Lung cancer

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Treatments for stage 4 non-small cell lung cancer

The following are treatment options for stage 4 non-small cell lung cancer. Your healthcare team will suggest treatments based on your needs and work with you to develop a treatment plan.

Chemotherapy

Chemotherapy may be offered for stage 4 non–small cell lung cancer if there are no genetic changes (mutations) that can be identified in the lung cancer tumours using cell and tissue studies. You need to be well enough to have chemotherapy.

The most common chemotherapy drug combination used to treat stage 4 non-small cell lung cancer is cisplatin or carboplatin with gemcitabine. Other chemotherapy combinations that may be used include:

  • cisplatin or carboplatin and docetaxel (Taxotere)
  • carboplatin and paclitaxel
  • gemcitabine and docetaxel
  • gemcitabine and vinorelbine
  • cisplatinand pemetrexed (Alimta) – only used for non-squamous types of non–small cell lung cancer

Pemetrexed may also be offered by itself as maintenance therapy to slow the return of lung cancer if the cancer has responded to chemotherapy. Yu will not be offered pemetrexed if you have already had it as part of your chemotherapy treatment.

Single drugs may be offered to treat stage 4 non–small cell lung cancer if you are in poor health. The drugs used include:

  • gemcitabine
  • paclitaxel
  • docetaxel

Targeted therapy

Targeted therapy may be offered instead of chemotherapy for stage 4 non–small cell lung cancer if there are genetic changes to the lung cancer cells. The type of targeted therapy given will depend on the type of genetic mutation that was identified using cell and tissue studies.

If testing does not show genetic mutations that can be treated with targeted therapy, you will not be offered it as treatment for stage 4 non-small cell lung cancer tumours.

Sometimes genetic changes are found in the cells during chemotherapy. If so, you may have targeted therapy when chemotherapy is finished, or your healthcare team may switch you to the targeted therapy drug alone.

EGFR targeted therapy

Epidermal growth factor receptor (EGFR) is a receptor on the surface of cells that sends signals to cells that allow them to grow and divide. A mutation in the EGFR gene can cause cancer cells to grow and divide more than normal. Cancer cells that have the EGFR mutation are called EGFR positive (EGFR+).

EGFR-positive stage 4 non-small cell lung cancer may be treated with erlotinib (Tarceva), gefitinib (Iressa) or osimertinib (Tagrisso) instead of chemotherapy.

Erlotinib may also be given as maintenance therapy for stage 4 non-small cell lung cancer after 4 cycles of chemotherapy with cisplatin or carboplatin.

ALK targeted therapy

Anaplastic lymphoma kinase (ALK) is a protein that helps with cell growth and division. It is controlled by the ALK gene. A very small number of non–small cell lung cancers have a mutation in the ALK gene. Cancer cells that have the ALK rearrangement are called ALK positive (ALK+).

ALK-positive stage 4 non-small cell lung cancer may be treated with crizotinib (Xalkori). If you can’t take crizotinib, other drugs that may be given are ceritinib (Zykadia), alectinib (Alecensaro) or brigatinib (Alunbrig).

ROS1 targeted therapy

The ROS1 gene makes a protein that is responsible for signals in cells and helps with cell growth. A mutation in the ROS1 gene can cause cancer cells to grow and divide more than normal. Cancer cells that have the ROS1 mutation are called ROS1 positive (ROS1+).

ROS1-positive stage 4 non-small cell lung cancer may be treated with crizotinib.

Entrectinib (Rozlytrek) may be offered for ROS1-positive stage 4 non–small cell lung cancer, if you have not been given crizotinib as a treatment.

BRAF V600E positivetherapy

BRAF is a protein that sends signals in cells and helps with cell growth. Changes in the BRAF gene, which is called BRAF V600E, can be found in higher amounts in some types of lung cancer. Cancer cells that have changes to this gene are called BRAF V600E positive (BRAF V600E+).

Stage 4 non–small cell lung cancer that is BRAF V600E positive may be treated with a combination of dabrafenib (Tafinlar) and trametinib (Mekinist).

Neurotrophic tyrosine receptor kinase (NTRK) therapy

Mutations in the NTRK gene can cause too much cell growth and lead to abnormal cells and cancer. Sometimes this mutation is found in non–small lung cancer. Cancer cells that have changes to this gene are called TRK fusion positive.

Stage 4 non-small cell lung cancer that is TRK fusion positive may be treated with larotrectinib (Vitrakvi).

Angiogenesis inhibitors

Bevacizumab (Avastin, MVASI, Zirabev) is a type of targeted therapy called anangiogenesis inhibitor. It targets a protein called vascular endothelial growth factor (VEGF), which helps new blood vessels grow. Bevacizumab is combined with the chemotherapy drugs carboplatin and paclitaxel. This combination may be offered for stage 4 non-small cell lung cancer.

Immunotherapy

Immunotherapy may be offered for stage 4 non-small cell lung cancer.

Necitumumab (Portrazza) in combination with the chemotherapy drugs cisplatin and gemcitabine (Gemzar) may be used to treat stage 4 squamous cell non–small cell lung cancer.

Pembrolizumab (Keytruda) may be used to treat stage 4 non-small cell lung cancer that expresses PD-L1.

Atezolizumab (Techcentriq) may be used in combination with bevacizumab, paclitaxel and carboplatin as the first treatment for stage 4 non–small cell lung cancer that does not have EGFR or ALK gene mutations.

Nivolumab (Opdivo) and ipilimumab (Yervoy) may be used in combination with cisplatin or carboplatin plus another chemotherapy drug. This treatment may be offered for stage 4 non–small cell lung cancer that does not have EGFR or ALK gene mutations and has very little PD-L1 in the cancer cells.

Endobronchial therapies

Endobronchial therapies remove a blockage caused by the cancer inside the lung. They are used to treat and prevent symptoms caused by stage 4 non–small cell lung cancer, such as coughing, problems breathing, bleeding and pain.

The type of endobronchial therapy used will depend on how quickly the symptoms must be treated.

Radiation therapy

External beam radiation therapy may be used for stage 4 non–small cell lung cancer if you can’t have chemotherapy. It is also used to relieve symptoms caused by the cancer (palliative radiation therapy).

Radiation therapy may also be used to treat non–small cell lung cancer that has spread to the bones or the brain.

Find out more bone metastases and brain metastases.

Surgery

Surgery may be used to treat stage 4 non–small cell lung cancer that has spread to the adrenal gland, brain or liver. For brain metastases, it is used when there is only one area of cancer found in the brain. For liver metastases, it may be offered if there is one area of cancer or a few areas of cancer found close together. Some people with stage 4 non–small cell lung cancer are not well enough to have surgery.

If you can’t have or don’t want cancer treatment

You may want to consider a type of care to make you feel better without treating the cancer itself. This may be because the cancer treatments don’t work anymore, they’re not likely to improve your condition or they may cause side effects that are hard to cope with. There may also be other reasons why you can’t have or don’t want cancer treatment.

Talk to your healthcare team. They can help you choose care and treatment for advanced cancer.

Clinical trials

Talk to your doctor about clinical trials open to people with non-small cell lung cancer in Canada. Clinical trials look at new ways to prevent, find and treat cancer. Find out more about clinical trials.

maintenance therapy

Treatment given after the first-line therapy (the first or standard treatment) to keep a disease (such as cancer) under control or to prevent it from coming back (recurring). It may be given for a long period of time.

Maintenance therapy may include drugs, vaccines, antibodies or hormones.

angiogenesis

The growth of new blood vessels.

squamous cell

A type of epithelial cell that is thin and flat and looks like a fish scale.

Squamous cells are found in the epithelium that makes up the surface of the skin. They are in the epithelium lining of organs such as the mouth, pharynx, esophagus, anus, cervix and vagina. Squamous cells also make up the lining of blood vessels and hollow areas of the body (called cavities).

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