Treatment of lung cancer

Treatment for lung cancer depends on a whole set of factors including the type of tumor, the stage of the disease, respiratory functionality and other factors linked to the patient’s general state of health.

Once the diagnosis has been established, the lung tumor board group of experts with their range of relevant specialisms convene a meeting to assess all the dimensions of the disease and propose the best possible treatment. The treatment to be performed is then chosen after discussion with the patient.

The aim of a surgical intervention is to remove the entire tumor and adjacent lymph nodes whilst preserving lung tissue as much as possible. The surgical procedure will be discussed according to the size of the tumor, its location and its potential loco-regional extensions along with the state of the patient, in particular in relation to their cardio-respiratory functionality. Operating techniques used are :

• thoracoscopy
• thoracotom

In 2011 the surgical team at the Division of Thoracic Surgery at the HUG introduced and have since developed mini-invasive surgical techniques (thoracoscopy), including pulmonary resections for cancer. Ongoing research and development focus primarily on limited resections for cancer via a thoracoscopy in order to limit the extension of pulmonary resection as far as possible, in particular for small pulmonary cancers (generally < 2 cm). This approach enables a cure which is just as good as with a more extensive resection and with a minimum impact on quality of life. Innovative techniques utilizing fluorescent markers are applied in order to precisely identify the zones to resect. 

Chemotherapy is based on the use of drugs called cytostatics that destroy cancerous cells or prevent their growth. In certain conditions, these treatments may be envisaged post-operation to destroy residual cancerous cells. They may also be used pre-operation to reduce the size of the tumor and to create better conditions for operating.

Chemotherapy may also be used in conjunction with radiotherapy in cases of locally advanced bronchial cancers (stage III according to the TNM classification).

In the event of advanced or metastatic disease that is therefore inoperable, conventional chemotherapy in combination with checkpoint inhibitors (immunotherapy) is the standard treatment. This treatment is indicated for patients where the tumor does not present any particular molecular change (for example, EGFR mutation or ALK or ROS1 translocation).

New categories of drugs have been developed, namely checkpoint inhibitors or immunotherapy and targeted treatments.

• The objective of immunotherapy is to induce a cell-mediated immune response, mainly cytotoxic T lymphocytes, capable of selectively destroying tumor cells. The anti-tumor immune response engages a cascade of interactions between the antigen-presenting cell, the tumor cell and the T lymphocytes. There is an undesirable inhibition in the oncological context of this specific immune response involving immune checkpoints. The treatment may be administered on its own or in combination with chemotherapy depending on the expression level of a protein expressed on the tumor cell that is called PD-L1 If the expression level is more than 50%, immunotherapy is the only treatment that can be envisaged; if the level is below 50% immunotherapy will be administered with chemotherapy. 
   
• The targeted treatment uses drugs to target specific molecules such as proteins that are present on the surface or inside the cancerous cells. These molecules contribute to the sending of signals that indicate the cells to grow or divide. By targeting these molecules the drugs interrupt the growth and propagation of the cancerous cells whilst limiting damage to normal cells. The targeted treatment can also be called molecular targeted therapy. 

Radiotherapy utilizes rays that reach the tumor and destroy the cancerous cells. The rays attack the cancer cells which, no longer able to divide or proliferate, eventually die.

For lung cancer radiotherapy is primarily indicated when an operation is not, or is no longer possible, and the tumor or its metastases are localized. Radiotherapy can also be combined with chemotherapy, either preceding or following it

Depending on the individual clinical case the experts may decide to propose a combined treatment of surgery, chemotherapy and/or radiotherapy.

palliative treatment is proposed where the objective is to avoid or limit all physical suffering (cough, pain, difficulty breathing, choking) as far as possible and to ensure the best possible quality of life.

• difficulty breathing
• cough
• pains
• bleeding
• others

There is a wide range of possible treatments and they must be assessed individually for each case. They cover the administration of drugs, such as anti-cough drugs, radiology or interventional pneumology methods, for example endovascular embolization, clearance of airways, placement of stents, pleural talcage, etc.