Lung Cancer Treatment

Lung cancer treatment may involve surgery, radiotherapy, chemotherapy, targeted therapy, immunotherapy or a combination of treatments. The treatment plan for lung cancer depends on its type and stage, the tumour’s molecular features, whether it can be removed completely and the person’s overall health.

Treatment may aim to cure lung cancer, reduce the risk of it returning, control its growth or relieve symptoms. Some people need one main treatment. Others receive several treatments before, during or after surgery or radiotherapy.

There is no single treatment for lung cancer that is suitable for everyone. Accurate diagnosis and staging are therefore important before treatment begins.

In Singapore, lung cancer is the third most common cancer for both men and women. Early-stage lung cancer may cause no symptoms, and common symptoms may not appear until more advanced stages. A persistent cough, chest pain, shortness of breath or unexplained weight loss needs medical assessment. Diagnostic tests help diagnose lung cancer and determine whether cancer has spread.

Cigarette smoking causes most lung cancer cases, but the disease also occurs in people who have never smoked. Risk factors for developing lung cancer include secondhand smoke, radon, outdoor air pollution, occupational carcinogens, older age, family history and some previous lung diseases. These risk factors indicate an increased risk of developing lung cancer, not a diagnosis.

How Is Lung Cancer Treatment Chosen?

A multidisciplinary healthcare team of cancer specialists usually reviews several pieces of information when recommending lung cancer treatment because the types of lung cancer can respond differently.

These include:

• The types of lung cancer, mainly NSCLC and SCLC
• The stage of the lung cancer
• The tumour’s location and relationship to nearby structures, including blood vessels
• Whether surrounding lymph nodes contain cancer
• Whether lung cancer can be removed completely
• Molecular biomarkers and PD-L1 test results
• Lung function, heart health and general fitness
• Other medical conditions
• Previous cancer treatment
• Symptoms and their effect on daily life
• The person’s priorities and treatment goals

Resectability and operability are related but different. Resectability describes whether lung cancer can be removed completely from a technical and cancer-control perspective. Operability describes whether a person is medically fit enough to undergo the proposed operation.

A tumour may be technically removable, but surgery may not be appropriate if the remaining lung function would be insufficient. Conversely, a fit person may still have cancer that cannot be removed completely because of its location or extent.

Lung Cancer Diagnosis and Diagnostic Tests

Lung cancer diagnosis and the treatment plan are developed together. Once lung cancer is diagnosed, tests confirm its type and show how far it has spread.

Imaging Tests and Staging

A chest X-ray may identify an abnormal area, but a CT scan provides more detailed information about the lungs, tumour and nearby structures. Further imaging tests may include positron emission tomography combined with CT (PET-CT) and magnetic resonance imaging (MRI) of the brain, depending on the suspected cancer type and stage.

PET-CT uses a small amount of radioactive material to show areas with increased metabolic activity and help assess nearby lymph nodes. Infection and inflammation may also appear active. These imaging tests can suggest cancer spread, but they cannot confirm that an area contains cancerous cells.

The TNM staging system describes the tumour, regional lymph nodes and distant metastasis. NSCLC is grouped from Stage 0 to Stage IV. SCLC is commonly described as limited-stage or disease outside the limited-stage area, although TNM staging may also be used.

Biopsy and Pathology

A biopsy removes tissue samples or cells for examination and helps diagnose lung cancer. The method depends on the tumour’s size and location, the person’s health and whether lymph nodes or other sites also need sampling.

Biopsy methods may include:

• Bronchoscopy for tumours within or close to the airways
• Endobronchial ultrasound (EBUS) for lymph nodes in the centre of the chest
• CT-guided needle biopsy for selected peripheral lung lesions
• Sampling of fluid around the lung when a pleural effusion is present
• Mediastinoscopy when additional surgical lymph node assessment is needed
• Surgical biopsy in selected cases

A pathologist determines whether abnormal cells are cancerous, distinguishes the main types of lung cancer, and identifies subtypes such as adenocarcinoma or squamous cell carcinoma. The biopsy should provide enough information for diagnosis while preserving tissue for biomarker testing when possible.

Molecular and Biomarker Testing

Molecular testing looks for genetic mutations and other changes within lung cancer cells that may influence treatment. Testing is particularly important in advanced NSCLC and may also affect treatment before or after surgery in selected earlier-stage cancers.

Depending on the cancer subtype and clinical situation, testing may look for alterations involving genes such as EGFR, ALK, ROS1, BRAF, KRAS, MET, RET, NTRK and HER2. The exact panel may change as evidence and treatment availability develop.

PD-L1 testing measures a protein that can help guide the use of certain immunotherapies. PD-L1 is not the same as a gene mutation, and it should be considered alongside the cancer type, stage and molecular results.

Biomarker testing may use tumour tissue or, in some situations, a blood sample called a liquid biopsy. A negative blood result does not always exclude a molecular alteration. Tissue testing may still be needed if it can be performed safely.

Assessing Fitness for Treatment

Tests may include a lung function test, blood tests, heart assessment and exercise evaluation. These tests estimate whether enough lung function will remain after part of the lung is removed.

Before chemotherapy, molecularly targeted medicines or immunotherapy, the team may assess blood counts and kidney, liver, heart or endocrine function. The tests required depend on the proposed treatment and the person’s medical history.

Understanding the Aim and Timing of Treatment

The healthcare team at Neumark Lung & Chest Surgery Centre may use several terms to describe when and why a treatment is given.

Palliative care does not mean that active cancer treatment has stopped. It can begin at diagnosis and continue alongside surgery, radiotherapy or systemic therapy.

Lung Cancer Treatment Options

Lung cancer treatment options allow doctors to treat lung cancer in different ways. Local treatments, such as surgery and radiotherapy, target a particular area. Systemic treatments travel through the bloodstream to treat lung cancer cells in different parts of the body.

Lung Cancer Surgery

Surgical procedures are commonly considered for early-stage NSCLC when the tumour can be removed completely, and the person is medically fit. Surgery may also form part of treatment for selected locally advanced cancers but has a much smaller role in SCLC.

An operation may remove:

• A wedge-shaped section of lung
• One anatomical lung segment
• One lung lobe
• Two neighbouring lobes of the right lung
• An entire lung in selected situations

The surgeon usually removes or samples lymph nodes during the operation. Examining these nodes helps establish the pathological stage and determine whether treatment should be considered after surgery.

Lung cancer surgery may be performed through open chest surgery or a minimally invasive approach such as Video-Assisted Thoracoscopic Surgery or Robotic-Assisted Thoracic Surgery. The appropriate approach depends on the tumour’s position, size, stage and technical complexity.

More information about eligibility, procedures, risks and recovery is available in the guide to lung cancer surgery.

Radiotherapy

Radiotherapy, also called radiation therapy, uses high-energy radiation to destroy cancer cells within a planned treatment area.

Radiotherapy may be used:

• As the main treatment for early-stage cancer when surgery is unsuitable
• Together with chemotherapy for locally advanced cancer
• Before or after surgery in selected cases
• To treat a limited number of metastatic sites
• To relieve pain, bleeding, airway pressure or other symptoms

Stereotactic body radiotherapy, also called stereotactic ablative radiotherapy, delivers a focused dose to a small target. It may be considered for selected lung cancers in the early stages when an operation is not appropriate.

When chemotherapy and radiotherapy are given during the same treatment period, this is called concurrent chemoradiotherapy. Some people cannot tolerate concurrent treatment and may receive the treatments sequentially instead.

Possible radiotherapy side effects include tiredness, skin irritation, discomfort when swallowing and inflammation of the lung. The risks depend on the treatment area, dose and surrounding organs.

Chemotherapy

Chemotherapy uses medicines that circulate through the bloodstream to treat cancer throughout the body. These medicines can kill cancer cells that divide quickly.

It may be given:

• Before surgery to shrink or control the cancer
• After surgery to reduce the risk of recurrence
• At the same time as radiotherapy
• As part of treatment for metastatic or recurrent cancer
• As the principal treatment for many SCLC cases

Chemotherapy commonly involves a combination of medicines delivered in treatment cycles. The exact combination depends on the cancer type, stage, previous treatment, kidney function and general health.

Chemotherapy can also affect normal cells. Possible side effects include tiredness, nausea, appetite changes, reduced blood counts, increased infection risk, numbness in the hands or feet and changes to the hair, skin or nails. Side effects vary between medicines and can often be reduced or managed with supportive treatment.

Targeted Therapy

Targeted therapy blocks a specific molecular change or signalling pathway that helps cancer cells grow. It is used only when testing shows that the cancer has an alteration that an available treatment can target.

Targeted therapy is an important option for many biomarker-defined advanced NSCLC cases. Selected targeted therapies may also be used after surgery or after chemoradiotherapy, particularly in earlier-stage cancers.

Many targeted treatments are taken as tablets, although the method of administration varies. They can cause skin changes, diarrhoea, liver abnormalities, heart effects, lung inflammation, or other treatment-specific problems. Cancer may also develop resistance over time, which can lead to further molecular testing and a change in treatment.

Immunotherapy

Immunotherapy treatment helps the body’s immune system recognise and attack cancer cells. Immune checkpoint inhibitors block signals that cancer cells may use to avoid an immune response.

Depending on the cancer type, stage, biomarkers and treatment history, immunotherapy may be used:

• Before or after surgery
• With chemotherapy before surgery
• After combined chemotherapy and radiotherapy
• With chemotherapy for advanced cancer
• On its own in selected advanced cancers
• As maintenance or consolidation treatment

Immunotherapy is not suitable for every person or every lung cancer. Molecular results, PD-L1 expression, autoimmune conditions, organ transplants and previous treatment may influence whether it is appropriate.

Immune-related side effects occur when the activated immune system inflames healthy tissue. These reactions may affect the lungs, bowel, liver, skin, thyroid gland or other organs. New breathlessness, persistent diarrhoea or other significant symptoms should be reported promptly.

Supportive and Palliative Care

Supportive care addresses the physical and emotional effects of lung cancer and its treatment. It can be provided from diagnosis through the advanced stages, including when treatment has curative intent.

Care may include:

• Relief of pain, breathlessness, cough or nausea
• Nutritional support
• Physiotherapy and pulmonary rehabilitation
• Help with fatigue, sleep or anxiety
• Smoking cessation support
• Drainage or control of a recurrent pleural effusion
• Procedures to relieve an obstructed airway
• Social, psychological and caregiver support

Early symptom management can help people remain active and continue treatment more comfortably.

Clinical Trials

Clinical trials study new treatments, treatment combinations and ways of using established treatments. A trial may be an option at different stages of lung cancer, but participation is voluntary.

The healthcare team can explain the purpose of a trial, possible alternatives, additional tests and known or uncertain risks.

Non-Small Cell Lung Cancer Treatment by Stage

NSCLC treatment can differ within the same stage because tumour location, lymph node involvement, biomarkers and fitness also matter. The following table provides a general overview.

Stage 0 Non-Small Cell Lung Cancer

At Stage 0, abnormal cells, including cancerous cells, remain within the lining where they began and have not invaded deeper tissue. Treatment may involve limited surgery or, for selected centrally located lesions, a bronchoscopic local treatment.

The tumour’s exact pathology and location determine the appropriate approach.

Stage I Non-Small Cell Lung Cancer

Stage I lung cancer remains confined to the lung without lymph node or distant spread.

Surgery is commonly considered when the person is medically fit. A lobectomy is frequently used, although segmentectomy or wedge resection may be appropriate for selected small tumours or when preserving lung tissue is important. Lymph node assessment remains part of cancer surgery.

Stereotactic radiation therapy may be considered when surgery is unsuitable. Treatment after surgery depends on the tumour’s size, pathological features, margins and biomarkers.

Stage II Non-Small Cell Lung Cancer

Stage II lung cancer may involve a larger tumour, nearby structures or regional lymph nodes, without distant metastasis.

Surgery may form part of treatment when the cancer is resectable. Chemotherapy and selected immunotherapy may be given before or after surgery. An eligible targeted medicine may be considered after surgery when testing identifies a relevant molecular alteration.

Radiation therapy may be used when surgery is not suitable or in selected situations after an operation.

Stage III Non-Small Cell Lung Cancer

Stage III lung cancer includes a wide range of locally advanced cancers. Determining whether surgery has a role requires detailed review of the tumour, involved lymph nodes and nearby structures.

Selected resectable Stage III cancers may be treated with systemic therapy before surgery, followed by an operation and sometimes further systemic treatment. Other resectable cancers may undergo surgery first, followed by treatment based on the pathological findings.

When the cancer cannot be removed completely, concurrent chemotherapy and radiotherapy commonly form the main treatment for people fit enough to receive both. Immunotherapy or, for selected biomarker-defined cancers, a molecularly targeted treatment may be considered after chemoradiotherapy.

Stage IV and Recurrent Non-Small Cell Lung Cancer

Stage IV lung cancer means cancer has spread to the opposite lung, pleura, pericardium or another part of the body. Recurrent lung cancer has returned after previous treatment.

Systemic treatment usually forms the basis of care. The choice may involve targeted therapy, immunotherapy, chemotherapy or a combination, depending on molecular alterations, PD-L1 expression, cancer subtype, previous treatment and general health.

Radiotherapy, surgery or another local procedure may still be useful for a limited metastatic pattern or to relieve symptoms. Further information is available in the dedicated guide to metastatic lung cancer treatment.

Small Cell Lung Cancer Treatment

Small cell lung cancer generally grows and spreads more quickly than non-small cell lung cancer. Treatment usually relies more heavily on systemic therapy and radiotherapy.

Very Early Small Cell Lung Cancer

Surgery may be considered for uncommon, very early SCLC that appears confined to the lung without lymph node involvement. Careful imaging and invasive lymph node staging are generally required before proceeding. Chemotherapy is usually recommended after surgery. Radiotherapy may also be considered according to the surgical and pathological findings.

Limited-Stage Small Cell Lung Cancer

Limited-stage SCLC can generally be included within a practical chest radiotherapy field. Treatment commonly involves chemotherapy combined with chest radiotherapy. Additional immunotherapy may be considered after chemoradiotherapy for selected patients. Preventive brain radiotherapy or regular brain MRI surveillance may also be discussed. The balance of potential benefit and side effects should be considered individually.

Extensive-Stage Small Cell Lung Cancer

Extensive-stage disease means cancer has spread beyond the area used to define limited-stage cancer. Initial treatment commonly involves chemotherapy combined with immunotherapy when suitable. Radiotherapy may be used to relieve symptoms caused by cancer in the brain, bones, chest or other areas. Selected patients whose cancer responds to systemic therapy may also be considered for chest radiotherapy.

Recurrent Small Cell Lung Cancer

Treatment for recurrent SCLC depends on how long the cancer remained controlled, where it has returned, previous treatment and general health. Options may include further chemotherapy, immunotherapy, radiotherapy, symptom-relieving procedures or a clinical trial.

Managing Side Effects During Treatment

Every treatment for lung cancer can cause side effects, but the pattern varies considerably. The healthcare team should explain which problems are expected, which can be managed at home and which require urgent assessment.

Prompt medical advice may be needed for:

• Fever or signs of infection during chemotherapy
• New or worsening breathlessness
• Significant chest pain
• Coughing up more than a small amount of blood
• Persistent vomiting or diarrhoea
• Confusion, weakness, seizures or severe headaches
• Symptoms of an allergic or infusion reaction
• Severe tiredness accompanied by dizziness or reduced alertness

Side effects do not necessarily mean treatment has failed. However, early reporting allows the team to provide supportive medicines, adjust the schedule or investigate potentially serious complications.

How Is the Response to Treatment Assessed?

The healthcare team may repeat CT, PET-CT, MRI or other imaging tests to assess whether the cancer has responded. The appropriate test and timing depend on the treatment and cancer stage.

After surgery, the pathology report provides information about:

• The cancer type and size
• Whether the tumour was removed with clear margins
• Whether lymph nodes contain cancer
• The final pathological stage
• Biomarkers that may affect further treatment

During systemic therapy, scans may show that the cancer has shrunk, remained stable or grown. Results are considered together with symptoms, physical health and treatment side effects.

After treatment with curative intent, follow-up usually includes clinical reviews and periodic chest imaging. The exact schedule depends on the stage, treatment received and current clinical guidance.

Planning Lung Cancer Treatment in Singapore

Lung cancer care may involve cancer specialists in thoracic oncology, medical oncology and clinical oncology. The multidisciplinary team may include a respiratory physician, thoracic surgeon, medical oncologist, radiation oncologists, radiologists, pathologists, specialist nurses and supportive care professionals.

Multidisciplinary review is particularly important when:

• Surgery may form part of treatment
• Lymph node findings are uncertain
• Stage III cancer is suspected
• Several treatments could be appropriate
• The cancer has a potentially targetable molecular alteration
• More than one lung nodule is present
• Previous treatment has stopped controlling the cancer

A second opinion may be helpful when the diagnosis, stage or recommended treatment is uncertain. Pathology slides, scan images and molecular reports can usually be reviewed without repeating every test.

Thoracic Surgical Lung Cancer Specialists at Neumark

Neumark Lung and Chest Surgery Centre specialises in minimally invasive thoracic surgery with a multidisciplinary approach led by Dr Harish Mithiran, senior consultant thoracic surgeon at Gleneagles and Mount Alvernia hospitals.

A thoracic surgical assessment may be appropriate when imaging shows one or more suspicious lung tumours, a biopsy confirms potentially operable lung cancer or cancer specialists are considering surgery as part of a combined treatment plan.

The assessment may include reviewing the scans, pathology, lymph node findings, lung function and whether a section, lobe or entire lung would need to be removed. When other treatment is required, the thoracic surgeon may coordinate care with cancer specialists in medical oncology, clinical oncology, respiratory medicine and other relevant disciplines.

Patients can contact Neumark to discuss whether a thoracic surgical assessment is appropriate.

Frequently Asked Questions about Lung Cancer Treatment

Can lung cancer be cured?

Some early-stage and selected locally advanced lung cancers can be treated with curative intent. The likelihood depends on the cancer type, stage, ability to remove or control all known disease, tumour biology and response to treatment. Advanced lung cancer is usually treated to control the disease, relieve symptoms and support quality of life, although outcomes vary considerably.

Is surgery always required for lung cancer?

No. Surgery is mainly used for resectable non-small cell lung cancer in people medically fit for an operation. Radiotherapy may be used instead for some early cancers, while locally advanced or metastatic cancer often requires systemic therapy, radiotherapy or both.

How soon should lung cancer treatment begin?

Treatment should begin after the essential diagnostic, staging and biomarker information has been obtained. Starting without this information could lead to an unsuitable treatment. The required timing depends on the cancer type, symptoms and rate of progression. Small cell lung cancer and cancers causing serious symptoms may require more urgent treatment.

How do doctors know whether treatment is working?

Doctors assess symptoms, physical health and imaging results. Blood tests may monitor treatment safety, but they do not usually replace imaging. After surgery, the pathology report shows whether the tumour was removed completely and whether lymph nodes contain cancer.

Does lung cancer treatment differ for people who have never smoked?

Treatment is based on the cancer rather than smoking status alone. However, certain molecular alterations are more common in lung cancers affecting people who have never smoked. Biomarker testing may therefore identify a targeted treatment option.

What happens if a person is not fit for surgery?

An operation is not the only form of lung cancer treatment. Focused radiotherapy may be considered for selected early-stage cancers. Chemotherapy, immunotherapy, targeted therapy, conventional radiotherapy and supportive care may also be used according to the cancer and the person’s health.