Treatment for lung cancer

People with early NSCLC (stage 1 or 2) will generally be offered surgery to remove the tumour. How much of the lung is removed depends on several factors:

• the location and size of the cancer
• your general wellbeing and fitness
• how your lungs are working (lung function).

Surgery is not suitable for most people with late-stage lung cancer. If there is fluid in the pleural cavity (called pleural effusion) that keeps coming back, you may have minor surgery (pleurodesis) to control this.

Preparing for treatment

Quit smoking – If you smoke, your health care team will usually advise you to stop smoking before you start treatment for lung cancer.

Quitting smoking can improve how treatments work and reduce the impact of side effects such as breathlessness. Research shows that quitting smoking before surgery also reduces the chance of complications.

To work out a plan for quitting, talk to your doctor or call Quitline on 13 78 48.

Eat well and exercise – Your health care team may also suggest that you exercise and eat healthy foods before starting lung cancer treatment.

You may be referred to allied health professionals such as a dietitian or exercise physiologist to support you to make changes.

Preparing for treatment in this way is called “prehabilitation”. It can help you to cope with cancer treatment, recover more quickly and improve your quality of life.

Types of lung surgery

Surgery for lung cancer may remove all or part of a lung.

Lobectomy – This is the most common type of surgery for lung cancer. In a lobectomy, one of the lobes of the lung is removed. About 30–50% of the lung will be removed.

Pneumonectomy – If the cancer is in more than one lobe of a lung, or near where the airways enter the lung, a pneumonectomy may be done. In this procedure, a whole lung is removed. It’s possible to still breathe normally with one lung.

Segmentectomy – For some early-stage lung cancers that are on the edge of the lung, a segmentectomy may be used. In this procedure, a small part of the lobe is removed. In cases where a patient is very unwell, however, a wedge resection may be considered. A wedge resection removes only a very small amount of the lobe.

Removing lymph nodes

During surgery, lymph nodes near the cancer will also be removed to check whether the cancer has spread. Knowing if the cancer has spread to the lymph nodes also helps the doctors decide whether you need further treatment with chemotherapy or radiation therapy.

How the surgery is done

There are 2 ways to perform surgery for lung cancer, and both require a general anaesthetic. Each type of surgery has advantages in particular  situations – talk to your surgeon about the best option for you.

VATS – Lung cancer surgery can often be done using a keyhole approach. This is known as video-assisted thoracoscopic surgery (VATS). In this approach, the surgeon makes a few small cuts (incisions) in the chest wall.

A tiny video camera and operating instruments are passed through the cuts, and the surgeon performs the operation from outside the chest. A keyhole approach usually means a shorter hospital stay, faster recovery and fewer side effects.

Thoracotomy – If a long cut is made between the ribs in the side of the chest, the operation is called a thoracotomy. This may also be called open surgery. You will need to stay in hospital for 3–7 days.

Most hospitals in Australia have programs to reduce the stress of surgery and improve your recovery. Called enhanced recovery after surgery (ERAS) or fast track surgical (FTS) programs, they provide information about what to expect each day after surgery. 

What to expect after surgery

Exercises for breathlessness – A pulmonary rehabilitation program can help improve breathlessness and reduce the risk of chest infection. A physiotherapist will show you how to do exercises. To continue rehabilitation after you leave hospital, talk to your surgeon or visit  lungfoundation.com.au.

Pain – You may have some pain but this can be controlled. Managing the pain will allow you to do breathing exercises and help you to recover. Pain will improve when tubes are removed from the chest.

Tubes and drips – You will have several tubes in place, which will be removed as you recover. A drip in a vein in your arm (intravenous drip) will give you fluid and medicines. There may be tubes in your chest to drain fluid and help your lungs expand; and a tube in your bladder to check how much urine you pass.

Recovery time – You will probably go home after 3–7 days. It may take 4–8 weeks after VATS or 6–12 weeks after thoracotomy to get back to your usual activities. Walking can improve fitness, help clear your lungs and speed up recovery.

Download our booklet ‘Understanding Surgery’

Also known as radiotherapy, radiation therapy is the use of a controlled dose of radiation to kill or damage cancer cells so they cannot grow, multiply or spread.

Radiation therapy may be given on its own, after surgery or with chemotherapy (called chemoradiation). It may be recommended:

• if you are unable or choose not to have surgery
• to treat locally advanced (stage 3) NSCLC or limited-stage SCLC
• after surgery, if there is some cancer left behind (called a positive margin)
• after surgery, if tests show cancer in the lymph nodes between the lungs, to reduce the risk of cancer coming back in this area
• as palliative treatment to improve quality of life by relieving pain or other symptoms.

For lung cancer, the radiation is usually in the form of x-ray beams that come from a machine outside the body. This is called external beam radiation therapy (EBRT). It can be delivered in different ways depending on the type and stage of lung cancer.

Standard EBRT – This is usually given Monday to Friday over several weeks. For NSCLC, treatment aimed at making the signs and symptoms of cancer go away (curative course) may involve 20–30 radiation therapy sessions over 4–6 weeks. Palliative radiation therapy may involve up to about 10 treatments. For SCLC, treatment may be given twice a day for 3 weeks (about 30 treatments).

Stereotactic body radiation therapy (SBRT) – This is also called stereotactic ablative body radiation (SABR). It is a way of giving a very precise high dose of radiation therapy to small, early-stage NSCLC.

How SBRT is done

Stereotactic body radiation therapy (SBRT) precisely targets beams of high-dose radiation from different angles onto the tumour.

SBRT may be used when you are not well enough to have surgery, or surgery is not possible due to the location or size of the cancer. SBRT is often given as 3–4 treatment sessions over a couple of weeks. It is suitable only for tumours that are not close to major airways or major blood vessels.

Planning radiation therapy

Before treatment starts, you will have a planning session at the radiation therapy centre to design a treatment plan for you. During this appointment, you will have a CT scan to pinpoint the area to be treated, and marks will be put on your skin so the radiation therapist treats the same area each time. Often, you will have a 4-dimensional CT scan to monitor how the lung cancer moves as you breathe in and out. You may also be given some breathing exercises to help your breathing stay as regular as possible during the treatment sessions.

Having radiation therapy

Radiation therapy is delivered using a large machine called a linear accelerator. Each treatment day, a radiation therapist will help you to lie on the treatment table and make sure you are in the correct position before leaving the room. Before the radiation therapy is given, you will have an x-ray or CT scan to make sure the correct area is being treated. The radiation treatment itself takes only a few minutes, but a session may last 10–20 minutes because of the time it takes to set up the machine.

Side effects of radiation therapy

Radiation therapy itself is painless, but the radiation may affect some tissues of the body and cause various side effects. These side effects vary  depending on the dose of radiation, the number of treatments and the part of the chest treated. Most are temporary and disappear a few weeks or months after treatment.

Discomfort when swallowing and heartburn – If the cancer is in the centre of the chest and near the oesophagus, you may have some discomfort when swallowing, and heartburn during the treatment period and up to 4 weeks after treatment ends. Until these side effects improve, you may need to eat soft foods and avoid hot drinks.

Fatigue – Feeling tired is common after radiation therapy. Plan your daily activities so you can rest regularly. You may find that gentle physical exercise reduces fatigue.

Skin changes – The skin on your chest and back may become red or dry, like sunburn. It is important to avoid getting direct sunlight on these areas. Applying a moisturising cream daily can help protect your skin – talk to your medical team about which products they recommend.

Shortness of breath and cough – Radiation therapy may cause inflammation of the lungs. Called radiation pneumonitis, this may cause shortness of breath and/or a cough. This may happen during treatment, but it is more likely to appear 1–6 months after treatment ends. Radiation pneumonitis is usually temporary and can be treated.

Side effects can change from one treatment session to the next and may build up over time. Tell the radiation oncology team about any side effects you have, as most can be managed.

Download our booklet ‘Understanding Radiation Therapy’

Sometimes called systemic therapies, drug therapies can travel throughout the body to treat cancer cells wherever they may be. This can be helpful for cancer that has spread (metastatic cancer). The main types of drug therapies used to treat lung cancer are chemotherapy, immunotherapy and targeted therapy.

Chemotherapy

Chemotherapy is the use of drugs to kill cancer cells or slow their growth. Chemotherapy can be used at different times:

• before surgery to try to shrink the cancer and make it easier to remove (neoadjuvant chemotherapy)
• before or in combination with radiation therapy to make radiation therapy more effective (chemoradiation), or in combination with immunotherapy
• after surgery to reduce the risk of the cancer returning (adjuvant chemotherapy)
• when cancer is advanced – to reduce symptoms and improve quality of life (palliative chemotherapy).

Having chemotherapy

Chemotherapy is usually given through a vein (intravenously). It is commonly given as a period of treatment followed by a break to allow your body to recover. This is called a cycle. The number of cycles will depend on the type of lung cancer and any side effects you have. You will probably have chemotherapy as an outpatient, which means you will go to the treatment centre for chemotherapy but not stay overnight. Some types of chemotherapy come in tablet form and can be taken by mouth (orally) at home. Ask your doctor about the treatment plan recommended for you.

Side effects of chemotherapy

Chemotherapy works on cells that are dividing rapidly. Cancer cells divide rapidly, as do some healthy cells such as the cells in your blood, mouth, digestive system and hair follicles. Side effects occur when chemotherapy damages these normal cells. As the body constantly makes new cells, most side effects are temporary. Some side effects are listed below.

Anaemia – A low red blood cell count is called anaemia. This can make you feel tired, breathless or dizzy. Your treatment team will monitor your red blood cell levels and suggest treatment if necessary.

Risk of infections – Chemotherapy drugs can lower the number of white blood cells that fight infections caused by bacteria. If you get an infection  caused by a virus, such as a cold, flu or COVID-19, the risk of getting a bacterial infection is further increased. Talk to your doctor about being  vaccinated against flu and COVID-19. Good hand and mouth hygiene and social distancing are also important measures to reduce the risk of  infection. If you feel unwell or have a temperature above 38°C, call your doctor immediately or go to the hospital emergency department.

Mouth ulcers – Some chemotherapy drugs cause mouth sores, ulcers and thickened saliva, which make it difficult to swallow. Your treatment team will explain how to take care of your mouth.

Hair loss – You may lose hair from your head and chest, depending on the chemotherapy drugs you receive. The hair will grow back after treatment is completed, but the colour and texture may change.

Nausea, vomiting or constipation – You will usually be prescribed anti-nausea medicine with your chemotherapy drugs, but some people still feel sick (nauseous) or vomit. Constipation is also a common side effect of some types of anti-nausea medicines. Let your treatment team know if you have these side effects, as they may be able to give you additional medicines.

Download our booklet ‘Understanding Chemotherapy’

Immunotherapy

This is a type of drug treatment that uses the body’s own immune system to fight cancer. Immunotherapy drugs known as checkpoint inhibitors block proteins, such as PD-L1, that stop immune cells from recognising and destroying the cancer cells. Once the proteins are blocked, the immune cells can potentially recognise and attack the lung cancer.

Several checkpoint inhibitors have been approved for most types of advanced NSCLC. One has also been approved for extensive-stage SCLC when it is used together with chemotherapy. Several other checkpoint inhibitors are being tested in clinical trials for lung cancer, including using a combination of these drugs.

Immunotherapy may be used alone or with chemotherapy as a palliative treatment, or after chemoradiation. In the future, immunotherapy may be used for early-stage NSCLC, either before or after surgery.

Checkpoint inhibitors do not work for all types of lung cancer, but some people have had good results. Ask your oncologist about molecular testing and whether immunotherapy may be an option for you.

Side effects of immunotherapy

Immunotherapy can cause inflammation throughout the body, which leads to different side effects depending on which part of the body becomes inflamed.

Common side effects include fatigue, rash, painful joints and diarrhoea. Most people have mild side effects that can be treated easily and usually improve.

Let your treatment team know if you have new or worsening symptoms. If left untreated, some side effects can become serious and may even be life-threatening. For a detailed list of side effects, visit eviq.org.au.

Download our fact sheet ‘Understanding Immunotherapy’

Targeted therapy

This is a type of drug treatment that attacks specific features of cancer cells, known as molecular targets, to stop the cancer growing and spreading. The molecular targets are usually particular gene changes that are found in or on the surface of cancer cells.

Targeted therapy is currently available for people with NSCLC whose tumours have specific gene changes when cancer is advanced or has come back after initial surgery or radiation therapy. These drugs will only work if the cancer contains the particular gene targeted and, even then, they do not work for everyone. Ask your oncologist about molecular testing and whether targeted therapy is an option for you.

Targeted therapy can often be given by mouth as tablets or capsules.

This area of cancer treatment is changing rapidly, and it’s likely that new gene changes and targeted therapy drugs will continue to be discovered. Talk to your oncologist about any clinical trials that may be suitable for you.

Cancer cells often become resistant to targeted therapy drugs over time. If the first-line treatment stops working, your oncologist may suggest trying another targeted therapy drug or another systemic treatment. This is known as second-line treatment.

Side effects of targeted therapy

Although targeted therapy may cause less harm to healthy cells than chemotherapy, it can still have side effects. These side effects vary depending on the type of targeted therapy drugs used. Common side effects that may develop include an acne-like rash, fatigue, diarrhoea, nausea or vomiting.

Targeted therapies may also cause pneumonitis (inflammation of the lung tissue), which can lead to breathing problems. It’s important to report any new or worsening side effects to your treatment team. If left untreated, some side effects can become serious and may even be life-threatening. For a detailed list of side effects, visit eviq.org.au.

Download our fact sheet ‘Understanding Targeted Therapy’

If the cancer is advanced when it is first diagnosed or comes back after treatment (recurrence), your doctor will discuss palliative treatment for any symptoms caused by the cancer. They may refer you to a palliative care specialist.

Palliative treatment aims to manage symptoms without trying to cure the disease. It can be used at any stage of advanced lung cancer to improve quality of life and does not mean giving up hope. In fact, palliative treatment can help some people with advanced lung cancer to live fulfilling lives with minimal symptoms for many months or even years.

Systemic treatment (chemotherapy, immunotherapy and targeted therapy), radiation therapy and surgery may be used palliatively to slow the  spread of cancer and control symptoms such as pain or breathlessness. If you are experiencing a build-up of fluid in the lungs, various procedures can drain the fluid and help prevent it building up again.

Palliative treatment is one aspect of palliative care, in which a team of health professionals aims to meet your physical, emotional, cultural, spiritual and social needs. The team also supports families and carers.

Download our booklet ‘Understanding Palliative Care’

Download our booklet ‘Living with Advanced Cancer’