3.3: An overview of lung cancer treatment options

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Once your care team has determined the stage of lung cancer, they can create a personalized treatment plan based on all the information they’ve gathered. Although every case of lung cancer is unique, there are expert recommendations, like the NCCN (National Comprehensive Cancer Network) Guidelines®, that your care team will follow based on your lung cancer stage. Below is an overview of what your treatment path may look like according to stage, based on the NCCN Guidelines®. Below is an overview of what you can expect with each stage.

Main treatments for early or locally advanced non-small cell lung cancer (NSCLC)

With early or locally advanced NSCLC (stages I-III), the NCCN Guidelines® state the primary treatment options are: surgery, radiation therapy, and chemoradiation. There are several factors, like the TNM (tumor, node, and metastasis) system, that help determine what will work best for you.

Surgery for lung cancer

For many people with early or locally advanced NSCLC (stages I-III), surgery is a key part of treating lung cancer. The goal of surgery is to remove the tumor and any nearby tissue that may contain cancer cells. Whether surgery is an option depends on several factors, including your overall health, where the tumor is located, and the stage of your cancer.

Your TNM score—which describes the size of the tumor (T), whether cancer has spread to nearby lymph nodes (N), and whether it has spread to other parts of the body (M)—helps doctors determine if surgery is a safe and effective choice.

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Many patients also receive additional treatment before or after surgery, known as perioperative therapy. This can include chemotherapy, immunotherapy, targeted therapy, radiation therapy, or chemoradiation.

What is neoadjuvant therapy?

When treatment is given before surgery, it’s called neoadjuvant or preoperative therapy. For many patients with stage II or IIIA disease — especially when the tumor is at least 4 cm or there’s suspicion of lymph node involvement — doctors may recommend this approach. The goal is to shrink the tumor (or reduce its extent) so that surgery is safer and more effective.

Based on NCCN Guidelines®:

• Neoadjuvant chemotherapy (often platinum-based “doublet” therapy) is recognized as a valid option for patients with resectable non-small cell lung cancer who are likely to receive adjuvant therapy.
• More recently, immunotherapy plus chemotherapy before surgery has been added to the NCCN recommendations for select patients with resectable disease, expanding the options beyond chemotherapy alone.
• For stage II and stage III invasive tumors, chemoradiation or systemic therapy may be recommended.

The specific choice (chemo alone vs. chemo + immunotherapy) depends on the TNM stage, tumor size, lymph node status, biomarker results, and your overall health.

What is adjuvant therapy?

Even after the visible tumor is removed, there is a risk that cancer cells may remain in the body, either around the lung, in lymph nodes, or elsewhere. The goal of postoperative (adjuvant) therapy is to help eliminate those lingering cells, reduce the chance of recurrence, and improve long-term survival.

According to NCCN Guidelines® for NSCLC:

• Adjuvant chemotherapy (often a platinum-based combination) is recommended for many patients with pathologic stage II or III disease after surgery.
  
• In selected patients with earlier stages (e.g. high-risk stage IB), adjuvant therapy may also be considered, after careful evaluation of risks and benefits.
  
• For patients whose tumors have certain genetic mutations, targeted therapy may be given after surgery (often following chemotherapy), because it has been shown in trials to improve disease-free survival.
  
• For those with certain biomarkers (e.g. PD-L1 expression) or in specific stages (II to IIIA), adjuvant immunotherapy or immunotherapy + chemotherapy may also be options. 

What if I’m not a good fit for lung cancer surgery?

Not every patient is a good candidate for surgery. The location of the tumors or nodules may not be accessible, or there may be a health risk associated with surgery for some individuals. If surgery isn’t an option for you, radiation therapy or chemoradiation are still viable treatment options depending on your specific diagnosis.

Main treatment options for metastatic NSCLC

According to the NCCN Guidelines®, the main treatment for metastatic non-small cell lung cancer (NSCLC) is systemic therapy, and your care will be personalized based on three things: biomarker results (driver mutations), PD-L1 expression (an immune marker), and the cell type of the tumor. 

Cell type matters because it can affect which chemotherapy drugs are preferred and how likely certain mutations are to appear. If a driver mutation is found, doctors can choose a drug that directly targets the genetic change that is driving the growth and spread of cancer. PD-L1 is a protein that some cancer cells use to hide from your immune system. Doctors test your tumor for PD-L1 to see how likely it is that immunotherapy—specifically immune checkpoint inhibitors—will work. These drugs block PD-L1, helping your immune system recognize and attack the cancer. 

Because cancer can develop treatment resistance over time, your medical team will keep monitoring and may change therapies based on new test results or biopsies to stay one step ahead.

Consider a lung cancer clinical trial

Clinical trials are research studies that test new treatments or new ways of using existing treatments to advance care. They’re available for people at every stage of lung cancer, not just metastatic disease. Joining a clinical trial can give you access to promising therapies before they become widely available.

Thoracic oncologist Dr. Catherine Meador recommends that every patient ask about clinical trials.  “I think there is a little bit of a stigma that’s out there that a clinical trial is a last-ditch effort or something. That’s not true. Clinical trials, while they’re not approved, known therapies, we open them at our institutions because we think they’re compelling,” she says.

Don’t hesitate to bring up your clinical trial options whenever you’re discussing or updating your treatment plan; it could open the door to new possibilities.

Additional supportive resources

Your care plan goes beyond just treating the cancer—it’s also about supporting your overall well-being. There are many resources and strategies that can help manage side effects, maintain energy, and support your mental and emotional health.