Chemotherapy for non-small cell lung cancer

Chemotherapy (chemo) is treatment with anti-cancer drugs injected into a vein or taken by mouth. These drugs enter the bloodstream and go throughout the body, making this treatment useful for cancer that has spread (metastasized) to distant organs. Depending on the stage of lung cancer, chemo may be used in different situations:

• Chemo (sometimes along with radiation therapy) may be used to try to shrink a tumor before surgery. This is known as neoadjuvant therapy.
• Chemo (sometimes along with radiation therapy) may be given after surgery to try to kill any cancer cells that may have been left behind. This is known as adjuvant therapy.
• Chemo may be given as the main treatment (sometimes along with radiation therapy) for more advanced cancers or for some people who aren't healthy enough for surgery.

Doctors give chemo in cycles, with a period of treatment (usually 1 to 3 days) followed by a rest period to allow the body time to recover. Some chemo drugs, though, are given every day. Chemo cycles generally last about 3 to 4 weeks, and treatment typically involves 4 to 6 cycles. Chemo is often not recommended for patients in poor health, but advanced age by itself is not a barrier to getting chemo.

Most often, treatment for lung cancer uses a combination of 2 chemo drugs. Studies have shown that adding a third chemo drug doesn't add much benefit and is likely to cause more side effects. Single-drug chemo is sometimes used for people who might not tolerate combination chemotherapy well, such as those in poor overall health or who are elderly.

The chemo drugs most frequently used for non-small cell lung cancer are:

• Cisplatin
• Carboplatin
• Paclitaxel (Taxol^®)
• Albumin-bound paclitaxel (nab-paclitaxel, Abraxane^®)
• Docetaxel (Taxotere^®)
• Gemcitabine (Gemzar^®)
• Vinorelbine (Navelbine^®)
• Irinotecan (Camptosar^®, CPT-11)
• Etoposide (VP-16^®)
• Vinblastine
• Pemetrexed (Alimta^®)

Often a combination that includes either cisplatin or carboplatin plus one other drug is used. Sometimes combinations with less severe side effects, such as gemcitabine with vinorelbine or paclitaxel, may be used.

For people with advanced lung cancers who meet certain criteria, targeted therapy drugs such as bevacizumab (Avastin^®) or cetuximab (Erbitux^®) may be added to initial treatment as well (see the "Targeted therapies for non-small cell lung cancer" section).

If the initial chemo treatment for advanced lung cancer is no longer working, the doctor may recommend second-line treatment with a single drug such as docetaxel or pemetrexed. Another option may be the targeted therapy erlotinib (Tarceva^®) (see the "Targeted therapies for non-small cell lung cancer" section). Again, advanced age is no barrier to receiving these drugs as long as the person is in good general health.

Some doctors may recommend second-line treatment with a single chemo or targeted drug, even in people who have had a good response to their initial chemotherapy. The intent is to try to keep the lung cancer from growing or coming back for as long as possible and hopefully help patients live longer. This concept, known as maintenance therapy, is still being studied, as it's not yet clear if the possible benefits outweigh the risks and side effects. For more information, see "What's new in non-small cell lung cancer research and treatment?"

Possible side effects

Chemo drugs work by attacking cells that are dividing quickly, which is why they work against cancer cells. But other cells in the body, such as those in the bone marrow (where new blood cells are made), the lining of the mouth and intestines, and the hair follicles, also divide quickly. These cells are also likely to be affected by chemo, which can lead to certain side effects.

The side effects of chemo depend on the type and dose of drugs given and the length of time they are taken. Some common side effects include:

• Hair loss
• Mouth sores
• Loss of appetite
• Nausea and vomiting
• Diarrhea or constipation
• Low blood counts

Chemo can affect the blood-forming cells of the bone marrow, leading to low blood counts. This can cause:

• Increased chance of infections (from low white blood cell counts)
• Easy bruising or bleeding (from low blood platelet counts)
• Fatigue (from low red blood cell counts)

These side effects are usually short-term and go away after treatment is finished. There are often ways to lessen these side effects. For example, there are drugs that can be given to help prevent or reduce nausea and vomiting.

Some drugs such as cisplatin, vinorelbine, docetaxel, or paclitaxel can damage nerves. This can sometimes lead to symptoms (mainly in the hands and feet) such as pain, burning or tingling sensations, sensitivity to cold or heat, or weakness. This is called peripheral neuropathy. In most cases this goes away once treatment is stopped, but it may be long lasting in some people. For more information, see our document, Peripheral Neuropathy Caused by Chemotherapy.

You should report this or any other side effects you notice while getting chemotherapy to your medical team so that they can be treated promptly. In some cases, the doses of the chemotherapy drugs may need to be reduced or treatment may need to be delayed or stopped to prevent the effects from getting worse.

For more information about chemotherapy, please see our document, Understanding Chemotherapy: A Guide for Patients and Families.