Treatment for lung cancer includes surgery, chemotherapy, radiotherapy, immunotherapy and other targeted therapy drugs. People may be offered one or more different treatments depending on the stage and type of lung cancer as well as their general health.
Non-small-cell lung cancer (NSCLC) is the most common type of lung cancer, accounting for 87% of cases. NSCLCs can be broken down into 2 major sub-types: adenocarcinoma (sometimes referred to as non-squamous) and squamous cell carcinoma. With recent advances in scientific evidence, treatment for these subtypes is becoming increasingly different, with the identification of mutations in tumours being of particular importance in adenocarcinomas.
Small cell lung cancer (SCLC) is less common, accounting for around 12% of lung cancers. SCLC is an aggressive cancer which spreads at an early stage and so is nearly always advanced at the time of diagnosis, leading to limited curative-intent treatment options.
Adenocarcinoma is a cancer that starts in glandular cells, for example, ones that secrete mucus. These are often found in alveoli, the tiny air sacs in the lung.
Squamous cell carcinoma is a cancer that starts in squamous cells, which are thin, flat cells that line the airways.
Surgery for NSCLC has proven to be effective, with National Cancer Registration and Analysis Service (NCRAS) data showing that 45% of people with NSCLC were still alive 5 years post-surgery. Five-year survival rates for people with NSCLC who do not have surgery was 3%.
Over the last 10 years, surgery rates in NSCLC have doubled, from around 9% in 2006 to over 18% in 2017, exceeding the target of 17% set by the National Lung Cancer Audit (NLCA).
NICE recommends that people with non-small-cell lung cancer (NSCLC), who are well enough and for whom treatment with curative intent is suitable, should be offered a lobectomy (either open or thoracoscopic). It is encouraging that data from the National Lung Cancer Audit show that surgery rates for people with stage 1 to 2 lung cancer and a good performance status have increased from almost 52% in 2015 to almost 61% in 2017, though there does appear to be significant regional variation.
An open lobectomy (thoracotomy) is the removal of a lobe of the lung through a cut made around the side of the chest.
A thoracoscopic lobectomy is keyhole surgery, where a lobe of the lung is removed using several small incisions, guided by a camera. This is normally more suitable for smaller tumours.
Surgery rates for people with stage 1 to 2 lung cancer vary across the country
Overall surgery rates for NSCLC are increasing, but there is variation across the country
Chemoradiotherapy for NSCLC
For more advanced NSCLC, surgery or radiotherapy alone is often not appropriate as the cancer has spread too far for it to be possible or effective. Even for advanced cancers that have not spread too far the curative potential of radiotherapy alone is low. A chemotherapy regimen is often added to radiotherapy to control small clusters of cancer cells that have spread to other parts of the body. Additionally, many chemotherapy agents make the cancer more sensitive to the radiotherapy.
NICE recommends that chemoradiotherapy should be considered for people with stage 2 or 3 NSCLC when surgery isn’t suitable or is declined.
Chemoradiotherapy for people with stage 3 NSCLC is steadily increasing. The National Lung Cancer Audit reports that 34% of people with stage 3A NSCLC and good performance status received treatment with chemotherapy and either radical radiotherapy or surgery in 2017.
Chemotherapy, radiotherapy and chemoradiotherapy
Chemotherapy is a whole-body treatment where drugs are used to kill cancer cells by disrupting their growth. For early stage cancer, it can be used to shrink a tumour before surgery, making it easier to remove or it can be used after surgery to reduce the risk of the cancer coming back.
For people with advanced lung cancer, chemotherapy can be used to stop the cancer from spreading further and help people live longer.
Radiotherapy uses high energy x-rays to destroy cancer cells to stop them growing and spreading.
Radiotherapy can be used in early stage NSCLC for people who cannot have surgery.
It can also be used after surgery if it was not possible to remove all the cancerous tissue. In late stage lung cancer, radiotherapy can be used to manage symptoms.
Chemoradiotherapy is a combination of chemotherapy and radiotherapy. This is generally offered to people with stage 2 or 3 NSCLC who are reasonably well as it can be difficult to tolerate the side effects of both treatments.
Systemic anti-cancer treatment for NSCLC
Systemic anti-cancer treatments (SACT) include all treatments that are administered to the whole body, for example chemotherapy, immunotherapy and other medicines that disrupt the behaviour of the cancer cells. These treatments are more often used to treat advanced NSCLC. Clinical trials have demonstrated that people with advanced and incurable NSCLC can benefit from SACT, delivered to improve quality of life and to extend survival.
NICE has produced a number of recommendations relating to the treatment of NSCLC using targeted SACT and in March 2019 we published 2 algorithms for the treatment of squamous and non-squamous stage 3B and 4 NSCLC.
Baseline data from the NLCA show rates of SACT for people with advanced stage lung cancer (3B to 4) who have a good performance status are increasing, from almost 63% in 2016 to 66% 2017.
The Innovation scorecard estimates report is produced by NICE and published by NHS Digital. The report shows the trend in prescribing of NICE recommended first-generation (gefitinib and erlotinib) and second-generation (afatinib and osimertinib) tyrosine kinase inhibitors, which are indicated for the treatment of adults with locally advanced or metastatic epidermal growth factor receptor (EGFR) mutation-positive NSCLC.
Prescribing data indicates that the second-generation medicines have become a more popular treatment choice once available. Emerging evidence suggests that the second-generation medicines may be better in terms of prolonging progression free survival.
For the last 2 years, approximately 1,700 people in England received treatment each year with one of the EGFR targeted medicines.
Treatment for small cell lung cancer
Around 30% of SCLC cases are detected at stage 1 to 3. For those detected early enough, treatment with curative intent is an option. NICE recommends that twice-daily radiotherapy with concurrent chemotherapy should be offered to people with limited-stage disease SCLC. NICE also says that surgery should be considered in people with early-stage SCLC.
The NLCA shows that treatment with curative intent for people with SCLC has increased. In 2017, 42% of people with stage 1 to 3 SCLC with PS 0 to 2 received multi-modality treatment with chemotherapy and radical radiotherapy or occasionally surgery, which is a year on year increase since 2015.
For SCLCs that are detected at a late stage, chemotherapy and radiotherapy can be used to improve quality of life and chances of medium-term survival.
NICE recommends that people with limited-stage SCLC should be offered 4 to 6 cycles of cisplatin-based combination chemotherapy and that people with extensive-stage SCLC should be offered a platinum-based combination chemotherapy.
Data from the NCLA show that the proportion of people with SCLC who receive chemotherapy has remained steady for the last few years at around 70%, which meets the NLCA’s audit standard.
Changes in commissioning
Stereotactic ablative radiotherapy (SABR) is a type of radiotherapy used to treat cancers by directing narrow beams of radiation at the cancer from different angles. The tumour gets a high dose of radiation and the surrounding healthy tissues get a low dose, reducing the risk of damage to healthy tissue.
Oligometastatic disease occurs when cancer cells from the original (primary) tumour travel and form a small number of new (metastatic) tumours. SABR is not routinely commissioned for the treatment of oligometastatic disease and was selected by NHS England for the Commissioning through Evaluation (CtE), which is part of its Evaluative Commissioning Programme.
CtE enables a limited number of patients to access treatments that are not funded by the NHS but show significant promise for the future, while new clinical and patient experience data are collected. NICE is commissioned by NHS England to oversee individual CtE schemes. The updated policy which will contain a summary of the results of the CtE scheme will be published on the NHS England Specialised Commissioning document library once a decision has been made.