National Cancer Institute at the National Institutes of Health

Non-Small Cell Lung Cancer Treatment (PDQ)

Patient Version
Last Modified: 10/18/2013

Table of Contents

General Information About Non-Small Cell Lung Cancer

Stages of Non-Small Cell Lung Cancer

Recurrent Non-Small Cell Lung Cancer

Treatment Option Overview

Treatment Options by Stage

Occult Non-Small Cell Lung Cancer
Stage 0 (Carcinoma in Situ)
Stage I Non-Small Cell Lung Cancer
Stage II Non-Small Cell Lung Cancer
Stage IIIA Non-Small Cell Lung Cancer
Stage IIIB Non-Small Cell Lung Cancer
Stage IV Non-Small Cell Lung Cancer

Treatment Options for Recurrent Non-Small Cell Lung Cancer

To Learn More About Non-Small Cell Lung Cancer

Changes to This Summary (10/18/2013)

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General Information About Non-Small Cell Lung Cancer

Key Points for This Section

Non-small cell lung cancer is a disease in which malignant (cancer) cells form in the tissues of
the lung.
There are several types of non-small cell lung cancer.
Smoking increases the risk of non-small cell lung cancer.
Possible signs of non-small cell lung cancer include a cough that doesn't go away and
shortness of breath.
Tests that examine the lungs are used to detect (find), diagnose, and stage non-small cell lung
cancer.
Certain factors affect prognosis (chance of recovery) and treatment options.
For most patients with non-small cell lung cancer, current treatments do not cure the cancer.

Non-small cell lung cancer is a disease in which malignant (cancer) cells

form in the tissues of the lung.

The lungs are a pair of cone-shaped breathing organs in the chest. The lungs bring oxygen into the
body as you breathe in. They release carbon dioxide, a waste product of the bodys cells, as you
breathe out. Each lung has sections called lobes. The left lung has two lobes. The right lung is slightly
larger and has three lobes. Two tubes called bronchi lead from the trachea (windpipe) to the right and
left lungs. The bronchi are sometimes also involved in lung cancer. Tiny air sacs called alveoli and
small tubes called bronchioles make up the inside of the lungs.
 Anatom y of the respiratory sy stem , showing the trachea and both lungs and their lobes and airway s.
Ly m ph nodes and the diaphragm are also shown. Oxy gen is inhaled into the lungs and passes through the
thin m em branes of the alv eoli and into the bloodstream (see inset).

A thin membrane called the pleura covers the outside of each lung and lines the inside wall of the chest
cavity. This creates a sac called the pleural cavity. The pleural cavity normally contains a small
amount of fluid that helps the lungs move smoothly in the chest when you breathe.

There are two main types of lung cancer: non-small cell lung cancer and small cell lung cancer.

See the following PDQ summaries for more information about lung cancer:
 Small Cell Lung Cancer Treatment
Unusual Cancers of Childhood
Lung Cancer Prevention
Lung Cancer Screening
Smoking in Cancer Care

There are several types of non-small cell lung cancer.

Each type of non-small cell lung cancer has different kinds of cancer cells. The cancer cells of each
type grow and spread in different ways. The types of non-small cell lung cancer are named for the
kinds of cells found in the cancer and how the cells look under a microscope:

Squamous cell carcinoma: Cancer that begins in squamous cells, which are thin, flat cells that
look like fish scales. This is also called epidermoid carcinoma.
Large cell carcinoma: Cancer that may begin in several types of large cells.
Adenocarcinoma: Cancer that begins in the cells that line the alveoli and make substances such
as mucus.

Other less common types of non-small cell lung cancer are: pleomorphic, carcinoid tumor, salivary
gland carcinoma, and unclassified carcinoma.

Smoking increases the risk of non-small cell lung cancer.

Smoking cigarettes, pipes, or cigars is the most common cause of lung cancer. The earlier in life a
person starts smoking, the more often a person smokes, and the more years a person smokes, the
greater the risk of lung cancer. If a person has stopped smoking, the risk becomes lower as the years
pass.

Anything that increases your chance of getting a disease is called a risk factor. Having a risk factor
does not mean that you will get cancer; not having risk factors doesnt mean that you will not get
cancer. Talk with your doctor if you think you may be at risk.

Risk factors for lung cancer include the following:

Smoking cigarettes, pipes, or cigars, now or in the past.

Being exposed to secondhand smoke.
Having a family history of lung cancer.
Being treated with radiation therapy to the breast or chest.
Being exposed to asbestos, chromium, nickel, arsenic, soot, or tar in the workplace.
Being exposed to radon in the home or workplace.
Living where there is air pollution.
Being infected with the human immunodeficiency virus (HIV).
Using beta carotene supplements and being a heavy smoker.

When smoking is combined with other risk factors, the risk of lung cancer is increased.

Possible signs of non-small cell lung cancer include a cough that doesn't go
away and shortness of breath.

Sometimes lung cancer does not cause any symptoms and is found during a chest x-ray done for
another condition. Symptoms may be caused by lung cancer or by other conditions. Check with your
doctor if you have any of the following problems:

Chest discomfort or pain.

A cough that doesnt go away or gets worse over time.
Trouble breathing.
Wheezing.
Blood in sputum (mucus coughed up from the lungs).
Hoarseness.
Loss of appetite.
Weight loss for no known reason.
Feeling very tired.
Trouble swallowing.
Swelling in the face and/or veins in the neck.

Tests that examine the lungs are used to detect (find), diagnose, and stage
non-small cell lung cancer.

Tests and procedures to detect, diagnose, and stage non-small cell lung cancer are often done at the
same time. Some of the following tests and procedures may be used:

Physical exam and history : An exam of the body to check general signs of health, including
checking for signs of disease, such as lumps or anything else that seems unusual. A history of the
patients health habits, including smoking, and past jobs, illnesses, and treatments will also be
taken.

Laboratory tests : Medical procedures that test samples of tissue, blood, urine, or other
substances in the body. These tests help to diagnose disease, plan and check treatment, or
monitor the disease over time.

Chest x-ray: An x-ray of the organs and bones inside the chest. An x-ray is a type of energy
beam that can go through the body and onto film, making a picture of areas inside the body.
 X-ray of the chest. X-ray s are used to take pictures of organs and bones of
the chest. X-ray s pass through the patient onto film .

CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the
body, such as the chest, taken from different angles. The pictures are made by a computer
linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or
tissues show up more clearly. This procedure is also called computed tomography,
computerized tomography, or computerized axial tomography.

Sputum cytology : A procedure in which a pathologist views a sample of sputum (mucus

coughed up from the lungs) under a microscope, to check for cancer cells.

Fine-needle aspiration (FNA) biopsy of the lung: The removal of tissue or fluid from the
lung using a thin needle. A CT scan, ultrasound, or other imaging procedure is used to locate the
abnormal tissue or fluid in the lung. A small incision may be made in the skin where the biopsy
needle is inserted into the abnormal tissue or fluid. A sample is removed with the needle and sent
to the laboratory. A pathologist then views the sample under a microscope to look for cancer
cells. A chest x-ray is done after the procedure to make sure no air is leaking from the lung into
the chest.

Fine-Needle Aspiration Biopsy of the Lung. The patient lies on a table that
slides through the com puted tom ography (CT) m achine, which takes x-ray
pictures of the inside of the body . The x-ray pictures help the doctor see
where the abnorm al tissue is in the lung. A biopsy needle is inserted
through the chest wall and into the area of abnorm al lung tissue. A sm all
piece of tissue is rem ov ed through the needle and checked under the
m icroscope for signs of cancer.

Bronchoscopy : A procedure to look inside the trachea and large airways in the lung for
abnormal areas. A bronchoscope is inserted through the nose or mouth into the trachea and
lungs. A bronchoscope is a thin, tube-like instrument with a light and a lens for viewing. It may
also have a tool to remove tissue samples, which are checked under a microscope for signs of
cancer.
 Bronchoscopy . A bronchoscope is inserted through the m outh, trachea, and
m ajor bronchi into the lung, to look for abnorm al areas. A bronchoscope is a
thin, tube-like instrum ent with a light and a lens for v iewing. It m ay also
hav e a cutting tool. Tissue sam ples m ay be taken to be checked under a
m icroscope for signs of disease.

T horacoscopy : A surgical procedure to look at the organs inside the chest to check for
abnormal areas. An incision (cut) is made between two ribs, and a thoracoscope is inserted into
the chest. A thoracoscope is a thin, tube-like instrument with a light and a lens for viewing. It
may also have a tool to remove tissue or lymph node samples, which are checked under a
microscope for signs of cancer. In some cases, this procedure is used to remove part of the
esophagus or lung. If certain tissues, organs, or lymph nodes cant be reached, a thoracotomy
may be done. In this procedure, a larger incision is made between the ribs and the chest is
opened.

T horacentesis : The removal of fluid from the space between the lining of the chest and the
lung, using a needle. A pathologist views the fluid under a microscope to look for cancer cells.

Light and electron microscopy : A laboratory test in which cells in a sample of tissue are
viewed under regular and high-powered microscopes to look for certain changes in the cells.
 Immunohistochemistry study: A laboratory test in which a substance such as an antibody,
dye, or radioisotope is added to a sample of cancer tissue to test for certain antigens. This type
of study is used to tell the difference between different types of cancer.

Certain factors affect prognosis (chance of recovery) and treatment options.

The prognosis (chance of recovery) and treatment options depend on the following:

The stage of the cancer (the size of the tumor and whether it is in the lung only or has spread to
other places in the body).
The type of lung cancer.
Whether there are symptoms such as coughing or trouble breathing.
The patients general health.

For most patients with non-small cell lung cancer, current treatments do not
cure the cancer.

If lung cancer is found, taking part in one of the many clinical trials being done to improve treatment
should be considered. Clinical trials are taking place in most parts of the country for patients with all
stages of non-small cell lung cancer. Information about ongoing clinical trials is available from the NCI
Web site.

Stages of Non-Small Cell Lung Cancer

Key Points for This Section

After lung cancer has been diagnosed, tests are done to find out if cancer cells have spread
within the lungs or to other parts of the body.
There are three ways that cancer spreads in the body.
Cancer may spread from where it began to other parts of the body.
The following stages are used for non-small cell lung cancer:
Occult (hidden) stage
Stage 0 (carcinoma in situ)
Stage I
Stage II
Stage IIIA
Stage IIIB
Stage IV

After lung cancer has been diagnosed, tests are done to find out if cancer
cells have spread within the lungs or to other parts of the body.

The process used to find out if cancer has spread within the lungs or to other parts of the body is called
staging. The information gathered from the staging process determines the stage of the disease. It is
important to know the stage in order to plan treatment. Some of the tests used to diagnose non-small
cell lung cancer are also used to stage the disease. (See the General Information section.) Other tests
and procedures that may be used in the staging process include the following:

MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a
computer to make a series of detailed pictures of areas inside the body, such as the brain. This
procedure is also called nuclear magnetic resonance imaging (NMRI).

CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the
body, such as the brain and abdomen, taken from different angles. The pictures are made by a
computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the
organs or tissues show up more clearly. This procedure is also called computed tomography,
computerized tomography, or computerized axial tomography.

PET scan (positron emission tomography scan): A procedure to find malignant tumor
cells in the body. A small amount of radioactive glucose (sugar) is injected into a vein. The PET
scanner rotates around the body and makes a picture of where glucose is being used in the body.
Malignant tumor cells show up brighter in the picture because they are more active and take up
more glucose than normal cells do.

PET (positron em ission tom ography ) scan. The patient lies on a table that
slides through the PET m achine. The head rest and white strap help the
patient lie still. A sm all am ount of radioactiv e glucose (sugar) is injected
into the patient's v ein, and a scanner m akes a picture of where the glucose
is being used in the body . Cancer cells show up brighter in the picture
because they take up m ore glucose than norm al cells do.

Radionuclide bone scan : A procedure to check if there are rapidly dividing cells, such as
cancer cells, in the bone. A very small amount of radioactive material is injected into a vein and
travels through the bloodstream. The radioactive material collects in the bones and is detected
by a scanner.
Pulmonary function test (PFT ): A test to see how well the lungs are working. It measures
how much air the lungs can hold and how quickly air moves into and out of the lungs. It also
measures how much oxygen is used and how much carbon dioxide is given off during breathing.
This is also called lung function test.

Endoscopic ultrasound (EUS): A procedure in which an endoscope is inserted into the

body. An endoscope is a thin, tube-like instrument with a light and a lens for viewing. A probe at
the end of the endoscope is used to bounce high-energy sound waves (ultrasound) off internal
tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram.
This procedure is also called endosonography. EUS may be used to guide fine needle aspiration
(FNA) biopsy of the lung, lymph nodes, or other areas.

Endoscopic ultrasound-guided fine-needle aspiration biopsy . An endoscope

that has an ultrasound probe and a biopsy needle is inserted through the
m outh and into the esophagus. The probe bounces sound wav es off body
tissues to m ake echoes that form a sonogram (com puter picture) of the
ly m ph nodes near the esophagus. The sonogram helps the doctor see where
to place the biopsy needle to rem ov e tissue from the ly m ph nodes. This
tissue is checked under a m icroscope for signs of cancer.

Mediastinoscopy : A surgical procedure to look at the organs, tissues, and lymph nodes
between the lungs for abnormal areas. An incision (cut) is made at the top of the breastbone and
a mediastinoscope is inserted into the chest. A mediastinoscope is a thin, tube-like instrument
with a light and a lens for viewing. It may also have a tool to remove tissue or lymph node
samples, which are checked under a microscope for signs of cancer.
 Mediastinoscopy . A m ediastinoscope is inserted into the chest through an
incision abov e the breastbone to look for abnorm al areas between the lungs.
A m ediastinoscope is a thin, tube-like instrum ent with a light and a lens for
v iewing. It m ay also hav e a cutting tool. Tissue sam ples m ay be taken from
ly m ph nodes on the right side of the chest and checked under a m icroscope
for signs of cancer. In an anterior m ediastinotom y (Cham berlain
procedure), the incision is m ade beside the breastbone to rem ov e tissue
sam ples from the ly m ph nodes on the left side of the chest.

Anterior mediastinotomy : A surgical procedure to look at the organs and tissues between
the lungs and between the breastbone and heart for abnormal areas. An incision (cut) is made
next to the breastbone and a mediastinoscope is inserted into the chest. A mediastinoscope is a
thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove
tissue or lymph node samples, which are checked under a microscope for signs of cancer. This is
also called the Chamberlain procedure.

Lymph node biopsy : The removal of all or part of a lymph node. A pathologist views the
tissue under a microscope to look for cancer cells.

Bone marrow aspiration and biopsy : The removal of bone marrow, blood, and a small
piece of bone by inserting a hollow needle into the hipbone or breastbone. A pathologist views
the bone marrow, blood, and bone under a microscope to look for signs of cancer.

There are three ways that cancer spreads in the body.

Cancer can spread through tissue, the lymph system, and the blood:

Tissue. The cancer spreads from where it began by growing into nearby areas.
Lymph system. The cancer spreads from where it began by getting into the lymph system. The
cancer travels through the lymph vessels to other parts of the body.
Blood. The cancer spreads from where it began by getting into the blood. The cancer travels
through the blood vessels to other parts of the body.

Cancer may spread from where it began to other parts of the body.
When cancer spreads to another part of the body, it is called metastasis. Cancer cells break away from
where they began (the primary tumor) and travel through the lymph system or blood.

Lymph system. The cancer gets into the lymph system, travels through the lymph vessels, and
forms a tumor (metastatic tumor) in another part of the body.
Blood. The cancer gets into the blood, travels through the blood vessels, and forms a tumor
(metastatic tumor) in another part of the body.

The metastatic tumor is the same type of cancer as the primary tumor. For example, if non-small cell
lung cancer spreads to the brain, the cancer cells in the brain are actually lung cancer cells. The disease
is metastatic lung cancer, not brain cancer.

The following stages are used for non-small cell lung cancer:

Occult (hidden) stage

In the occult (hidden) stage, cancer cannot be seen by imaging or bronchoscopy. Cancer cells are
found in sputum (mucus coughed up from the lungs) or bronchial washing (a sample of cells taken from
inside the airways that lead to the lung). Cancer may have spread to other parts of the body.

Stage 0 (carcinoma in situ)

In stage 0, abnormal cells are found in the lining of the airways. These abnormal cells may become
cancer and spread into nearby normal tissue. Stage 0 is also called carcinoma in situ.

Stage I
 Stage I non-sm all cell lung cancer. In stage IA, cancer is in the lung only and is 3 cm or sm aller. In stage IB,
the cancer is (a) larger than 3 cm but not larger than 5 cm , (b) has spread to the m ain bronchus, and/or (c)
has spread to the innerm ost lay er of the lung lining. Part of the lung m ay hav e collapsed or becom e
inflam ed (not shown).

In stage I, cancer has formed. Stage I is divided into stages IA and IB:

Stage IA: The tumor is in the lung only and is 3 centimeters or smaller.
Stage IB: Cancer has not spread to the lymph nodes and one or more of the following is true:
The tumor is larger than 3 centimeters but not larger than 5 centimeters.
Cancer has spread to the main bronchus and is at least 2 centimeters below where the
trachea joins the bronchus.
Cancer has spread to the innermost layer of the membrane that covers the lung.
Part of the lung has collapsed or developed pneumonitis (inflammation of the lung) in the
area where the trachea joins the bronchus.

Stage II

Stage II is divided into stages IIA and IIB. Stage IIA and IIB are each divided into two sections
depending on the size of the tumor, where the tumor is found, and whether there is cancer in the lymph
nodes.

Stage IIA:

Stage IIA non-sm all cell lung cancer. Cancer has spread to certain ly m ph nodes on the sam e side of
the chest as the prim ary tum or; the cancer is (a) 5 cm or sm aller, (b) has spread to the m ain
bronchus, and/or (c) has spread to the innerm ost lay er of the lung lining. OR, cancer has not spread
to ly m ph nodes; the cancer is (d) larger than 5 cm but not larger than 7 cm , (e) has spread to the
m ain bronchus, and/or (f) has spread to the innerm ost lay er of the lung lining. Part of the lung m ay
hav e collapsed or becom e inflam ed (not shown).
(1) Cancer has spread to lymph nodes on the same side of the chest as the tumor. The lymph
nodes with cancer are within the lung or near the bronchus. Also, one or more of the following is
true:

The tumor is not larger than 5 centimeters.

Cancer has spread to the main bronchus and is at least 2 centimeters below where the
trachea joins the bronchus.
Cancer has spread to the innermost layer of the membrane that covers the lung.
Part of the lung has collapsed or developed pneumonitis (inflammation of the lung) in the
area where the trachea joins the bronchus.

or

(2) Cancer has not spread to lymph nodes and one or more of the following is true:

The tumor is larger than 5 centimeters but not larger than 7 centimeters.
Cancer has spread to the main bronchus and is at least 2 centimeters below where the
trachea joins the bronchus.
Cancer has spread to the innermost layer of the membrane that covers the lung.
Part of the lung has collapsed or developed pneumonitis (inflammation of the lung) in the
area where the trachea joins the bronchus.
Stage IIB:

Stage IIB non-sm all cell lung cancer. Cancer has spread to certain ly m ph nodes on the sam e side of
the chest as the prim ary tum or; the cancer is (a) larger than 5 cm but not larger than 7 cm , (b) has
spread to the m ain bronchus, and/or (c) has spread to the innerm ost lay er of the lung lining. Part of
the lung m ay hav e collapsed or becom e inflam ed (not shown). OR, (d) the cancer is larger than 7
cm ; (e) has spread to the m ain bronchus, (f) the diaphragm , (g) the chest wall or the lining of the
chest wall; and/or (h) has spread to the m em brane around the heart. There m ay be one or m ore
separate tum ors in the sam e lobe of the lung; cancer m ay hav e spread to the nerv e that controls the
 diaphragm ; the whole lung m ay hav e collapsed or becom e inflam ed (not shown).

(1) Cancer has spread to nearby lymph nodes on the same side of the chest as the tumor. The
lymph nodes with cancer are within the lung or near the bronchus. Also, one or more of the
following is true:

The tumor is larger than 5 centimeters but not larger than 7 centimeters.
Cancer has spread to the main bronchus and is at least 2 centimeters below where the
trachea joins the bronchus.
Cancer has spread to the innermost layer of the membrane that covers the lung.
Part of the lung has collapsed or developed pneumonitis (inflammation of the lung) in the
area where the trachea joins the bronchus.

or

(2) Cancer has not spread to lymph nodes and one or more of the following is true:

The tumor is larger than 7 centimeters.

Cancer has spread to the main bronchus (and is less than 2 centimeters below where the
trachea joins the bronchus), the chest wall, the diaphragm, or the nerve that controls the
diaphragm.
Cancer has spread to the membrane around the heart or lining the chest wall.
The whole lung has collapsed or developed pneumonitis (inflammation of the lung).
There are one or more separate tumors in the same lobe of the lung.

Stage IIIA

Stage IIIA is divided into three sections depending on the size of the tumor, where the tumor is found,
and which lymph nodes have cancer (if any).
 Stage IIIA non-sm all cell lung cancer (1 ). Cancer has spread to certain ly m ph
nodes on the sam e side of the chest as the prim ary tum or. The cancer m ay hav e
spread to (a) the m ain bronchus; (b) lung lining, chest wall lining, or chest wall;
(c) diaphragm ; and/or (d) m em brane around the heart; and/or (e) there m ay be
one or m ore separate tum ors in the sam e lobe of the lung. Cancer m ay hav e
spread to the nerv e that controls the diaphragm , and part or all of the lung m ay
hav e collapsed or becom e inflam ed (not shown).

(1) Cancer has spread to lymph nodes on the same side of the chest as the tumor. The lymph nodes with
cancer are near the sternum (chest bone) or where the bronchus enters the lung. Also:

The tumor may be any size.

Part of the lung (where the trachea joins the bronchus) or the whole lung may have collapsed or
developed pneumonitis (inflammation of the lung).
There may be one or more separate tumors in the same lobe of the lung.
Cancer may have spread to any of the following:
Main bronchus, but not the area where the trachea joins the bronchus.
Chest wall.
Diaphragm and the nerve that controls it.
Membrane around the lung or lining the chest wall.
Membrane around the heart.

or
 Stage IIIA lung cancer (2 ). Cancer has spread to certain ly m ph nodes on the sam e
side of the chest as the prim ary tum or. The cancer m ay hav e spread to (a) the
m ain bronchus; (b) the lung lining, chest wall lining, or chest wall; (c)
diaphragm ; (d) heart and/or m em brane around the it; (e) m ajor blood v essels
that lead to or from the heart; (f) trachea; (g) esophagus; (h) sternum ; and/or (i)
carina; and/or (j) there m ay be one or m ore separate tum ors in any lobe of the
sam e lung. Cancer m ay hav e spread to the nerv es that control the diaphragm
and lary nx, and the whole lung m ay hav e collapsed or becom e inflam ed (not
shown).

(2) Cancer has spread to lymph nodes on the same side of the chest as the tumor. The lymph nodes with
cancer are within the lung or near the bronchus. Also:

The tumor may be any size.

The whole lung may have collapsed or developed pneumonitis (inflammation of the lung).
There may be one or more separate tumors in any of the lobes of the lung with cancer.
Cancer may have spread to any of the following:
Main bronchus, but not the area where the trachea joins the bronchus.
Chest wall.
Diaphragm and the nerve that controls it.
Membrane around the lung or lining the chest wall.
Heart or the membrane around it.
 Major blood vessels that lead to or from the heart.
Trachea.
Esophagus.
Nerve that controls the larynx (voice box).
Sternum (chest bone) or backbone.
Carina (where the trachea joins the bronchi).

or

Stage IIIA non-sm all cell lung cancer (3 ). Cancer has spread to (a) the heart; (b)
m ajor blood v essels that lead to or from the heart; (c) trachea; (d) esophagus; (e)
sternum ; and/or (f) carina. Cancer m ay hav e spread to the nerv e that controls
the lary nx (not shown).

(3) Cancer has not spread to the lymph nodes and the tumor may be any size. Cancer has spread to any
of the following:

Heart.
Major blood vessels that lead to or from the heart.
Trachea.
Esophagus.
 Nerve that controls the larynx (voice box).
Sternum (chest bone) or backbone.
Carina (where the trachea joins the bronchi).

Stage IIIB

Stage IIIB is divided into two sections depending on the size of the tumor, where the tumor is found,
and which lymph nodes have cancer.

Stage IIIB non-sm all cell lung cancer (1 ). Cancer has spread to ly m ph nodes
abov e the collarbone or on the opposite side of the chest as the prim ary tum or.
The cancer m ay hav e spread to (a) the m ain bronchus; (b) lung lining, chest
wall lining, or chest wall; (c) diaphragm ; (d) heart or the m em brane around it;
(e) m ajor blood v essels that lead to or from the heart; (f) trachea; (g) esophagus;
(h) sternum ; and/or (i) carina; and/or (j) there m ay be one or m ore separate
tum ors in any of the lobes of the lung. Part or all of the lung m ay hav e collapsed
or becom e inflam ed and cancer m ay hav e spread to the backbone and/or the
nerv es that control the diaphragm and lary nx (not shown).

(1) Cancer has spread to lymph nodes above the collarbone or to lymph nodes on the opposite side of
the chest as the tumor. Also:

The tumor may be any size.

 Part of the lung (where the trachea joins the bronchus) or the whole lung may have collapsed or
developed pneumonitis (inflammation of the lung).
There may be one or more separate tumors in any of the lobes of the lung with cancer.
Cancer may have spread to any of the following:
Main bronchus.
Chest wall.
Diaphragm and the nerve that controls it.
Membrane around the lung or lining the chest wall.
Heart or the membrane around it.
Major blood vessels that lead to or from the heart.
Trachea.
Esophagus.
Nerve that controls the larynx (voice box).
Sternum (chest bone) or backbone.
Carina (where the trachea joins the bronchi).

or

Stage IIIB non-sm all cell lung cancer (2 ). Cancer has spread to certain ly m ph
nodes on the sam e side of the chest as the prim ary tum or and to (a) the heart; (b)
m ajor blood v essels that lead to or from the heart; (c) trachea; (d) esophagus; (e)
 sternum ; and/or (f) carina; and/or (g) there m ay be separate tum ors in different
lobes of the sam e lung. Cancer m ay hav e spread to the backbone and/or the
nerv e that controls the lary nx (not shown).

(2) Cancer has spread to lymph nodes on the same side of the chest as the tumor. The lymph nodes with
cancer are near the sternum (chest bone) or where the bronchus enters the lung. Also:

The tumor may be any size.

There may be separate tumors in different lobes of the same lung.
Cancer has spread to any of the following:
Heart.
Major blood vessels that lead to or from the heart.
Trachea.
Esophagus.
Nerve that controls the larynx (voice box).
Sternum (chest bone) or backbone.
Carina (where the trachea joins the bronchi).

Stage IV

Stage IV non-sm all cell lung cancer. The cancer has spread to the other lung,
and/or to ly m ph nodes, fluid around the lungs or heart, and/or other places in
the body , such as the brain, liv er, adrenal glands, kidney s, or bones.

In stage IV, the tumor may be any size and cancer may have spread to lymph nodes. One or more of the
following is true:

There are one or more tumors in both lungs.

Cancer is found in fluid around the lungs or the heart.
Cancer has spread to other parts of the body, such as the brain, liver, adrenal glands, kidneys, or
bone.

Recurrent Non-Small Cell Lung Cancer

Recurrent non-small cell lung cancer is cancer that has recurred (come back) after it has been treated.
The cancer may come back in the brain, lung, or other parts of the body.

Treatment Option Overview

Key Points for This Section

There are different types of treatment for patients with non-small cell lung cancer.
Nine types of standard treatment are used:
Surgery
Radiation therapy
Chemotherapy
Targeted therapy
Laser therapy
Photodynamic therapy (PDT)
Cryosurgery
Electrocautery
Watchful waiting
New types of treatment are being tested in clinical trials.
Chemoprevention
New combinations
Patients may want to think about taking part in a clinical trial.
Patients can enter clinical trials before, during, or after starting their cancer treatment.
Follow-up tests may be needed.

There are different types of treatment for patients with non-small cell lung
cancer.

Different types of treatments are available for patients with non-small cell lung cancer. Some
treatments are standard (the currently used treatment), and some are being tested in clinical trials. A
treatment clinical trial is a research study meant to help improve current treatments or obtain
information on new treatments for patients with cancer. When clinical trials show that a new treatment
is better than the standard treatment, the new treatment may become the standard treatment. Patients
may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who
have not started treatment.

Nine types of standard treatment are used:

Surgery

Four types of surgery are used to treat lung cancer:

Wedge resection: Surgery to remove a tumor and some of the normal tissue around it. When a
slightly larger amount of tissue is taken, it is called a segmental resection.

Wedge resection of the lung. Part of the lung lobe containing the cancer and
a sm all am ount of healthy tissue around it is rem ov ed.

Lobectomy: Surgery to remove a whole lobe (section) of the lung.

 Lobectom y . A lobe of the lung is rem ov ed.

Pneumonectomy: Surgery to remove one whole lung.

Pneum onectom y . The whole lung is rem ov ed.

Sleeve resection: Surgery to remove part of the bronchus.

Even if the doctor removes all the cancer that can be seen at the time of the surgery, some patients may
be given chemotherapy or radiation therapy after surgery to kill any cancer cells that are left.
Treatment given after the surgery, to lower the risk that the cancer will come back, is called adjuvant
therapy.

Radiation therapy
Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill
cancer cells or keep them from growing. There are two types of radiation therapy. External radiation
therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation
therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed
directly into or near the cancer.

Radiosurgery is a method of delivering radiation directly to the tumor with little damage to healthy
tissue. It does not involve surgery and may be used to treat certain tumors in patients who cannot have
surgery.

The way the radiation therapy is given depends on the type and stage of the cancer being treated. It
also depends on where the cancer is found. For tumors in the airways, radiation is given directly to the
tumor through an endoscope.

Chemotherapy

Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing
the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a
vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body
(systemic chemotherapy). When chemotherapy is placed directly into the cerebrospinal fluid, an
organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas
(regional chemotherapy). The way the chemotherapy is given depends on the type and stage of the
cancer being treated.

See Drugs Approved for Non-Small Cell Lung Cancer for more information.

Targeted therapy

Targeted therapy is a type of treatment that uses drugs or other substances to identify and attack
specific cancer cells without harming normal cells. Monoclonal antibodies and tyrosine kinase
inhibitors are two types of targeted therapy being used in the treatment of non-small cell lung cancer.

Monoclonal antibody therapy is a cancer treatment that uses antibodies made in the laboratory from a
single type of immune system cell. These antibodies can identify substances on cancer cells or normal
substances that may help cancer cells grow. The antibodies attach to the substances and kill the cancer
cells, block their growth, or keep them from spreading. Monoclonal antibodies are given by infusion.
They may be used alone or to carry drugs, toxins, or radioactive material directly to cancer cells.

Monoclonal antibodies used to treat non-small cell lung cancer include bevacizumab and cetuximab.
Bevacizumab binds to vascular endothelial growth factor (VEGF) and may prevent the growth of new
blood vessels that tumors need to grow. Cetuximab binds to epidermal growth factor receptor (EGFR)
and works to stop cancer cells from growing and dividing.

Tyrosine kinase inhibitors are targeted therapy drugs that block signals needed for tumors to grow.
Tyrosine kinase inhibitors may be used with other anticancer drugs as adjuvant therapy.

Tyrosine kinase inhibitors used to treat non-small cell lung cancer include erlotinib and gefitinib. They
are types of epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors. Crizotinib is a type of
tyrosine kinase inhibitor that is used to treat non-small cell lung cancer with certain gene changes.
See Drugs Approved for Non-Small Cell Lung Cancer for more information.

Laser therapy

Laser therapy is a cancer treatment that uses a laser beam (a narrow beam of intense light) to kill
cancer cells.

Photodynamic therapy (PDT)

Photodynamic therapy (PDT) is a cancer treatment that uses a drug and a certain type of laser light to
kill cancer cells. A drug that is not active until it is exposed to light is injected into a vein. The drug
collects more in cancer cells than in normal cells. Fiberoptic tubes are then used to carry the laser light
to the cancer cells, where the drug becomes active and kills the cells. Photodynamic therapy causes
little damage to healthy tissue. It is used mainly to treat tumors on or just under the skin or in the lining
of internal organs. When the tumor is in the airways, PDT is given directly to the tumor through an
endoscope.

Cryosurgery

Cryosurgery is a treatment that uses an instrument to freeze and destroy abnormal tissue, such as
carcinoma in situ. This type of treatment is also called cryotherapy. For tumors in the airways,
cryosurgery is done through an endoscope.

Electrocautery

Electrocautery is a treatment that uses a probe or needle heated by an electric current to destroy
abnormal tissue. For tumors in the airways, electrocautery is done through an endoscope.

Watchful waiting

Watchful waiting is closely monitoring a patients condition without giving any treatment until
symptoms appear or change. This may be done in certain rare cases of non-small cell lung cancer.

New types of treatment are being tested in clinical trials.

This summary section describes treatments that are being studied in clinical trials. It may not mention
every new treatment being studied. Information about clinical trials is available from the NCI Web
site.

Chemoprevention

Chemoprevention is the use of drugs, vitamins, or other substances to reduce the risk of cancer or to
reduce the risk cancer will recur (come back).

New combinations

New combinations of treatments are being studied in clinical trials.

Patients may want to think about taking part in a clinical trial.

For some patients, taking part in a clinical trial may be the best treatment choice. Clinical trials are part
of the cancer research process. Clinical trials are done to find out if new cancer treatments are safe and
effective or better than the standard treatment.

Many of today's standard treatments for cancer are based on earlier clinical trials. Patients who take
part in a clinical trial may receive the standard treatment or be among the first to receive a new
treatment.

Patients who take part in clinical trials also help improve the way cancer will be treated in the future.
Even when clinical trials do not lead to effective new treatments, they often answer important
questions and help move research forward.

Patients can enter clinical trials before, during, or after starting their cancer
treatment.

Some clinical trials only include patients who have not yet received treatment. Other trials test
treatments for patients whose cancer has not gotten better. There are also clinical trials that test new
ways to stop cancer from recurring (coming back) or reduce the side effects of cancer treatment.

Clinical trials are taking place in many parts of the country. See the Treatment Options section that
follows for links to current treatment clinical trials. These have been retrieved from NCI's listing of
clinical trials.

Follow-up tests may be needed.

Some of the tests that were done to diagnose the cancer or to find out the stage of the cancer may be
repeated. Some tests will be repeated in order to see how well the treatment is working. Decisions
about whether to continue, change, or stop treatment may be based on the results of these tests. This is
sometimes called re-staging.

Some of the tests will continue to be done from time to time after treatment has ended. The results of
these tests can show if your condition has changed or if the cancer has recurred (come back). These
tests are sometimes called follow-up tests or check-ups.

Treatment Options by Stage

Occult Non-Small Cell Lung Cancer

Treatment of occult non-small cell lung cancer depends on the stage of the disease. Occult tumors are
often found at an early stage (the tumor is in the lung only) and sometimes can be cured by surgery.

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with
occult non-small cell lung cancer. For more specific results, refine the search by using other search
features, such as the location of the trial, the type of treatment, or the name of the drug. Talk with your
doctor about clinical trials that may be right for you. General information about clinical trials is
available from the NCI Web site.

Stage 0 (Carcinoma in Situ)

Treatment of stage 0 may include the following:

Surgery (wedge resection or segmental resection).

Photodynamic therapy using an endoscope.
Electrocautery, cryosurgery, or laser surgery using an endoscope.

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with
stage 0 non-small cell lung cancer. For more specific results, refine the search by using other search
features, such as the location of the trial, the type of treatment, or the name of the drug. Talk with your
doctor about clinical trials that may be right for you. General information about clinical trials is
available from the NCI Web site.

Stage I Non-Small Cell Lung Cancer

Treatment of stage I non-small cell lung cancer may include the following:

Surgery (wedge resection, segmental resection, sleeve resection, or lobectomy).

External radiation therapy (for patients who cannot have surgery or choose not to have
surgery).
A clinical trial of chemotherapy or radiation therapy following surgery.
A clinical trial of surgery followed by chemoprevention.
A clinical trial of treatment given through an endoscope, such as photodynamic therapy (PDT).

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with
stage I non-small cell lung cancer. For more specific results, refine the search by using other search
features, such as the location of the trial, the type of treatment, or the name of the drug. Talk with your
doctor about clinical trials that may be right for you. General information about clinical trials is
available from the NCI Web site.

Stage II Non-Small Cell Lung Cancer

Treatment of stage II non-small cell lung cancer may include the following:

Surgery (wedge resection, segmental resection, sleeve resection, lobectomy, or

pneumonectomy).
Chemotherapy followed by surgery.
Surgery followed by chemotherapy.
External radiation therapy (for patients who cannot have surgery or choose not to have
surgery).
A clinical trial of radiation therapy following surgery.

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with
stage II non-small cell lung cancer. For more specific results, refine the search by using other search
features, such as the location of the trial, the type of treatment, or the name of the drug. Talk with your
doctor about clinical trials that may be right for you. General information about clinical trials is
available from the NCI Web site.

Stage IIIA Non-Small Cell Lung Cancer

Treatment of stage IIIA non-small cell lung cancer that can be removed with surgery may include the
following:

Surgery followed by chemotherapy.

Chemotherapy followed by surgery.
Surgery followed by chemotherapy combined with radiation therapy.
Surgery followed by radiation therapy.
A clinical trial of new combinations of treatments.

Treatment of stage IIIA non-small cell lung cancer that cannot be removed with surgery may include
the following:

Chemotherapy and radiation therapy given as separate treatments over the same period of time.
External radiation therapy alone (for patients who cannot be treated with combined therapy, as
palliative treatment to relieve symptoms and improve the quality of life).
Internal radiation therapy or laser surgery, as palliative treatment to relieve symptoms and
improve the quality of life.
A clinical trial of new combinations of treatments.

For more information about supportive care for symptoms including cough, shortness of breath, and
chest pain, see the PDQ summary on Cardiopulmonary Syndromes.

Non-small cell lung cancer of the superior sulcus, often called Pancoast tumor, begins in the upper part
of the lung and spreads to nearby tissues such as the ribs and vertebrae. Treatment of Pancoast tumors
may include the following:

Radiation therapy alone.

Radiation therapy followed by surgery.
Chemotherapy and radiation therapy given as separate treatments over the same period of time,
followed by surgery.
Surgery alone.
A clinical trial of new combinations of treatments.

Some stage IIIA non-small cell lung tumors that have grown into the chest wall may be completely
removed. Treatment of chest wall tumors may include the following:

Surgery.
Surgery and radiation therapy.
Radiation therapy alone.
Chemotherapy combined with radiation therapy and/or surgery.
A clinical trial of new combinations of treatments.

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with
stage III non-small cell lung cancer. For more specific results, refine the search by using other search
features, such as the location of the trial, the type of treatment, or the name of the drug. Talk with your
doctor about clinical trials that may be right for you. General information about clinical trials is
available from the NCI Web site.

Stage IIIB Non-Small Cell Lung Cancer

Treatment of stage IIIB non-small cell lung cancer may include the following:
 Chemotherapy followed by external radiation therapy.
Chemotherapy and radiation therapy given as separate treatments over the same period of time.
Chemotherapy followed by surgery.
External radiation therapy alone for patients who cannot be treated with chemotherapy.
External or internal radiation therapy as palliative therapy, to relieve pain and other symptoms
and improve the quality of life.
Clinical trials of new radiation therapy schedules and new combinations of treatments.

For more information about supportive care for symptoms such as cough, shortness of breath, and
chest pain, see the following PDQ summaries:

Cardiopulmonary Syndromes
Pain

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with
stage III non-small cell lung cancer. For more specific results, refine the search by using other search
features, such as the location of the trial, the type of treatment, or the name of the drug. Talk with your
doctor about clinical trials that may be right for you. General information about clinical trials is
available from the NCI Web site.

Stage IV Non-Small Cell Lung Cancer

Treatment of stage IV non-small cell lung cancer may include the following:

Combination chemotherapy.
Maintenance therapy with an anticancer drug to help keep cancer from progressing, after
combination chemotherapy.
Combination chemotherapy and targeted therapy with a monoclonal antibody.
Targeted therapy with a tyrosine kinase inhibitor.
External radiation therapy as palliative therapy, to relieve pain and other symptoms and
improve the quality of life.
Laser therapy and/or internal radiation therapy.
A clinical trial of new drugs and combinations of treatments.

For more information about supportive care for symptoms including cough, shortness of breath, and
chest pain, see the following PDQ summaries:

Cardiopulmonary Syndromes
Pain

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with
stage IV non-small cell lung cancer. For more specific results, refine the search by using other search
features, such as the location of the trial, the type of treatment, or the name of the drug. Talk with your
doctor about clinical trials that may be right for you. General information about clinical trials is
available from the NCI Web site.

Treatment Options for Recurrent Non-Small Cell Lung Cancer

Treatment of recurrent non-small cell lung cancer may include the following:
 External radiation therapy as palliative therapy, to relieve pain and other symptoms and
improve the quality of life.
Chemotherapy.
Targeted therapy with a tyrosine kinase inhibitor.
Laser therapy or internal radiation therapy using an endoscope.
Radiosurgery (for certain patients who cannot have surgery).
Surgery to remove a very small amount of cancer that has spread to the brain.

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with
recurrent non-small cell lung cancer. For more specific results, refine the search by using other search
features, such as the location of the trial, the type of treatment, or the name of the drug. Talk with your
doctor about clinical trials that may be right for you. General information about clinical trials is
available from the NCI Web site.

To Learn More About Non-Small Cell Lung Cancer

For more information from the National Cancer Institute about non-small cell lung cancer, see the
following:

Lung Cancer Home Page

What You Need To Know About Lung Cancer
Lung Cancer Prevention
Lung Cancer Screening
Drugs Approved for Non-Small Cell Lung Cancer
Understanding Cancer Series: Targeted Therapies (Advances in Targeted Therapies)
Targeted Cancer Therapies
Lasers in Cancer Treatment
Photodynamic Therapy for Cancer
Smoking Home Page (Includes help with quitting)
Secondhand Smoke and Cancer

For general cancer information and other resources from the National Cancer Institute, see the
following:

Understanding Cancer Series: Cancer

Cancer Staging
Chemotherapy and You: Support for People With Cancer
Radiation Therapy and You: Support for People With Cancer
Coping with Cancer: Supportive and Palliative Care
Questions to Ask Your Doctor About Cancer
Cancer Library
Information For Survivors/Caregivers/Advocates

Changes to This Summary (10/18/2013)

The PDQ cancer information summaries are reviewed regularly and updated as new information
becomes available. This section describes the latest changes made to this summary as of the date
above.

Editorial changes were made to this summary.

About This PDQ Summary

About PDQ

Physician Data Query (PDQ) is the National Cancer Institute's (NCI's) comprehensive cancer
information database. The PDQ database contains summaries of the latest published information on
cancer prevention, detection, genetics, treatment, supportive care, and complementary and
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Purpose of This Summary

This PDQ cancer information summary has current information about the treatment of non-small cell
lung cancer. It is meant to inform and help patients, families, and caregivers. It does not give formal
guidelines or recommendations for making decisions about health care.

Reviewers and Updates

Editorial Boards write the PDQ cancer information summaries and keep them up to date. These Boards
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The information in this patient summary was taken from the health professional version, which is
reviewed regularly and updated as needed, by the PDQ Adult Treatment Editorial Board.

Clinical Trial Information

A clinical trial is a study to answer a scientific question, such as whether one treatment is better than
another. Trials are based on past studies and what has been learned in the laboratory. Each trial
answers certain scientific questions in order to find new and better ways to help cancer patients.
During treatment clinical trials, information is collected about the effects of a new treatment and how
well it works. If a clinical trial shows that a new treatment is better than one currently being used, the
new treatment may become "standard." Patients may want to think about taking part in a clinical trial.
Some clinical trials are open only to patients who have not started treatment.

Clinical trials are listed in PDQ and can be found online at NCI's Web site. Many cancer doctors who
take part in clinical trials are also listed in PDQ. For more information, call the Cancer Information
Service 1-800-4-CANCER (1-800-422-6237).

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The best way to cite this PDQ summary is:

National Cancer Institute: PDQ Non-Small Cell Lung Cancer Treatment. Bethesda, MD: National
Cancer Institute. Date last modified <MM/DD/YYYY>. Available at:
http://cancer.gov/cancertopics/pdq/treatment/non-small-cell-lung/Patient. Accessed
<MM/DD/YYYY>.

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