Non-small cell lung cancer (NSCLC) is the most common type of lung cancer in the world, representing about 90 percent of all lung cancer diagnoses. A wide variety of treatment options are available for people who have been diagnosed with NSCLC, and researchers are working toward new breakthroughs that can improve outcomes.

Treatment advances in cancer research have led to an improvement in overall survival for people with NSCLC. For example, one study released in 2020 indicated that death rates for males with the condition fell by 6.3 percent per year between 2013 and 2016. Similar mortality improvements were observed among females. The study authors attributed the improvements in part to new treatment options.

To further understand how treatment advancements have improved outcomes for people living with NSCLC, MyLungCancerTeam sat down with Dr. Joy Feliciano. Dr. Feliciano is a thoracic oncology specialist at Johns Hopkins Bayview Medical Center in Baltimore, Maryland, and an assistant professor of oncology at Johns Hopkins University School of Medicine.

What is the typical diagnosis process for NSCLC?

The diagnosis of NSCLC can have many steps. The first part of diagnosis is finding a concerning tumor or mass on some kind of scan. The next step to diagnosis is to get a biopsy of the tumor to confirm what cell type of cancer it is. And then once that cancer is confirmed to be an NSCLC, we complete staging of the lung cancer. NSCLC is typically separated into different stages based on where in the body the cancer has spread.

When the lung cancer has gone to lymph nodes, particularly in the middle of the chest, that's what we call stage 3 or locally advanced disease. The terms “stage 4 lung cancer” and “advanced-stage lung cancer” tend to be used interchangeably. Metastatic lung cancer is another term for it, but in general, that means the cancer has gone to other areas of the body outside of the lung.

Which symptoms might prompt someone to pursue a diagnosis of NSCLC?

The symptoms for non-small cell lung cancer can be varied, and really can depend on what other medical issues you may have, but also where in the body the tumor has gone or where the tumor is located. For example, if it closes off an airway, you may develop a cough or shortness of breath. So the symptoms really depend on where the cancer is or where the cancer has spread to.

What might cause NSCLC besides smoking?

More information is coming out about what other factors may make someone more prone to developing lung cancer, particularly if they haven't smoked. Some factors that might contribute are exposures to indoor pollution or radon. Other factors can be genetic. There can be genetically inherited types of mutations that predispose you to unique kinds of lung cancer. So it can be both environmental and genetic, or a combination of the two.

How is getting an NSCLC diagnosis different in 2021 compared to that same diagnosis in 2011?

In the last 10 years, there have been more drugs developed for lung cancer than in the last 30 years combined. There are new treatments, such as immunotherapies or targeted therapies, that can sometimes move cases of NSCLC into earlier stages of disease.

What types of treatments could someone expect after getting a diagnosis of NSCLC?

Non-small cell lung cancer is not just one type of lung cancer, and therefore there are many different types of treatments. The treatments for non-small cell lung cancer will depend on a couple of things. First of all, what cell type of lung cancer it is, and also the stage of the cancer.

Early-stage lung cancers are treated very differently than advanced-stage lung cancers. And particularly in advanced-stage lung cancers, something called biomarker testing and molecular testing are factors in what type of treatment is going to be the most effective in your specific type of lung cancer.

Immunotherapies are a type of medication that we use in locally advanced [stage 3] and advanced [stage 4] lung cancer. Immunotherapies work by getting your own immune system to attack the cancer.

Chemotherapies are also used, which are medications that can kill cancer cells throughout the body.

And then a very broad category of treatments are called targeted therapies. Targeted therapies tend to be used in patients with very specific genetically and molecularly driven lung cancers, which are identified during biomarker and molecular testing. The majority of these targeted therapies are taken orally in pill form.

Following a diagnosis of NSCLC, what should people know about the treatment course?

What to expect from treatment really depends on what stage of lung cancer and what type of lung cancer you have. For example, patients who have an early stage lung cancer may be candidates for surgery followed by chemotherapy.

For locally advanced disease, the backbone of treatment is usually a combination of chemotherapy with radiation, followed by immunotherapy in some patients.

For advanced or metastatic disease, the goal of treatment is to try to get control of the disease throughout the body. That's why we use systemic treatment, meaning it gets into the bloodstream. Systemic treatments include chemotherapy, immunotherapy, or targeted therapies.

Can you share more information about immunotherapy?

Immunotherapy treatment is a broad category of treatments that have come into practice in the last five to 10 years. There are a few different categories of immunotherapy.

The most common type of immunotherapy that we use in lung cancer involves immune checkpoint inhibitors. Normally, your immune system would like to get rid of things that shouldn't be in your body, but cancer is able to hide from your immune system. Immune checkpoint inhibitors work by revealing the cancer to your immune system so that your own immune system can recognize it and attack.

Should people with NSCLC get the COVID-19 vaccine?

Yes. That's a rapidly expanding area of knowledge for us right now. The guidelines recommend that people who are eligible for vaccination and who have medical conditions such as cancer should get the vaccine if they can. Those who have underlying medical conditions may be at higher risk of complications from COVID-19.

In people who have had certain treatments for cancer, such as bone marrow transplants, a vaccine may not be quite as effective or successful at creating an immune response. Again, the data is limited in patients who have cancer, but we don't yet see any contraindication to people with cancer getting COVID-19 vaccinations.

What types of questions should people with NSCLC ask their oncologists?

What's most important for patients and their families or friends is to ask details about what their treatment is going to entail. Ask what to expect from your specific treatment, but also ask what you can do to really help yourself feel like you can have some control over the situation. For example, what kinds of exercise they can do, what kinds of activities they should participate in, when they should call the doctor — all of those things are important to ask your doctor.

Why are you optimistic about advances being made in non-small cell lung cancer?

I'm hopeful because so many advances have already been made in such a short amount of time. Before about 15 years ago, we treated all NSCLCs the same. But as we've gotten to understand more about the biology, we've realized that actually there are many different types and many different possible treatments for each unique type of lung cancer. Seeing how many new drugs have been developed in the last 10 years, and seeing that there are many more in development, it gives me hope that, little by little, we'll continue to make improvements in treatment of advanced NSCLC.

What should people who are diagnosed with NSCLC know about clinical trials?

There are many types of clinical trials. Some people may get nervous when they hear the term “clinical trials,” because they may perceive it as being something that’s never been tried in humans before. There are really hundreds — if not thousands — of different types of trials out there for patients with illnesses such as lung cancer, and trials can have different goals.

For example, we may be combining already-known effective treatments to see if we can improve outcomes even more. There are studies where we are combining immunotherapy plus another drug in order to try and improve outcomes even further. Some of those drugs may be combinations that we have already approved in lung cancer, but we just may not have tried out the combination. Not all clinical trials mean it’s something brand new and never tested.

The other thing to keep in mind is that not all clinical trials use a placebo. Some patients tell me they’re nervous about a clinical trial because they don’t want to be assigned to placebos, which are inactive compounds. Again, there are many different types of trials, and not all trials have a placebo arm. You may choose a study where all patients enrolled get treatment with an active compound.

Clinical trials are also an opportunity to help other people in the future. If we didn’t have people participating in clinical trials, we would have never made the advances we’ve made in the last five years.

What should inspire people diagnosed with NSCLC to stay hopeful about the treatment journey?

It's really crucial to remain hopeful when someone is diagnosed with lung cancer. Because of new treatments for lung cancer in the past 10 years, the mortality for cancer overall has had its greatest decline. We've already seen that needle shift in the last decade, just from this one cancer, and how it impacts all of cancer. We see so many opportunities right now for advances in lung cancer.

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Resources

1. Is Non-Small Cell Lung Cancer Caused by Smoking? — Moffitt Cancer Center
2. Recent Advances in Lung Cancer Treatment Resulting in Lower Death Rates — American Cancer Society
3. New treatments spur sharp reductions in lung cancer mortality rate — National Cancer Institute