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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 create a treatment plan.
Before starting treatment for stage 4 non–small cell lung cancer, immunohistochemical or molecular tissue testing is done to look for certain gene changes (mutations) in the cancer cells. These include epidermal growth factor receptor (EGFR), anaplastic lymphoma kinase (ALK), ROS1, MET amplification and BRAF mutations. These changes affect the type of treatment given because some drugs may be more effective against cancer cells with gene changes.
The type of non–small cell lung cancer will also affect which chemotherapy drugs will be offered. Some drugs cannot be used with squamous cell types of non–small cell lung cancer.
Chemotherapy is a standard treatment for stage 4 non–small cell lung cancer. It may be offered as the first treatment for people who are well enough to have chemotherapy.
The chemotherapy drug combinations that may be offered are:
- cisplatin and gemcitabine (Gemzar) – most commonly used
- cisplatin and vinorelbine (Navelbine)
- cisplatin and docetaxel (Taxotere)
- carboplatin (Paraplatin, Paraplatin AQ) and paclitaxel (Taxol)
- cisplatin and pemetrexed (Alimta) – only used for adenocarcinoma (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. Pemetrexed is not used if it was part of the first chemotherapy treatment.
Single drugs may be offered to people with stage 4 non–small cell lung cancer who are in poor health. The drugs used include vinorelbine, gemcitabine, paclitaxel or docetaxel.
Targeted therapy may be offered for stage 4 non–small cell lung cancer. The type of targeted therapy will depend on the type of gene change found during molecular tissue testing.
EGFR tyrosine kinase inhibitors (EGFR TKIs) may be offered as the first treatment for EGFR-positive (EGFR+) non–small cell lung cancer. EGFR+ means that the cancer cells have the EGFR mutation. EGFR TKIs are not given when the EGFR status is negative or not known because treatment may not be effective.
The types of EGFR TKIs that may be offered are:
- gefitinib (Iressa)
- erlotinib (Tarceva)
- afatinib (Giotrif)
ALK targeted therapy may be offered as treatment instead of chemotherapy for non–small cell lung cancer that has the ALK gene rearrangement. This is because it is more effective at shrinking tumours than chemotherapy. The ALK targeted therapy drug that is used is crizotinib (Xalkori) or ceritinib (Zykadia).
Crizotinib may also be given instead of chemotherapy for non–small cell lung cancer that has the ROS1 gene mutation.
Angiogenesis inhibitors stop the growth of new blood vessels, which tumours need to get the nutrients to survive. The angiogenesis inhibitor used for advanced or metastatic non–small cell lung cancer is bevacizumab (Avastin, Mvasi). It is usually combined with carboplatin and paclitaxel. If the cancer responds to the chemotherapy, it is continued by itself until the cancer starts to grow again.
Immunotherapy with necitumumab (Portrazza) in combination with the chemotherapy drugs gemcitabine (Gemzar) and cisplatin may be offered for stage 4 squamous cell non–small cell lung cancer. It may be offered as the first treatment for people who are not able to have surgery.
Immunotherapy with pembrolizumab (Keytruda) may be used to treat metastatic non-small cell lung cancer that expresses PD-L1.
Endobronchial therapies are done inside the large airways of the lung (the bronchi) to remove a blockage and help with symptoms. 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.
Endobronchial therapies that quickly relieve symptoms are:
- bronchial debridement
- stent placement
- laser surgery
Endobronchial therapies that work more slowly to prevent symptoms are:
- photodynamic therapy (PDT)
- cryosurgery – rarely used
External beam radiation therapy may be used for stage 4 non–small cell lung cancer in people who are not able to have chemotherapy. It is 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.
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 rather than treat 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.
You may be asked if you want to join a clinical trial for non–small cell lung cancer. Clinical trials look at new ways to prevent, find and treat cancer. Find out more about clinical trials.