Treatment

• Management is determined by the type of lung cancer and the stage at presentation.

• If available, multidisciplinary tumor board involvement is recommended in the care of all patients with lung cancer.

• Early implementation of palliative care measures improves the patient's quality of life and may prolong survival

• Indication: most lung cancers

• Commonly used agents: cisplatin plus a second agent (e.g., etoposide)

• Indication: advanced or metastatic NSCLC with a demonstrated oncogenic mutation

• Mechanism of action: target up-regulated pathways that cause expression of the malignant phenotype

• Commonly used agents: tyrosine kinase inhibitors (TKIs) specific to the mutation OR receptor monoclonal antibodies

  • EGFR mutation: EGFR TKI (e.g., osimertinib) OR receptor monoclonal antibody (e.g., cetuximab)

  • ALK rearrangement: ALK TKI (e.g., alectinib)

  • ROS1 rearrangements: crizotinib

  • BRAF mutation: dabrafenib PLUS trametinib

• Indications

  • Locally advanced or metastatic NSCLC

  • Extensive-stage SCLC

• Mechanism of action: alters T-cell function and improves intrinsic cell-mediated immunity

  • Blocks the PD-L1/PD-1 interaction, improving the antitumor effect of endogenous T cells

  • Commonly referred to as immune checkpoint inhibitors (ICIs)

• Commonly used agents: durvalumab, pembrolizumab, and atezolizumab

Radiation therapy is most commonly used in conjunction with chemotherapy in lung cancer, but it also has other indications in lung cancer management.

• Indications

  • Limited-stage SCLC

  • Early or locally advanced (occasionally oligometastatic) NSCLC

  • Palliative care for SVC syndrome, painful bone metastases, tissue invasion, and hemoptysis

  • To prevent or slow the growth of brain metastases

• Techniques: Depending on the subtype of lung cancer and the therapeutic goal, different techniques are available.

• Indications

  • Stage I–II SCLC and NSCLC without mediastinal lymph node involvement [34][35]

  • Select patients with stage III NSCLC

• Contraindications to surgery

  • Disease characteristics: N3 disease, bulky N2, multiple N2

  • Significant comorbidities

• Preoperative assessment: Preoperative pulmonary function testing is required prior to lung resection surgery (see “Preoperative cardiac assessment” and “Preoperative pulmonary assessment”). [61][62]

  • A preoperative FEV1 < 1.5 L and DLCO < 60% predicts a poor outcome after lobectomy.

  • A preoperative FEV1 < 2 L and DLCO < 80% predicts a poor outcome after pneumonectomy.