There are two main types of lung cancer: small-cell, and non-small-cell. Non-small-cell lung cancer (NSCLC) is the most common type, accounting for roughly 85 percent of all cases. Smoking is the major cause of NSCLC, although this disease can affect nonsmokers, too. Non-small-cell lung cancer is a very serious illness. If caught early, though, there are effective therapies. For some people whose cancer has spread, new treatments, especially in the emerging fields of targeted therapy and immunotherapy, can slow disease progression and improve quality of life, according to the National Cancer Institute. (1,2)
Squamous Cell Carcinoma
Squamous cell carcinoma accounts for about 25 to 30 percent of all lung cancer cases. It starts in the squamous cells, flat cells that line the lung’s airways. This type of cancer usually grows in the center of the lung. Squamous cell carcinoma is nearly always associated with smoking.
Adenocarcinoma
Adenocarcinoma accounts for about 40 percent of all lung cancers. Adenocarcinoma often develops in the outer parts of the lung. As with squamous cell carcinoma, it is linked to smoking, though it can also occur in patients who have never smoked. More women develop adenocarcinoma than men, and it’s the most common type to affect younger people.
Other Kinds of NSCLC
Less-common forms of NSCLC include adenosquamous carcinoma, large-cell carcinoma, and sarcomatoid carcinoma, according to the American Cancer Society and MedlinePlus. (3,4)
What Makes Non-Small-Cell Lung Cancer Unique?
Non-small-cell lung cancer, as the name implies, occurs in cells that are larger than those affected in small-cell lung cancer. Small-cell lung cancer is less common, accounting for only about 15 percent of all lung cancers, and is nearly always associated with smoking.It starts in the bronchia, the main passageways into the lungs. Physicians treat small-cell and non-small-cell lung cancers differently, so knowing the type is vital. Doctors determine the cancer type by performing a biopsy, a procedure to remove a small piece of lung tissue, and examining the cells under a microscope. In addition to the two main categories of lung cancer, there are a few other rare types, according to the Moffitt Cancer Center. (3,5)
What Type of Lung Cancer Is More Aggressive?
Non-small-cell lung cancer usually grows more slowly than small-cell lung cancer, and small-cell lung cancer is more likely to spread to other parts of the body before it is diagnosed. When cancer metastasizes, it becomes much harder to treat. In general, non-small-cell lung cancer doesn’t respond as well to chemotherapy as small-cell lung cancer. But while small-cell lung cancer often responds well to initial chemotherapy, it often comes back quickly. (5) Other causes of NSCLC include:
Radon: Radon exposure is the second leading cause of lung cancer, according to the Environmental Protection Agency (EPA). This colorless gas can come up through soil and find its way into buildings through small gaps and cracks, according to the American Lung Association. (6)Arsenic: Drinking water with high levels of arsenic is a lung cancer hazard.Radiation therapy: Receiving radiation to the chest area — typically for the treatment of another cancer, such as lymphoma or breast cancer — can lead to lung cancer.Air pollution: Extended exposure to air pollution can raise lung cancer risk.Other chemicals: Working with or being around certain chemicals can increase the chance of developing lung cancer. Some potentially harmful substances include asbestos, uranium, beryllium, vinyl chloride, nickel chromates, coal products, mustard gas, diesel exhaust, gasoline, chloromethyl ethers, chloride, and formaldehyde. (3)
RELATED: What Are the Causes of Lung Cancer? Sometimes, NSCLC doesn’t cause any symptoms at all. Patients might only find out they have lung cancer after getting an X-ray for another reason. When there are symptoms, they may include:
A cough that doesn’t go away or worsensShortness of breathTrouble breathingWheezingChest pain or discomfortBlood in coughed-up mucusHoarsenessWeight lossLoss of appetiteTirednessTrouble swallowingSwelling in the face or the veins in the neck (2)
RELATED: What Are the Symptoms of Lung Cancer? These tests could include:
Physical exam: Doctors might perform a general health check to look for lumps or any other signs of cancer. They may also ask about family history and health habits.Blood or urine tests: Lab tests can help diagnose and monitor the disease.Chest X-Ray: A simple X-ray can let doctors see the organs and bones inside the chest.CT (computerized tomography) scan: This imaging procedure combines a series of X-rays images taken at different angles to create pictures of areas inside the body.Sputum cytology: A pathologist analyzes a sample of sputum (mucus coughed up from the lungs) under a microscope to look for cancer cells.Thoracentesis: This procedure uses a needle to remove fluid from the space between the lining of the chest and the lung. A pathologist examines the fluid to look for cancer cells.Brain MRI: This is magnetic resonance imaging of the brain, as lung cancer can spread to the brainPET scan: This is a highly accurate form of scan that can see not only cancer in the lungs but if it has spread to other parts of the body.
If doctors suspect NSCLC, they’ll perform a biopsy in order to make an official diagnosis. This procedure involves analyzing lung cells under a microscope. There are different ways to collect cell samples, including the following:
Fine-needle aspiration: Doctors collect tissue or fluid from the lung with a thin needle inserted through a small incision in the skin. An imaging procedure, such as a CT scan, may help physicians locate the target area. For help placing the needle, doctors sometimes use an endoscopic ultrasound. This involves inserting a thin tube, with a light and lens on the end, down the patient’s throat.Bronchoscopy: A bronchoscopy is a procedure done to view the trachea and large airways of the lung and remove tissue samples. Doctors insert a bronchoscope, a slender instrument with a light and lens, through the nose or mouth.Thoracoscopy: This procedure allows doctors to look at the organs inside the chest and collect samples of lung or lymph node tissue. It involves inserting a thoracoscope (a thin instrument with a light and a lens) through an incision between two ribs.Mediastinoscopy: A mediastinoscopy helps physicians look for abnormal areas in organs, tissues, and lymph nodes between the lungs, then collect samples. Doctors insert the mediastinoscope (a thin instrument with a light and a lens) through an incision at the top of the breastbone.Lymph node biopsy: With this procedure, physicians remove all or part of a lymph node for examination in the lab. (2)
RELATED: How Do Doctors Diagnose Lung Cancer? The stages for NSCLC proceed from 1 to 4. In general, the higher the number, the more advanced the disease:
Stage 1: The cancer is only located in the lungs and hasn’t spread to nearby lymph nodes.Stage 2: The cancer is larger, or has spread to some nearby lymph nodes, whether it’s larger or not.Stage 3: The cancer is very large, or has spread to nearby tissue or more distant lymph nodes in the chest.Stage 4: The cancer has spread to both lungs, to fluid in the areas around the lungs, or to distant organs in the body, such as the brain or liver.
In addition to the stage number, doctors also identify lung cancer with a letter (A, B, or C), and a second number (1, 2, or 3). In each case, the higher the number or letter, the more advanced the cancer. A stage 4B lung cancer, for instance, is much further advanced than a stage 1A1 lung cancer, according to the LUNGevity Foundation. (4) RELATED: What Are the Stages of Lung Cancer?
Surgery
Doctors may recommend surgery if the cancer hasn’t spread beyond nearby lymph nodes. There are different types, including:
Lobectomy: Removal of one of the lobes of the lungWedge or Segment Removal: Removal of only a small part of the lungPneumonectomy: Removal of the entire lung (4)
Sometimes surgeons use a method which involves only small incisions, known as video-assisted thoracoscopic surgery (VATS). Doctors insert a thoracoscope into the chest, then remove a lung lobe through the scope, according to the LUNGevity Foundation. (9)
Radiofrequency Ablation
Radiofrequency ablation (RFA) uses high-energy radio waves to heat and destroy tumors. This procedure may be an option for people with NSCLC who have small tumors that are located near the outer edge of the lungs. This is only used for patients who are not good candidates for surgery due to health concerns. RFA is usually performed as an outpatient procedure, with local anesthesia, notes the American Cancer Society. (10)
Chemotherapy
Chemotherapy (aka chemo) uses drugs to kill cancer cells. Doctors usually administer it through an intravenous (IV) infusion, but some chemo drugs also come in pill form. Patients sometimes receive chemo before or after surgery, or at both times, or simultaneously with radiation therapy. For advanced NSCLC, chemotherapy is usually used alone. Chemotherapy drugs are generally used in combinations of two, rather than alone. Some common drugs for NSCLC are:
cisplatin (Platinol)carboplatin (Paraplatin)docetaxel (Taxotere)gemcitabine (Gemzar)paclitaxel (Taxol)paclitaxel protein-bound (Abraxane)irinotecan (Camptosar)vinorelbine (Navelbine)pemetrexed (Alimta)etoposide (Vepesid)vinblastine (Velban)
Per the American Cancer Society, chemotherapy can cause side effects, such as: (4,9,11)
Hair lossNauseaVomitingLoss of appetiteMouth soresDiarrheaConstipationFatigueEasy bruising or bleedingIncreased risk of infections
Radiation
Radiation therapy uses high-energy rays or particles to kill cancer cells. Patients might receive this therapy before or after surgery, or both, or while they’re getting chemo. Sometimes doctors use it to shrink tumors that have spread to other areas in the body. The two kinds of radiation therapy for NSCLC are:
External beam radiation: This uses a machine outside the body to deliver radiation to the cancer.Brachytherapy: Doctors place small amounts of radioactive material directly into the cancer or the airway next to the cancer.
According to the American Cancer Society, radiation can cause side effects, such as: (12)
FatigueNauseaVomitingLoss of appetiteWeight lossSkin changes, such as blistering or peelingHair loss on treated areas
Targeted Treatments
Targeted therapy works by attaching to or blocking specific targets unique to a cancer cell. Targeted medication can be used alone or in combination with chemo and can be given as a pill or through IV injection. Some common targeted treatments for NSCLC include:
Angiogenesis inhibitors: These medicines block new blood vessel growth. They include bevacizumab (Avastin) and ramucirumab (Cyramza).Epidermal growth factor receptor (EGFR) inhibitors: EGFR is a protein on the surface of cancer cells that helps them grow. EGFR is mutated in a subset of lung cancer patients so that the “on” growth signal is always present. Drugs that block the signal from EGFR include afatinib (Gilotrif), gefitinib (Iressa), osimertinib (Tagrisso), dacomitinib (Vizimpr), and necitumumab (Portrazza).ALK inhibitors: ALK is a gene that is sometimes abnormal (mutated, or more accurately “rearranged”) in people with NSCLC. Similar to EGFR mutations, these changes result in the “on” growth switch to always be on. Medicines that target the ALK mutation include crizotinib (Xalkor), ceritinib (Zykadia), alectinib (Alecensa), brigatinib (Alunbrig), and lorlatinib (Lorbrena).BRAF inhibitors: In some cases of NSCLC, the cells have mutations in the BRAF gene, again, telling the cells to grow in an uncontrolled way. Drugs that block this mutation include dabrafenib (Tafinlar) and trametinib (Mekinist).New developments: More recent advances include drugs to treat HER2, KRAS, ROS1, NTRK, and MET mutations as well as RET rearrangements.
Targeted medicines often cause less severe side effects than chemotherapy, but per the American Cancer Society they can still lead to problems, such as: (9,13)
FatigueBleedingHeadachesMouth soresLoss of appetiteNauseaVomitingDiarrheaConstipationSkin problemsJoint painVision changesHigh blood pressureIncreased risk of infections
Immunotherapy
Immunotherapy stimulates the body’s own immune system to kill cancer cells. It is now incorporated in the first treatment of most patients with lung cancer, other than those who have a specific mutation that can be treated with a targeted therapy. Immunotherapy medicines are given as an infusion. Other examples of immunotherapy drugs include:
nivolumab (Opdivo)ipilimumab (Yervoy)cemiplimab (Libtayo)pembrolizumab (Keytruda)atezolizumab (Tecentriq)durvalumab (Imfinzi)
Side effects might include:
FatigueCoughNauseaItchingRashDiarrheaConstipationLoss of appetiteJoint pain
In rare cases, the use of immunotherapy can cause the immune system to attack other parts of the body, which can lead to serious or life-threatening problems in certain organs, according to the American Cancer Society. (9,14)
Laser Therapy
Rarely, lasers may be used to treat small tumors in the linings of the airways. They can also help open up airways that are blocked by larger tumors. Doctors pass a bronchoscope down the throat and aim the laser beam at the tumor to burn it away. This procedure is typically done under general anesthesia, notes the Moffitt Cancer Center. (15)
Clinical Trials
Patients with NSCLC may want to consider participating in a clinical trial. These studies take place in various locations around the country. Clinical trials offer access to novel, investigational therapies that aren’t yet available to the general public. (2) More information on clinical trials is available on the National Cancer Institute’s Clinical Trials Information for Patients and Caregivers page. RELATED: What Are Treatments for Lung Cancer? The problem is that so many cases of NSCLC are detected when the cancer has already spread throughout the body. (4) Survival rates tell you the percentage of people who survive a specific type and stage of cancer for a certain amount of time. They’re based on population averages and aren’t necessarily a prediction for how long an individual will live. Survival rates also include people who die from causes other than cancer. Additionally, the rates that are often published are based on historic data and do not account for the many advances made in the past decade in which patients have benefited from many new drugs approved by the FDA. According to the American Cancer Society, the survival rates for people with NSCLC are as follows:
The five-year survival rate for those with stage 1A1 is about 92 percent. For those with stage 1A2, it’s about 83 percent. For those with stage 1A3, it’s about 77 percent. And for those with stage 1B, it’s about 68 percent.The five-year survival rate for people with stage 2A is about 60 percent. For stage 2B, it’s about 53 percent.The five-year survival rate for people with stage 3A is about 36 percent. For stage 3B, it’s about 26 percent. And for stage 3C, it’s about 13 percent.The five-year survival rate for people with stage 4A is about 10 percent. For those with stage 4B, it’s less than 1 percent.
It’s important to remember that survival rates are only estimates, not predictions. Plus the statistics above are somewhat outdated and don’t reflect the positive impact of targeted therapies and immunotherapy. A doctor can help explain any prognosis in detail, notes the American Cancer Society. (16)
Does Non-Small-Cell Lung Cancer Recur?
NSCLC may recur, meaning it can come back after treatment and a period of time where the patient is considered cancer-free. When lung cancer recurs, it can develop in the lungs or in other areas of your body. But it’s still considered lung cancer even if it comes back in a different spot, such as the bones or brain. If lung cancer returns, the patient and doctor need to discuss a new treatment approach. Clinical trials are also an option, notes the Moffitt Cancer Center. (17)
Smoke or have smoked in the pastHave been exposed to secondhand smokeHave been around cancer-causing agents, such as radon, mustard gas, asbestos, uranium, arsenic, diesel, coal, or othersHad radiation therapy to your chestHave a family history of lung cancerHad lung cancerHave been exposed to air pollutionHave taken beta-carotene supplements while being a smoker
There may be certain measures you can take to lower your risk of NSCLC. The first step is to avoid cigarette smoking or quit smoking right away. When you stop smoking before cancer develops, your damaged lung tissue starts to repair itself. Quitting smoking can lower your risk of lung cancer and help you live longer, regardless of how many years you’ve smoked. Avoiding exposure to harmful substances and chemicals can also help you reduce your risk of NSCLC. Additionally, the American Cancer Society notes that some studies suggest that consuming a diet high in fruits and vegetables can help protect you from lung cancer, whether you’re a smoker or not. (19) RELATED: Lung Cancer Risk Factors and Prevention Today, many medical organizations recommend that people who are at high risk for developing lung cancer be screened with low-dose computerized tomography (LDCT) every year. The U.S. Preventive Services Task Force recommends yearly screening for adults who are 50 to 80 years old, have a 20-pack-a-year smoking history, and currently smoke or have quit smoking within the past 15 years. Patients who fall into this category should talk to their doctors about whether lung cancer screening is right for them. Screening can be stopped once a person has not smoked for 15 years, develops a health problem that might limit his or her life expectancy, or can’t or won’t have lung surgery. While some studies have shown lung cancer screening saves lives, others have suggested early screening exposes people to unnecessary risks. Researchers are also looking at simpler and less expensive ways to screen for lung cancer, such as breath, blood, and saliva tests. (20) RELATED: Lung Cancer Risk: Should You Get Screened?
What type of NSCLC do I have?Where is the cancer?What stage is the cancer?Will I need any other tests before we can talk about a treatment plan?Have my cancer cells been checked for gene changes that could affect my treatment options?What treatments do you recommend? Why do you recommend these treatments?Are there other treatment options that I should consider?How much experience do you have in treating this type of cancer?What are the chances that my cancer can be cured?What will the treatment be like?How long will treatment last?How will I know if the treatment is working?What will my options be if my cancer comes back?Should I get a second opinion?Where can I find credible information about my cancer?Are there clinical trials I should explore for the treatment of my cancer?Will my health insurance cover my treatments? Who can help me with insurance issues?
It’s a good idea to bring a list of questions to a doctor’s visit and take careful notes for reviewing later. (22) LUNGevity Foundation: The LUNGevity Foundation focuses on increasing quality of life and survivorship for people diagnosed with lung cancer by accelerating research into early detection and more effective treatments, as well as providing community, support, and education for individuals and families affected by lung cancer. CancerCare: CancerCare is a nonprofit that supplies free, professional support services for people with lung cancer, as well as treatment information. It also offers lung cancer support groups led by oncology social workers. Lung Cancer Alliance: The Lung Cancer Alliance can help locate other people living nearby who have the same cancer. The organization provides educational materials, free one-on-one support, and a blog site. Lung Cancer Research Foundation: The Lung Cancer Research Foundation is an advocacy organization and source for information and free publications about the disease. Its goal is to improve lung cancer awareness and fund research. American Lung Association: The American Lung Association offers numerous services and endorses local support groups called the Better Breathers Club. Aimed at patients and caregivers who are affected by chronic lung diseases, the Better Breathers Clubs meet regularly at locations around the country. Cancer Financial Assistance Coalition: The Cancer Financial Assistance Coalition is an alliance of organizations that help cancer patients manage their financial challenges. American Cancer Society: The American Cancer Society has many resources to support people with lung cancer. The organization funds programs to help patients with healthcare-related lodging expenses and transportation. Its National Cancer Information Center provides information and support to people with cancer 24 hours a day, 365 days a year. National Cancer Institute: The National Cancer Institute is a go-to source for reliable information about cancer topics, research, and clinical trials. ClinicalTrials.gov: ClinicalTrials.gov is a searchable database of ongoing research studies.
