Understanding Metastatic Non-Small Cell Lung Cancer (NSCLC)
Metastatic non-small cell lung cancer (NSCLC) is a complex illness that requires careful planning and coordinated treatment. It is considered an advanced form of NSCLC, classified as Stage 4. It begins in the lung and spreads to other parts of the body, most often the brain, bones, liver or adrenal glands. Although it is an advanced stage of disease, the outlook today thankfully is not what it was a decade ago. With targeted drugs, immunotherapy and precisely delivered radiotherapy, many patients live longer and healthier lives, especially when treatment is tailored to the tumour’s biology.
NSCLC is the most common type of lung cancer, accounting for around 85 percent of all lung cancers. It includes several subtypes, including adenocarcinoma and squamous cell carcinoma. Lung cancer is the third leading cause of cancer-related deaths in Singapore, significantly impacting people diagnosed across different populations. In the metastatic setting, decisions are based on accurate diagnosis, molecular testing, and the patient’s overall health status. The aim is to control disease, extend survival, and preserve quality of life while treating symptoms with precision and accuracy.
Causes and Risk Factors for NSCLC
Smoking remains the most substantial risk factor for NSCLC. That includes current smokers, former smokers, and those exposed to second-hand smoke. Other contributors include air pollution, occupational exposure to carcinogens such as asbestos or diesel exhaust, radon exposure, and a family history of lung cancer. Increasingly, oncologists see lung cancer in non-smokers, often driven by gene alterations such as EGFR, ALK, ROS1, MET, RET, or KRAS mutations.
However, only a subset of these genetic changes is considered to initiate or promote cancer progression. Among these, EGFR mutations are particularly significant in NSCLC, as they play a key role in tumour growth and have led to the development of targeted therapies, including EGFR inhibitors approved by regulatory agencies. These genetic changes are significant because they can be matched with targeted therapies that are far more effective than conventional chemotherapy in the right patients. All these risk factors and genetic changes contribute to the rising number of lung cancer cases worldwide.
Early Signs and Symptoms of NSCLC
The symptoms of metastatic non-small cell lung cancer vary. Some people have few or no symptoms early on, while others have clear warning signs. Common symptoms include a persistent cough, coughing up blood, chest pain, breathlessness or wheezing. Loss of appetite, unintentional weight loss and fatigue are also common.
When the cancer has spread, symptoms can appear in the affected organs. Bone pain, headaches, weakness, seizures, yellowing of the skin, abdominal pain, or lymph node involvement may indicate metastatic disease. Paraneoplastic syndromes are rare symptoms that can affect various parts of the body before primary cancer symptoms appear.
Any ongoing chest symptoms, particularly in a current or former smoker, warrant a medical review. Even in non-smokers, persistent cough or breathlessness should not be ignored. Prompt evaluation enables doctors to initiate treatment at the earliest possible time, often leading to improved outcomes.
Diagnosis and Staging for NSCLC
A careful diagnostic pathway underpins every treatment plan. This usually starts with a chest X-ray or a CT scan to identify suspicious nodules or mass lesions. A PET CT scan may be used to map active disease sites throughout the body. A brain MRI can be helpful if neurological symptoms are present.
A firm diagnosis requires a tissue sample for accurate evaluation. This can be obtained through bronchoscopy, endobronchial ultrasound-guided biopsy, CT-guided needle biopsy, or, in some cases, surgical biopsy. Removing a sample of the tumour and surrounding healthy tissue is vital for accurate diagnosis and to assess margins. Molecular testing is essential in metastatic non-small cell lung cancer because it identifies targetable gene alterations, and the test results significantly influence treatment choice. A blood test, known as a liquid biopsy, can sometimes detect these changes if tissue is hard to obtain.
Staging follows the TNM system, which describes the size and extent of the lung tumour, lymph node involvement and any spread to other organs. In metastatic disease, the emphasis is on determining the full extent of the cancer and identifying the most effective systemic therapy, while also planning local treatments where they are likely to add benefit. Stage 4 NSCLC represents the most advanced stage of the disease, characterised by metastasis to distant organs.
Treatment Options for NSCLC
Treatment for metastatic non-small cell lung cancer often includes a combination of tailored approaches. The choice depends on molecular profile, spread pattern, symptoms, performance status and patient goals. In metastatic cancer, a primary aim of treatment is to improve the quality of life for patients, as a cure is rarely possible.
Systemic therapy is the core of treatment. Targeted therapies are used when specific gene alterations are present. Drugs targeting EGFR, ALK, ROS1, BRAF, MET, RET, and other receptors can rapidly shrink tumours and keep them under control for months or years. Immunotherapy has transformed care for many patients whose tumours express PD-L1 or who lack targetable mutations. Immune checkpoint inhibitors, used alone or in combination with chemotherapy, can help the immune system recognise and attack cancer cells. Chemotherapy still plays an important role, especially when no actionable mutations are present.
Radiotherapy is used for control and symptom relief and has different types for different purposes. Stereotactic radiosurgery can treat small brain metastases with excellent precision. Stereotactic body radiotherapy can target lung or adrenal lesions. Broader-field radiotherapy can relieve pain from bone metastases or reduce tumour pressure on airways or nerves.
Supportive care is integrated throughout, addressing symptoms such as breathlessness, pain, cough, appetite, sleep disturbances, and mood disturbances. Treatments for metastatic NSCLC aim to extend life expectancy, even though prognosis is generally worse in advanced stages of the disease. The approach to treating metastatic NSCLC is similar to that for other cancers that have spread, with a focus on prolonging survival and managing metastatic symptoms.
Targeted Therapies
Targeted therapies have revolutionised the treatment of non-small cell lung cancer by targeting the specific genetic mutations that drive the growth and spread of lung cancer cells. Unlike traditional chemotherapy, which affects both healthy cells and cancer cells, targeted therapies are designed to block the action of specific genes or proteins, such as the epidermal growth factor receptor (EGFR), KRAS, and BRAF, which are crucial for cancer cell survival and proliferation.
These treatments can be used alone or in combination with chemotherapy and radiation therapy, providing a more personalised approach to managing non-small cell lung cancer. By directly targeting the underlying drivers of the disease, targeted therapies help many patients achieve better outcomes and improved quality of life, even in advanced stages where the cancer has spread beyond the lungs.
When Thoracic Surgery Helps
Although systemic therapy is the mainstay in metastatic non-small cell lung cancer, surgery still has a role in specific situations. A multidisciplinary team makes these decisions, comprising thoracic surgeons, medical oncologists, radiation oncologists, respiratory physicians, and radiologists.
Common examples where surgery can assist include a resectable primary lung tumour with a solitary brain or adrenal metastasis. In such cases, doctors may initially offer systemic therapy. If the disease responds and remains confined, surgeons may remove the primary tumour and, in some instances, the metastatic site. This approach is called local consolidative therapy and can include either surgery or stereotactic radiotherapy. Studies show it can delay progression and may improve survival in selected patients.
Surgery can also be used after a good response to targeted therapy or immunotherapy. If the cancer becomes confined to a single area in the lung, conversion surgery may be offered to remove the remaining disease and help achieve longer control.
Symptom-relieving surgery plays another critical role by addressing bleeding, infection, chest wall involvement, or a blocked airway that is not responding to other treatments. In addition, surgical biopsy or lymph node sampling may be needed when less invasive tests cannot provide a diagnosis or when tumour resistance needs to be analysed to guide the next line of therapy.
Minimally invasive techniques are preferred when possible. Video-Assisted Thoracic Surgery (VATS) and Robotic-Assisted Surgery (RATS) allow precise operations through small incisions. Depending on the situation, the surgeon may perform a wedge resection, segmentectomy or lobectomy, often with lymph node dissection.
Ideal candidates have limited metastatic burden, controlled disease outside the chest, good exercise tolerance and a favourable response to systemic therapy. Surgery is not the first-line treatment for stage four disease, but when used judiciously, it can complement modern therapies and improve outcomes.
Living With Metastatic NSCLC
Metastatic non-small cell lung cancer is a demanding diagnosis, but long-term support makes a difference. Patients benefit from clear information, a named point of contact, and access to allied health professionals such as physiotherapists, dietitians and counsellors. Pulmonary rehabilitation can help maintain lung function and stamina. Smoking cessation support is vital. Vaccinations and general health checks reduce the risk of infection and treatment interruptions.
Follow-up check-ups are important, through regular clinic visits, blood tests and scans. Doctors watch for changes that suggest drug resistance or progression at a specific site. As cancer progresses, treatment strategies evolve. A new biopsy may be recommended to test for resistance mutations, which can lead to a different targeted therapy.
Financial counselling and insurance support are often part of the journey. In Singapore, specialist care at centres such as Gleneagles Hospital and Mount Alvernia Hospital includes access to advanced imaging, day therapy units and well-established multidisciplinary meetings. These networks ensure that care is coordinated, efficient and consistent.
How Neumark Supports Your Care
At Neumark Lung and Chest Surgery Centre, we focus on precise diagnosis and personalised treatment plans for metastatic non-small cell lung cancer. We work closely with medical and radiation oncologists to sequence treatments at the appropriate times and to plan surgery when it adds value. When surgery is appropriate, we use minimally invasive techniques that offer faster recovery and less pain. Our team operates at Gleneagles Hospital and Mount Alvernia Hospital, where patients can benefit from comprehensive facilities, intensive care support when needed, and access to the full range of oncology services at both centres.
If you or a loved one has been diagnosed with metastatic non-small cell lung cancer, the right plan starts with a careful assessment. Contact Neumark to arrange a consultation. We are here to guide you through each stage with clarity, compassion and skilled hands.