Advanced Lung Cancer Treatment - Chemotherapy vs Radiotherapy

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1 Which treatment for advanced lung cancer This information tells you about the treatments for advanced lung cancer. Chemotherapy and radiotherapy can both be used to treat advanced lung cancer. They can shrink the cancer and so help to relieve symptoms. Chemotherapy can also help to keep the cancer at bay and keep you well for longer. You can find information on Which is the best treatment? Treating breathlessness caused by a blocked airway Treating fluid on the lung (pleural effusion) Treating a blockage in the vein (superior vena cava obstruction) New treatments Deciding about treatments Which is the best treatment? The treatment that is best for you depends on The type of lung cancer you have Where the cancer has spread to in the body The treatment you have already had Any other medical conditions you might have If the cancer spread is just in one area, for example in one or two bones, you may have radiotherapy. If the doctor thinks the cancer is in more than one area of the body, you may have chemotherapy. This is because chemotherapy treats the whole body and radiotherapy treats only the area it is aimed at. If you have already had radiotherapy to a particular part of the body, it may not be possible to give any more to that area. This is because there is a maximum amount of radiation that can be given to each part of the body before too many side effects are caused. Your doctor may suggest chemotherapy instead. Treating breathlessness caused by a blocked airway If the cancer is blocking, or partly blocking, an airway your doctor may suggest several treatment options. You may have internal radiotherapy (endobronchial radiotherapy), electrocautery, laser therapy, light treatment 1

2 (photo dynamic therapy) or treatment with a freezing probe (cryotherapy). These are all ways of destroying the cancer that is causing the blockage. If the tumour is squashing your airway and making it difficult for you to breathe comfortably, your doctor may suggest putting in a rigid tube to keep the airway clear. This tube is called a stent. Treating fluid on the lung (pleural effusion) It is quite common for people with lung cancer to develop a collection of fluid between the sheets of tissue covering the lung (the pleura). This is called a pleural effusion. It is a nuisance because it takes up space in your chest - space that your lung would normally fill when you breathed in. A pleural effusion can make you quite breathless because the affected lung doesn't have enough space to expand properly. The treatment is to drain off the fluid. This is called thoracentesis (thora - sen - tee - sis) and despite the name, is fairly simple. Your doctor will ask you to sit comfortably, leaning forward onto a table or back of a chair. First, you will have a local anaesthetic injection in one side of your back, where the drain will go in. When this has had time to work, the doctor will make a small cut and put in a larger needle called a cannula. This hollow needle is attached to a tube with a drainage bottle or bag on the end. If you have more than a litre of fluid inside your chest, it will have to be drained off slowly. So the doctor will put in a stitch to hold the cannula in place. Once it is secure, you can walk around carrying the drainage bottle. You will have to stay in hospital for a day or two while the fluid drains. Remember- if your tube is connected to a bag or bottle, don't raise it above the level where the tube goes into your chest. If you do, you could allow the fluid back in. If there is not much fluid, the needle won't have to be in long and you may just have a dressing put over it temporarily. Once the drainage has stopped, you will have a chest X-ray to make sure it has all gone and then the drain can come out. This only takes a second. Your nurse will put a dressing over the small wound site and then you can go home. If you had a stitch to hold the drain in, this will need to come out in about a week. What if the fluid comes back? Unfortunately, the fluid can build up again. You can have it drained more than once. But it isn't a good idea to keep on doing it, as you are likely to get an infection there in the end. If this is happening to you, or your doctor thinks it likely, you may have treatment to try to stop the fluid collecting. This is called pleurodesis (ploo-rodee-sis). The fluid collects between the two pleural membranes that cover the lung. The idea of this treatment is to stick the two pleura together, so there is no space for the fluid to collect. This won't hurt your breathing in any way. 2

3 The procedure is the same as above. But after the fluid has drained off, your doctor will give you an injection into the chest drain. The injection will be something to irritate the pleura and make them stick together. It could be plain talc, or an antibiotic or a chemotherapy drug called bleomycin. Once the talc or drug is in, the doctor will clamp off the tube for an hour or so. Your doctor may ask you to shift position every 10 minutes or so (side to side and front to back). This helps to move the drug or talc around inside so that it coats the pleura all over. After the hour is up, your doctor may connect a suction tube, which helps to encourage the pleura to stick to each other. You may have a bit of chest pain after the talc or drug has gone in. Do ask for painkillers if you need them. Then the tube can come out, the stitch pulled together and a dressing put on. Once again, the stitch will need to come out after about a week. Treating superior vena cava obstruction (SVCO) This can sometimes be a symptom of advanced lung cancer. The vena cava is a large vein that carries blood from the brain, head and arms back to the heart. If the cancer constricts or blocks this vein, there is a build up behind the blockage causing fluid to seep out from the bloodstream and collect in the tissues of the face, causing swelling. People developing SVCO might notice swelling around their eyes, particularly first thing in the morning. SVCO can come on quite quickly or take several weeks to develop. Treatments are aimed at reducing the obstruction and relieving symptoms. Steroids, such as prednisolone or dexamethasone, are often used to decrease swelling. Other treatments depend on the type of lung cancer you have. Chemotherapy might be used for small cell lung cancer and radiotherapy for non small cell lung cancer. Sometimes doctors put a metal sleeve (stent) inside the vein to keep it open. They might use this if SVCO develops rapidly, particularly if the cancer has not yet been fully diagnosed. Or they might put in a stent if chemotherapy or radiotherapy does not help relieve symptoms. A Cochrane Review in 2001 looked into treatment of SVCO for lung cancer. This type of review pulls together the results from several trials to come to an overall conclusion. The reviewers found that insertion of a stent improved symptoms in over 9 out of 10 patients (90%) with SVCO. They found chemotherapy and radiotherapy relieved symptoms in between 6 and 7 out of 10 patients (60%-70%). But they weren t able to find out how well steroids worked. Or the best time to use a stent either at the time SVCO is diagnosed or after trying other treatments first. 3

4 New treatments There may be trials of experimental treatments going on which you could take part in. These may be trials for new chemotherapy drugs or new combinations of drugs. There are some new biological therapies being researched in lung cancer. One type of biological therapy being used and tested for non small cell lung cancer is erlotinib (Tarceva). This is a type of drug known as a tyrosine kinase inhibitor (TKI). These drugs block the signals that cancer cells need to grow. In June 2005, erlotinib was licensed in Europe for patients with advanced non small cell lung cancer that has continued to grow despite having chemotherapy. We won't know how widely available erlotinib will be on the NHS in England and Wales until NICE (National Institute for Health and Clinical Excellence) publish their final guidance. In June 2006 the equivalent body in Scotland, the SMC (Scottish Medicines Consortium) approved erlotinib on the NHS in Scotland for treatment of advanced non small cell lung cancer. Your doctor can only prescribe erlotinb in this situation if you've had at least one prior chemotherapy treatment that hasn't worked and you're eligible for docetaxel chemotherapy. Another drug that has been licensed for use in advanced non small cell lung cancer is pemetrexed. However, NICE has looked at the evidence for this treatment and decided in August 2007 that it is not effective enough to recommend its use in this situation, so it won't be available on the NHS. In January 2008, the SMC (Scottish Medicines Consortium) made the same decision regarding the NHS in Scotland. Patients already receiving pemetrexed can continue until they and their doctors decide to stop it. Angiogenesis is the term used to describe the growth of new blood vessels. Cancers need to grow their own blood vessels as they get bigger. Without its own blood supply, a cancer cannot continue to grow. Anti-angiogenesis is the name for treatment to block the development of new blood vessels. This is also a type of biological therapy. Bevacizumab (also called Avastin) is an anti-angiogenic monoclonal antibody (MAB). Antibodies are made by our immune system to help recognise and destroy infections and damaged cells. A MAB is an antibody that is made in the laboratory and can be reproduced in large numbers. 'Monoclonal' means that all the copies are the same. MABs can be used against a particular cancer if they target the cells of that cancer, but not normal cells. In August 2007, bevacizumab was licensed in Europe for the treatment of advanced non small cell lung cancer, in combination with platinum-based chemotherapy, such as cisplatin or carboplatin. But we won't know how widely available bevacizumab will be on the NHS in England and Wales until NICE (National Institute for Health and Clinical Exellence) have looked at this treatment. 4

5 Deciding about treatment It can be difficult to decide which treatment to try, or whether to have treatment at all, when you have an advanced cancer. You will need to consider your quality of life while you are having the treatment. This includes side effects as well as stresses such as travelling back and forth to the hospital. Most importantly, you will need to understand what can be achieved with the treatment you are being offered. Your doctor will discuss the options for treatment with you. There may be a counsellor or specialist nurse at the hospital you could chat to. You may also want to talk things over with a close relative or friend. Suggestion: If you would like to talk to someone outside your own friends and family, ask your doctor or nurse about counselling and support organisations. For more information about lung cancer, visit our website You can find a wide range of detailed, up to date information for people affected by cancer, including a clinical trials database that you can search for trials in cancer care in the UK. For answers to your questions about cancer call our Cancer Information Nurses on , 9am till 5pm Monday to Friday Adapted from Cancer Research UK s Patient Information Website CancerHelp UK in May 2008 CancerHelp UK is not designed to provide medical advice or professional services and is intended to be for educational use only. The information provided through CancerHelp UK and our nurse team is not a substitute for professional care and should not be used for diagnosing or treating a health problem or disease. If you have, or suspect you may have, a health problem you should consult your doctor. Copyright Cancer Research UK 2008 Cancer Research UK Charity Number