful, then chemo-therapy is recommended after the surgery.

If the main tumor can be removed but theother tumor (or tumors) cannot be, optionsinclude initial surgery, or initial chemotherapyor chemoradiation and then surgery. If initialsurgery is selected, further treatment dependson the status of the tumor margins. If the

44


Initial treatmentStage and extent of tumor

Surgery

Surgery

Chemotherapyalone

Surgery

Chemotherapy alone,or chemoradiation*

Chemoradiation*Stage IIIB (T4, N0–N1)All cancer cannot be completelyremoved – no fluid in chest

Stage IIIB (T4, N0–N1)Main cancer can be completelyremoved but seperate tumornodule can’t be removed

Stage IIIB (T4, N0–N1)All cancer can be completelyremoved, including a seperatetumor nodule

OR

margins do not contain cancer cells, chemo-therapy with optional radiation therapy isrecommended. If the edges of the specimen doshow cancer cells, then chemoradiation withadditional chemotherapy is recommended.

For those not choosing to have surgery first,options include either initial chemotherapyor chemoradiation. Both of these options arethen followed by surgery with additionaltreatment depending on whether the tumormargins are positive or negative. If there are

no cancer cells at the edge of the specimen,only chemotherapy is recommended. If thereare cancer cells at the edges of the specimen,radiation therapy followed by chemotherapyis recommended.

If the surgeon concludes that it is notpossible to completely remove the tumor andthere is no fluid in the patient’s chest,chemoradiation followed by chemotherapy isrecommended.

45


Findings

Chemotherapy

Chemotherapywith or withoutradiation therapy

Chemoradiation* withadditional chemotherapy

Chemotherapy

Chemotherapy Radiation therapy





Non-small cell lung cancer: Treatment of stage IIIB



Non-small cell lung cancer:Evaluation and treatment of stage IIIB This Decision Tree describes work-up andtreatment for patients who appear to havecancer that has spread to lymph nodes on theopposite side of the mediastinum or above

the collar bone (N3). N3 disease must beconfirmed through biopsy of any suspiciouslymph nodes. A thoracoscopy is done to lookfor cancer cells in the space between thelungs and the chest wall. A PET scan, brainMRI, and pulmonary function tests may alsobe done. If all these test results are normal,

46


Additional tests and resultsStage and extent of tumor

• Biopsy of any suspicious lymphnode to check for cancer inmediastinum (mediastinoscopy),or other side of chest, or supraclavicular (above the collarbone), or in the neck, or elsewhere

• Thoracoscopy, if suspectedspread of cancer in the lining ofthe chest cavity

• PET scan

• Brain MRI

• Pulmonary function tests (if notpreviously done)

Stage IIIB(T1–T3, N3)

meaning the enlarged lymph nodes did notcontain cancer and the cancer has not spreadto distant areas or organs, then the cancer istreatable with surgery. Refer to the decisiontrees on pages 28 and 32. If the biopsies doshow cancer cells but there is no distant

metastasis, then chemoradiation followed bymore chemotherapy, is recommended. If thetests show the cancer has spread to distantareas, then treatment for widespread diseaseshould be considered, as outlined on page 50.

47

Non-small cell lung cancer: Evaluation and treatment of stage IIIB

Initial treatment

See the Decision Trees onpages 28 and 32 to treatfor appropriate stage


See the Decision Treefor NSCLC stage IVtreatment (page 50)

Tests and biopsies findno additional cancer insuspicious areas

The suspiciouslymph node orchest wall containscancer, but there isno distant spread

The cancer hasspread outside thechest (metastatic)



Non-small cell lung cancer:Treatment of stage IIIB Two different types of T4 tumors are discussedhere. T4 means the tumor has spread to otherstructures in the chest or it is producing fluidthat surrounds the lung (pleural effusion) orheart (pericardial effusion), and surgery isgenerally not an option.

If your doctor suspects you have a T4 tumorthat has spread widely to lymph nodes (N2 orN3), then these nodes should be biopsied bymediastinoscopy, or with needle aspiration,or biopsy guided by ultrasound, or perhapsby removing a node above the collarbone.Looking in the chest cavity with a lighted tube,

called thoracoscopy, tells how far the cancerhas grown. Tests should also be done to lookfor spread outside the chest (brain MRI andPET scan).

If the lymph nodes do not contain cancercells, the cancer is classified as T4, N0, N1and may be treated with surgery or as recom-mended on page 44. If the lymph nodes onthe same or opposite side of the chest docontain cancer (N2 or N3), then treatmentwith chemoradiation, followed by additionalchemotherapy is recommended. Finally, if thetests show the cancer has spread outside thechest to distant sites, then treatment shouldbe as discussed for stage IV on page 50.

48



• Biopsy of any suspicious lymph node tocheck for cancer in mediastinum (mediastinoscopy), or other side of chest,or supraclavicular (above the collarbone),or in the neck, or elsewhere

• Thoracoscopy, if suspected spread ofcancer in the lining of the chest cavity

• Brain MRI

• PET scan

Remove chest fluid and possiblyremove fluid around heart

Thoracoscopy may be needed tocheck for spread of cancer in thelining of the chest cavity

Stage IIIB (T4, N2–N3)

Stage IIIB – Fluid in chest cavityor around heart

If there is fluid around the lungs or theheart, a sample of the fluid can be removedand examined for cancer cells. If cancer can’tbe diagnosed from cells in the fluid, it may benecessary to perform a thoracoscopy to makesure that the fluid is not related to cancerthat has spread to the lining of the chest. Ifthere are no cancer cells in the fluid, then thecancer should be treated according to its T

and N stage as discussed on pages 28 and 32.If there are cancer cells in the fluid, surgery isnot a treatment option. The fluid should bedrained with a catheter (a tube used to with-draw fluids). Sometimes a small piece of thesac around the heart needs to be removed sothat the fluid pressure doesn’t build up. Thentreatment should be given as for stage IVdisease (page 50).

49

Non-small cell lung cancer: Treatment of stage IIIB

Initial treatment

Treat for appropriate T4, N0–N1 stageIII (see the Decision Tree on page 44)

See the Decision Trees on pages 28and 32 to treat for appropriate stage


Treat as stage IV cancer (see DecisionTrees on page 50). Special treatmentmay be needed to keep fluid fromcoming back

Treat as stage IV cancer (seeDecision Tree on page 50)

Tests and biopsies findno cancer in suspiciouslymph nodes on otherside of chest

Lymph node on oppositeside of chest containscancer (N2–N3)

Nodes negative onsame side of chest

Nodes positive onsame side of chest

The cancer hasspread outside thechest (metastatic)

No cancer cellsseen in fluid

Cancer cellsseen in fluid



Non-small cell lung cancer:Treatment of stage IV Sometimes there is only 1 tumor nodule inone site of distant spread. This can only bedetermined after a complete evaluation withmediastinoscopy, bronchoscopy, brain MRI,and PET scan. Treatment options depend onwhere the cancer has spread.

If the cancer has spread only to the brainand there is only 1 tumor, one option is surgeryfollowed by radiation therapy. Two differenttypes of radiation therapy may be recom-

mended, either radiation therapy to theentire brain, or radiation therapy focusedspecifically at the site where the metastasiswas removed. This second type of radiationtherapy is called stereotactic radiosurgery. Asanother option, stereotactic radiosurgery canbe the first treatment, followed by radiationto the entire brain. After treatment of the brainmetastases, surgical removal of the lungtumor depends on its stage, as noted in theDecision Tree.

50



• Mediastinoscopy to checkfor spread of cancer tomediastinal lymph nodes

• Bronchoscopy, to look for additional tumors

• Brain MRI

• PET scan

Tests as indicated by symptoms

A single tumor isfound in the brain

Cancer has onlyspread to one orboth adrenal glands(confirm spread byneedle biopsy)

Cancer has spread toone additional sitein another lobe ofthe same lung, or inthe other lung, butno major lymphnode involvement

Stage IV (single site) M1 with a singletumor in a distant site

Stage IV (multiple sites)M1 with more than onetumor in one or moredistant sites

If the cancer has only spread to the adrenalglands, which is confirmed by a biopsy, and thecancer in the lung is T1, T2; N0, N1; or T3, N0(which means it can be completely removedby surgery), then both the adrenal glandtumors and the lung cancer can be removedor treatment for stage IV cancer (see page56) can be given. Additional treatment thendepends on the stage of the disease.

Sometimes there is a separate cancer inanother lobe of the lung or in the other lung.Both tumors should be removed if the cancerhas not spread to the lymph nodes or to distantsites and then further treated according totheir T and N stage.

If there are multiple sites of spread, thensurgery is not recommended. For furthertreatment recommendations, see page 56.

51

Non-small cell lung cancer: Treatment of stage IV

Initial treatment Adjuvant (additional)treatment

Surgical removal oflung tumor followedby chemotherapy

OR

Chemotherapy followed by surgery

Completely remove both tumors ifpossible, with additional treatmentif needed based on T and N stage

Surgery to remove brain tumor with radiation (whole brain orstereotactic radiosurgery)

OR

Stereotactic radiosurgery with orwithout whole brain radiation

Remove adrenal tumor with surgeryif lung tumor appears curable withfurther surgery (T1–T2, N0–N1 or T3, N0)

OR

Treat as recurrent or stage IV cancer(see Decision Tree on page 56)

Treat as recurrent or stage IV cancer(see Decision Tree on page 56)

Treat as recurrent orstage IV cancer (seeDecision Tree onpage 56)

T1–T2, N0–N1;

T3, N0

T1–T2, N2;

T3, N1–N2;

Any T, N3;

T4, any N


Non-small cell lung cancer: Follow-up and treatment of stage IV andrecurrent cancerAfter your initial treatment with surgery,chemotherapy, and/or radiation therapy, the

guidelines recommend that you have regularfollow-up tests and exams (physical exam andchest CT scan) to check for recurrence (cancercoming back). Tumors may recur locally (in thelung), regionally (near the lungs), or distantly

52


Follow-up and findings after initial treatment

• Physical exam, andcontrast-enhancedchest CT every 4 to 6months for 2 years,then physical examand non-contrast-enhanced chest CTscan every year

• Smoking cessationcounseling

Recurrent cancer inside airpassages causing partialor complete blockage

Lung tumor can be completelyremoved by surgery

Cancer in mediastinallymph nodes

Cancer blocks the superior venacava (large vein in the chest)

Cancer is causing severebleeding into the air passages

Spread to distant organs causinglocalized symptoms, or spreadto many areas of the brain

Spread to bones causingpain and/or fractures

Only one tumorin a distant organ

Cancerreturnedin or nearthe lungs

Cancerreturnedin a distantorgan

Cancer is widespread

Consider removing recurrent tumor (see Decision Tree on page 50)

• Place a stent inside vein• External beam radiation

Chemoradiation* (if no previous radiation)

• Surgical removal• External beam radiation therapy

• Laser, stent, or other surgery to open blockage• Brachytherapy (internal radiation)• External beam radiation therapy• Photodynamic (light) therapy

(in distant organs). It is very important thatyou to stop smoking and your doctor shouldtalk to you about ways to do this.

If the tumor recurs in or near the lung,treatment depends on exactly where it islocated and what symptoms it may be causing.

53

Treatment for recurrent cancer and metastasis

Close observationwith no treatment

OR

Chemotherapy

External beam radiation therapy to relieve symptoms

External beam radiation therapy to relieve symptoms,and surgery to prevent/repair fractures if needed.Drug therapy to strengthen bones may be considered.

• External beam radiation therapy• Brachytherapy• Laser surgery• Photodynamic therapy• Embolization (blocking the cancer’s blood vessels)• Surgical removal of the tumor

Treat for systemic disease (see Decision Tree on page 56)

Chemotherapyand/or supportivecare (see DecisionTrees on page 56)

Chemotherapyand/or supportivecare (see DecisionTrees on page 56)

Cancerhas notspread

Cancerhas spreadoutsidechest

Non-small cell lung cancer: Follow-up and treatment ofstage IV and recurrent cancer



The tumor may recur in the airways andblock breathing passages. Treatment optionsinclude vaporizing the tumor with a laser;having a stent (hollow tube) placed inside theairway to keep it open; radiation therapy, witheither brachytherapy (placing a small radio-active pellet inside the airway) or externalbeam radiation; and photodynamic therapy(see description on page 18).

It may be possible to have surgery to removethe recurrence in some cases. Radiation ther-apy is another option. If the tumor is locatedin the mediastinum, chemotherapy togetherwith radiation is recommended, but only if

the patient has not had radiation therapy inthe past.

If the cancer is pressing on the large veinleading to the heart (the superior vena cava),a stent (hollow tube) can be placed inside thevein to keep it from collapsing. Radiationtherapy is another option for shrinking tumorspressing on this vein. When cancer presses onand collapses this vein, blood flow from thehead and arms is reduced, and there may besevere swelling in both the face and arms,which is uncomfortable.

If the tumor is causing bleeding into theairways, treatment options are similar to when

54


NOTES

the airway is blocked, but bleeding can also becontrolled by blocking off the blood supplyto the tumor (called tumor embolization).

If the lung cancer comes back at only 1distant site, the treatment options depend onthe number and location of the recurrenttumors. If only 1 tumor is found, surgery toremove it may be an option (see pages 50).

If cancer that has spread to the bones iscausing pain, external beam radiation can helprelieve the pain. If the cancer has weakenedthe bone enough that a fracture (broken bone)might occur, doctors may also recommendsurgery to strengthen it. This can help relieve

pain and help the patient resume usualactivities. Drug therapy may also be used tostrengthen bones weakened by tumor. If thecancer has spread to distant organs or morethan 1 brain metastasis, external beam radia-tion therapy is used to relieve symptoms.

Although these treatments are describedin the section on follow-up and recurrence,they also apply to patients who have distantmetastases when their lung cancer is firstdiagnosed. Doctors may also recommendsystemic therapy – treatment, usually chemo-therapy, that goes throughout the body toattack the cancer (see page 56).

55

Non-small cell lung cancer: Follow-up and treatment ofstage IV and recurrent cancer (continued)

NOTES

Non-small cell lung cancer:Treatment of stage IV andrecurrent cancer This Decision Tree focuses on the role of chemo-therapy and how long the treatments shouldcontinue. Because chemotherapy can causesevere side effects, it is recommended only forpeople in relatively good health. Patients in verypoor health may have serious, life-threateningcomplications of chemotherapy.

In deciding which patients should receivechemotherapy, NCCN doctors use precisedefinitions of good health or poor healthbased on the Eastern Cooperative OncologyGroup (ECOG) Performance Scale. See page

8 for more information about the ECOGPerformance Scale.

The NCCN recommends chemotherapyfor patients with widespread disease who arein good health. The targeted therapy beva-cizumab in addition to chemotherapy is anoption for patients who are in good healthand who have nonsquamous NSCLC (and donot have any history of coughing up blood orbrain metastasis, and are not using any bloodthinning drugs). Chemotherapy alone is givenfor patients with a good or intermediate per-formance status. Patients are then evaluatedafter completing the first round of chemo-therapy. If the cancer grows after the first

56


Systemicchemotherapyand supportivecare

Bevacizumab*withchemotherapy

OR

Chemotherapy

Supportive care

Chemotherapy

Chemotherapy

Good generalhealth(PerformanceStatus 0–1)

Candidate forbevacizumab*

Not a candidatefor bevacizumab*

Intermediategeneral health(PerformanceStatus 2)

Poor generalhealth(PerformanceStatus 3–4)

Treatment

cycle, the patient should be treated accordingto the guidelines for progressive disease (seepage 58). If the cancer shrinks or at leastdoesn’t grow, another cycle of therapy is given.If there is no tumor growth after 2 treatments,chemotherapy should be continued for 4 to 6total cycles or until the tumor begins to growagain. Further treatment after the cancerbegins to grow is outlined on page 58.

For patients in poor health, the guidelinesrecommend supportive care. Supportive careis intended to relieve symptoms and to help

keep patients as comfortable as possible, butit is not intended to directly attack the cancer.

Although participation in clinical trials is agood option for any patient with lung cancer, astudy of a very new treatment in early stages oftesting (called a phase I or phase II clinical trial)may be a good option for patients who getsicker while on chemotherapy. Deciding on theright time to discontinue chemotherapy andfocus on supportive care is never easy. Goodcommunication with doctors, nurses, family,and clergy, as well as discussions with hospicestaff can help people facing this situation.

57

Non-small cell lung cancer: Treatment of stage IV and recurrent cancer

Chemotherapycontinued for totalof 4 to 6 courses,or until the cancerbegins to grow

See the Decision Tree for progressivedisease (page 58)

Cancer continues togrow and spreadduring first cycle ofchemotherapy

Cancer begins togrow and spread

Tumor shrinks ordoes not grow

Two chemotherapytreatments given

Response Treatment Response


* Bevacizumab is used only for patients with nonsquamousNSCLC and no history of bleeding problems or brain metastasis and not on anticoagulation therapy (see page 17 of text)

Non-small cell lung cancer:Treatment of stage IV with diseaseprogression This Decision Tree describes treatment afterthe cancer has begun to grow again. A differ-ent type of chemotherapy may be given forthose in good health. Docetaxol, pemetrexed,or the targeted therapy, erlotinib are treat-ment options at this point. If the tumorgrows while on this therapy, erlotinib is an

option for those who remain in good health(performance status 0 to 2), if the patient hasnot already received this drug. If the patienttaking erlotinib has further tumor growth,supportive care is an option. If the patientremains in good health, then participation ina clinical trial is another option.

Supportive care is recommended forpatients in poor health (performance status3 to 4).

58


Docetaxel

OR

Pemetrexed

OR

Erlotinib

Supportive care

Good generalhealth(Performancestatus 0–2)

Tumor grows

Poor generalhealth(Performancestatus 3–4)

Good generalhealth(Performancestatus 0–2)

Poor generalhealth(Performancestatus 3–4)

Treatment Response

59

Non-small cell lung cancer: Treatment of stage IV with disease progression

Erlotinib

Supportive care

OR

Clinical Trial

Supportive care

Supportive care

Tumor grows(progression)

General healthgets worse

Health remainsgood

Treatment TreatmentResponse


NOTES

Non-small cell lung cancer:Treatment of second primary Concern about the cancer coming back (thisis called recurrence) is an important issue forpeople with lung cancer and their doctors.But, there is another follow-up issue thatmany patients don’t think about: the risk ofdeveloping a second lung cancer. The riskfactors that contributed to your lung cancer(such as smoking, in most cases) have already

changed many cells throughout your lungs. Itis possible for people with 1 lung cancer todevelop a second cancer. This is a possibilitythat your doctors are watching out for, so if asecond cancer does develop they can find itat the earliest possible stage and start treat-ment when a cure is still possible.

Sputum cytology (using a microscope tolook for cancer cells in the mucus you coughup) is one way of finding a second lung cancer.

60


Bronchoscopy

OR

Autofluorescence

OR

Hematoporphyrin fluorescence(tests that find small cancers bycausing them to give off light)

New lung cancerdetected only by sputum cytology(cancer cells seenunder the microscope)

New lung cancerseen on chest x-ray or CT scan

Work-up depends on stageof the new cancer (seeDecision Tree on page 24)

Results of follow-up

Sometimes sputum cytology finds new lungcancers so small that they can’t be seen ona chest x-ray or a CT scan. In that case,bronchoscopy is used to thoroughly check thelining of your airways. Shining a special lightthrough the bronchoscope may cause cancersto glow, so they can be more easily recognized.

This test is called an autofluorescence test. Asimilar test called hematoporphyrin fluores-cence also uses a chemical that makes smallcancers more likely to glow under a speciallight. This test is very similar to photodynamictherapy, which is mentioned as a treatmentoption (see page 18). Tissue samples (biopsies)

61

Non-small cell lung cancer: Treatment of second primary

Same as treatment options for first lungcancer (see Decision Tree on page 24)

Treatment depends on stage of the newcancer (see Decision Tree on page 24)

Destroy cancer with:

• Surgery

• Brachytherapy (internal radiation)

• Laser therapy

• Photodynamic therapy

OR

Watch closely and repeat bronchoscopyevery 3 months

Repeat bronchoscopy every 3 months

New cancer is T1–T3

New cancer is Tis (cancercells have not invadedthe lung tissue)

Work-up did notfind any cancer

Treatment


are taken from any abnormal areas found bythese tests.

If cancer cells are found and a tumor canalso be seen (T1-T3), your work-up (startingon page 24) is the same as when your firstcancer was diagnosed. Once the stage isdetermined, treatment is similar, but not

identical. Because the treatments of yourfirst lung cancer affected the health andamount of your remaining lung tissue, youroptions for treatment of a second cancer maybe limited.

If these areas turn out to be small cancersthat have not spread (Tis), doctors try to remove

62


NOTES

or destroy them by local surgery, brachytherapy(placing small radioactive pellets inside theairway next to the cancer), laser surgery, orphotodynamic therapy. As another option theareas with cancer can be closely watched bydoing a bronchoscopy every 3 months.

If results of sputum cytology tests arepositive, but no tumors are found, doctors will

be concerned that a cancer is present but isstill too small to detect. They will repeatbronchoscopy every 3 months so that theycan find the source of the cancer cells anddestroy the tumor as soon as possible.

If a new cancer is seen on chest x-ray orCT scan, work-up and treatment depends onthe stage of the new cancer.

63

Non-small cell lung cancer: Treatment of second primary(continued)

NOTES

Small cell lung cancer: Initial work-up and staging This Decision Tree begins when small cell lungcancer (SCLC) has been diagnosed, based onthe results of a biopsy (a small piece of tissuethat has been removed from the tumor) orcytology (examination of cell samples, suchas cells in sputum, cells in the fluid that hascollected around the lungs, or cells that havebeen scraped from the lining of the airways).

The next step after diagnosis is a series ofexaminations and tests that doctors call theinitial work-up. The medical history andphysical exam focus on symptoms that may

suggest spread beyond your lungs and alsoconsider your overall health. Several tests aredone to determine the clinical stage of thecancer. For example, a chest CT scan helpsdetermine your tumor size and location, andalso evaluates the size of lymph nodes withinthe chest. If these lymph nodes are enlarged,they may contain cancer cells that have spreadfrom the lung tumor. SCLC frequently spreadsto the liver, adrenal glands, brain, and bone.Various tests are done to look at these areas;such as a CT scan of your liver and adrenalglands, a brain MRI or CT scan, and a bonescan. Another test that is sometimes done is

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• Medical history and physical exam

• Pathology review

• CT scan of chest, liver, and adrenal glands

• MRI or CT scan of head (MRI is preferred)

• Bone scan (optional if PET scan done)

• PET scan is optional

• Chest x-ray (optional)

• Blood cell counts

• Blood chemistry tests including LDH

• Smoking cessation counseling and intervention

Patient has small cell lung cancerbased on biopsy or cytology testresults of main lung tumor or ofa metastatic site

Diagnosis Initial work-up (evaluation)

a PET scan, which may be combined with aCT scan. If a PET scan is done, the bone scanis optional.

A variety of blood tests are done to checkhow well your liver and kidneys are workingand to make sure your blood cell counts arenot too low. Low blood cell counts or problemswith internal organs could mean that there isa higher risk of complications and side effectsof certain lung cancer treatments, so thesetests must be done before your treatmentbegins. Other blood test results can suggest a

cancer has spread outside the lung. Forexample, such spread is more likely whenblood levels of an enzyme called LDH (lactatedehydrogenase) are too high.

The results of your initial work-up areused to determine the clinical stage of yourcancer. The clinical stage tells you which ofthe Decision Trees are most relevant to yourtreatment. If you have any questions aboutyour clinical stage, check the information onpage 14, and talk to your doctor.

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Limited stage

Extensive stage

See additional work-up(page 66)

See additional work-up(page 72)

Additional work-upClinical stage


Small cell lung cancer: Initial work-up and staging

Small cell lung cancer: Limitedstage work-up If your clinical stage appears limited afterinitial tests, the guidelines recommend moretests to make sure that your cancer is notmore advanced.

Pulmonary function tests may be necessaryto measure how well the lungs take in andexhale air and how efficiently they transferoxygen into the blood. If the bone or PETscan showed any areas that may be cancer,additional x-rays are done to further evaluatethe abnormal areas. An MRI may be done ifthe x-rays still cannot determine whether

there has been tumor spread. A sample ofyour bone marrow may be checked under themicroscope to look for lung cancer cells.

If your chest x-ray shows fluid around yourlungs (pleural effusion), some of the fluid isremoved through a needle inserted throughthe ribs into the space next to the lungs. Asample of the fluid is looked at under themicroscope to see if cancer cells are present.If no cancer cells are found, a surgeon mayalso look into the chest cavity with a smalltelescope-like tube called a thoracoscope tofurther look for cancer there. If any of thesetests find lung cancer cells, then your cancer

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• Pulmonary function tests, if indicated

• X-rays or MRI of bone if the bonescan shows possible cancer spread

• Bone marrow biopsy and aspirationmay be recommended in some cases

• If fluid around the lung is found, thefluid should be checked for cancercells. If cancer not found in fluid,thoracoscopy may be done

Limitedstage

Clinical stage Additional work-up

is reclassified as extensive stage rather thanlimited stage. See page 70 for a discussion ofyour treatment options.

If no evidence of cancer spread is foundand there appears to be only 1 tumor nodule,then a PET scan will be done to see if thecancer has spread to the mediastinal lymphnodes or anywhere else. If needed, the PETscan can also be used to guide a biopsy pro-cedure. For example, a procedure known as

mediastinoscopy (see page 11) may be done.This procedure removes some lymph nodesinside the chest. These lymph nodes can alsobe removed during exploratory surgery. Thelymph nodes can then be examined to see ifthey contain any cancer cells.

Sometimes there is more than 1 lung tumor,but no lymph node spread. These cases arestill treated as limited stage SCLC.

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Small cell lung cancer: Limited stage work-up

PET scan Treatment (see page 68)

Treatment (see page 68)

Treat asextensivestage disease(see page 70)

Mediastinoscopy

OR

Exploratory surgeryor endoscopy tocheck for spread ofcancer to mediastinal(center of chest)lymph nodes

Single lung tumorwith no evidenceof spread

Cancer is moreadvanced than singlelung tumor but stilllimited stage

Cancer cells found inbone marrow and/orpleural fluid, or MRI orx-rays suggest cancerhas spread to bone

Findings Treatment

Small cell lung cancer: Treatmentfor limited stage People with small cell lung cancer (SCLC) arenot commonly treated with surgery becausetheir cancer usually has spread at the time ofdiagnosis. However, if the imaging tests showonly 1 lung tumor and there is no evidenceof spread elsewhere in the body (based onimaging tests, bone marrow biopsy, thora-coscopy, etc.), you might benefit from surgery.If no spread to mediastinal lymph nodes isfound by mediastinoscopy, the guidelines

recommend that you have an operation toremove your lung tumor and the mediastinalnodes. Chemotherapy is then given after theoperation. Radiation is added to the chemo-therapy if the lymph nodes removed at surgerycontain cancer cells.

If the mediastinoscopy shows that lungcancer cells have spread to your mediastinallymph nodes or there is more than 1 tumor,your cancer has spread too far to be removedby surgery and your treatment will be deter-mined by your health status. NCCN doctors

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Single lung tumorwith no spread

Limited disease,but more thana single tumor

No cancer inmediastinallymph nodes

Cancer inmediastinallymph nodes

Patient in good general health

Patient in good general health

Patient in poor generalhealth related to cancer

Patient in poor generalhealth unrelated to cancer

Patient in poor generalhealth related to cancer

Patient in poor generalhealth unrelated to cancer

Test results

use precise definitions of good health or poorhealth based on the Eastern CooperativeOncology Group (ECOG) Performance Scale.(Refer to page 8 for more information aboutthe ECOG Performance Scale.) For example, ifyour performance status is good, chemother-apy with radiation therapy is recommendedbecause this combination is more effective inhelping patients live longer and in preventing

or treating symptoms of SCLC. Poor perform-ance status may be related either to thetumor or to other health problems.Chemotherapy with (or without) radiationtherapy is recommended if your poor per-formance status is related to the tumor. If youhave significant other medical problems, thenindividualized treatment and supportive careis recommended.

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Small cell lung cancer: Treatment for limited stage

Chemotherapy

Chemotherapy together with radiationtherapy to the mediastinum

Chemotherapy together withradiation therapy to the chest

Chemotherapy togetherwith radiation therapy

Individualized treatment and supportive care

Individualized treatment and supportive care

Chemotherapy with orwithout radiation therapy

Chemotherapy with orwithout radiation therapy

Surgery toremove tumorand mediastinallymph nodes

No cancer inlymph nodes

Cancer inlymph nodes

Treatment

Small cell lung cancer: Work-upand treatment for extensive stage If you have extensive stage small cell lungcancer (SCLC), your treatment depends onexactly where your cancer has spread andyour general state of health. In deciding whichpatients should receive chemotherapy, NCCNdoctors use precise definitions of good healthor poor health (that is, your performancestatus), as described on page 8. Chemotherapyhas been shown to help patients with extensive

stage SCLC who are in good or fair generalhealth to live longer. It can also relieve somesymptoms and delay the onset of others.However, if your general health is very poor, youmay not be able to withstand the side effectsof chemotherapy or benefit from it. In thiscase, your doctor may select a treatment planbased on your individual medical situation.

In addition to having chemotherapy, theguidelines recommend radiation therapyaimed at any areas causing symptoms. Such

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X-rays of weight-bearing areas thatwere abnormal onbone scan

Extensivestage

Extensive stage withno symptoms andno spread to brain

Extensive stagewith spread causingserious symptoms

Extensive stage withspread to brain

Work-upCinical stage

areas would include blood vessels or airwaysthat are blocked by tumor, metastases in legor hip bones, or metastases pressing on thespinal cord or spinal nerves causing paralysisor pain.

If the cancer has spread to the brain,whole brain radiation therapy and chemo-therapy are recommended, but the order of

the treatment depends on whether symptomsare present. If there are no symptoms,chemotherapy is given first, followed bywhole brain radiation therapy. If the brainmetastases are symptomatic, whole brainradiation therapy is given first, followed bythe chemotherapy, unless the tumor outsidethe brain needs immediate treatment.

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Small cell lung cancer: Work-up and treatment for extensive stage


Chemotherapy alongwith supportive care

Individualized therapy basedon patient’s medical situationincluding supportive care

Chemotherapy with radiation therapyto the cancer involving the spinal cord

Chemotherapy followed bywhole brain radiation therapy

Chemotherapy with or without radiationtherapy aimed at areas of cancer spreadthat are causing these symptoms

Whole brain radiation therapyfollowed by chemotherapyunless immediate chemotherapyor other treatment is required

Patient in good orfair general health

Patient in poorgeneral health

Spread to largeblood vessels inthe chest or tobone or blockageof lung passages

Spread to thespinal cord

No symptoms

Symptoms present

Initial treatment

Small cell lung cancer: Adjuvanttreatment After your initial treatment has been com-pleted, the guidelines recommend that youhave follow-up tests and exams that includean optional chest x-ray; CT scan of the chest,liver, and adrenal glands; brain CT or MRI(MRI is preferred); imaging tests of knownareas of disease; and blood tests to check forrecurrence (cancer coming back). Based on

results of the imaging tests, the cancer’sresponse to treatment is classified as com-plete response, partial response, or progressivedisease.

A complete response means that alltumors in your body seem to have completelydisappeared or are less than 10% of the sizethey were on the original imaging tests, suchas CT scans. This response does not guaranteethat all of your cancer cells have been

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• Chest x-ray (optional)

• CT scans of chest, liver,and adrenal glands

• MRI scan (preferred) or CTscan of head for patientswho will receive brainradiation to prevent brainmetastases

• Other imaging tests tocheck status of knowncancer spread

• CBC and blood chemistrytests

Complete response(main lung tumor nolonger visible) or hasshrunk to 10% or less

Partial response (tumorsshrank by 50% but didnot completely disappear)

Progressive disease(cancer continuedto grow or spread)

Limitedstage

Extensivestage

Additional work-up Findings

destroyed. In fact, most patients with a com-plete response still have some cancer cellsscattered throughout their body. Doctors worryabout a recurrence in the brain, becausechemotherapy doesn’t easily cross from thebloodstream into the brain. For this reason,brain radiation is recommended, even if CT

or MRI scans of the brain do not detect anytumors. This form of radiation is known asprophylactic (preventive) cranial irradiation(PCI). In patients with a complete responsewho initially had limited stage disease, PCI isstrongly recommended. The guidelines alsorecommend PCI for patients with a complete

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Strongly recommendbrain radiation to prevent growth ofbrain metastases

Recommend brain radiation to preventgrowth of brain metastases

Consider brain radiationas preventative measure

Supportive care

• Oncologist visits every 2 to 3months for the first year, every 3to 4 months for years 2 and 3,every 4 to 6 months during years4 and 5, then every year

• Each visit should include historyand physical exam, chest imaging,and blood tests based on symptoms and other test results

• Any new lung nodule after 2 yearsshould be completely re-evaluated

• Smoking cessation counseling


Follow-up

Small cell lung cancer: Adjuvant treatment


response who originally had extensive disease.It can be considered for patients with a partialresponse, but the benefits of this approachare not as clear for these patients.

If you have either a complete or partialresponse to initial therapy, you should have

frequent check-ups (that is, follow-up with anoncologist) according to the schedule in thisDecision Tree. Every visit should include amedical history, physical exam, chest imag-ing, and blood tests. If you have any newsymptoms or if your chest imaging results or

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NOTES

physical exam is abnormal, additional testsare done to check whether the cancer hascome back. If a cancer is found after 2 years,it will be assumed to be a new second cancerand should be treated as such with a biopsy andre-evaluation as described on page 64. It is

also very important to stop smoking. Yourdoctor can give you information to help youwith this.

If the cancer continues to grow with treat-ment, supportive care is recommended.

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Small cell lung cancer: Adjuvant treatment (continued)

NOTES

Small cell lung cancer: Treatment ofrecurrent disease This Decision Tree discusses what to do if thecancer comes back after it has shrunk or dis-appeared, or if it continues to grow duringchemotherapy. If the cancer shrank or disap-peared with chemotherapy and comes back,

new (and different) chemotherapy can begiven. This different therapy is continued untilthe cancer begins to grow, at which time thechoices are either a clinical trial of newtreatments or supportive care to relieve anysymptoms and keep the patient comfortable.If the cancer comes back and chemotherapy

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Different chemotherapy

Supportive care

OR

Clinical trial

Supportive care, including radiation forsymptom relief

OR

Consider participating in clinical trial

OR

Different chemotherapy for patients ingood general health

Relapse (cancercoming back)

OR

Cancer growsduring initialtreatment

Treatment

is not a good option then a clinical trial orsupportive care is the recommended treat-ment. If the cancer did not respond to theinitial chemotherapy (that is, did not shrinkor increased in size), then the guidelines

recommend supportive care (including radi-ation therapy for symptom relief), or a clinicaltrial, or a different chemotherapy regimen ifyou are in good health.

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Clinical trial

OR

Supportive care

Continue untiltreatments areunsuccessful

Response Treatment

Small cell lung cancer: Treatment of recurrent disease

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NOTES

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NOTES

Terri Ades, MS, APRN-BC, AOCNAmerican Cancer Society

Kimberly A. Stump-Sutliff, MSN, AOCNSAmerican Cancer Society

Miranda Hughes, PhDNational Comprehensive Cancer Network

Joan McClure, MSNational Comprehensive Cancer Network

Mary Dwyer Rosario, MSNational Comprehensive Cancer Network

Dottie Shead, MSNational Comprehensive Cancer Network

David S. Ettinger, MDThe Sidney Kimmel ComprehensiveCancer Center at Johns Hopkins

Gregory P. Kalemkerian, MDUniversity of MichiganComprehensive Cancer Center

The Lung Cancer Treatment Guidelines for Patients were developed by a diverse group of expertsand were based on the NCCN clinical practice guidelines. These patient guidelines were translated,reviewed, and published with help from the following individuals:

The original NCCN Lung Cancer Clinical Practice Guidelines were developed by the followingNCCN Panel Members:

Non-Small Cell Lung Cancer Panel

Wallace Akerley, MD Huntsman Cancer Institute at the University of Utah

Gerold Bepler, MD, PhD H. Lee Moffitt Cancer Center &Research Institute

Andrew Chang, MD University of MichiganComprehensive Cancer Center

Richard T. Cheney, MD Roswell Park Cancer Institute

Lucian R. Chirieac, MD Dana-Farber/Brigham and Women’sCancer Center | MassachusettsGeneral Hospital Cancer Center

Thomas A. D’Amico, MD Duke Comprehensive Cancer Center

Todd L. Demmy, MD Roswell Park Cancer Institute

David S. Ettinger, MD / Chair The Sidney Kimmel ComprehensiveCancer Center at Johns Hopkins

Steven J. Feigenberg, MD, FACS Fox Chase Cancer Center

Robert A. Figlin, MDCity of Hope

Ramaswamy Govindan, MDSiteman Cancer Center at Barnes-Jewish Hospital and WashingtonUniversity School of Medicine

Frederic W. Grannis, Jr., MD City of Hope

Thierry Jahan, MD UCSF Comprehensive Cancer Center

Mohammad Jahanzeb, MD St. Jude Children’s ResearchHospital/University of TennesseeCancer Institute

Anne Kessinger, MD UNMC Eppley Cancer Center at The Nebraska Medical Center

Ritsuko Komaki, MD, FACR University of Texas M. D. AndersonCancer Center

Mark G. Kris, MD Memorial Sloan-Kettering Cancer Center

Corey J. Langer, MD Fox Chase Cancer Center

Quynh-Thu Le, MD Stanford Comprehensive Cancer Center

Renato Martins, MD Fred Hutchinson Cancer ResearchCenter/Seattle Cancer Care Alliance

Gregory A. Otterson, MD Arthur G. James Cancer Hospital &Richard J. Solove Research Instituteat The Ohio State University

Jyoti D. Patel, MD Robert H. Lurie ComprehensiveCancer Center of NorthwesternUniversity

Francisco Robert, MD University of Alabama at BirminghamComprehensive Cancer Center

David J. Sugarbaker, MD Dana-Farber/Brigham and Women’sCancer Center | MassachusettsGeneral Hospital Cancer Center

Douglas E. Wood, MD Fred Hutchinson Cancer ResearchCenter/Seattle Cancer Care Alliance

Small Cell Lung Cancer Panel

Wallace Akerley, MD Huntsman Cancer Institute at the University of Utah

Robert J. Downey, MD Memorial Sloan-Kettering Cancer Center

David S. Ettinger, MD The Sidney Kimmel ComprehensiveCancer Center at Johns Hopkins

Frank Fossella, MD University of Texas M. D. AndersonCancer Center

John C. Grecula, MD Arthur G. James Cancer Hospital &Richard J. Solove Research Instituteat The Ohio State University

Thierry Jahan, MD UCSF Helen Diller FamilyComprehensive Cancer Center

Bruce E. Johnson, MD Dana-Farber/Brigham and Women’sCancer Center | MassachusettsGeneral Hospital Cancer Center

Gregory P. Kalemkerian, MD / Chair University of MichiganComprehensive Cancer Center

Anne Kessinger, MD UNMC Eppley Cancer Center at TheNebraska Medical Center

Marianna Koczywas, MD City of Hope

Corey J. Langer, MD Fox Chase Cancer Center

Renato Martins, MD Fred Hutchinson Cancer ResearchCenter/Seattle Cancer Care Alliance

Harvey B. Niell, MD St. Jude Children’s ResearchHospital/ University of TennesseeCancer Institute

Charles C. Pan, MDUniversity of MichiganComprehensive Cancer Center

Nithya Ramnath, MD Roswell Park Cancer Institute

Neal Ready, MDiv, PhDDuke Comprehensive Cancer Center

Francisco Robert, MD University of Alabama at BirminghamComprehensive Cancer Center

Charles C. Williams, Jr., MD H. Lee Moffitt Cancer Center &Research Institute

NCCN Lung Cancer Treatment Guidelines IV Cancer Treatment Guidelines for Patients Advanced Cancer...

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