Stage Four Lung Cancer: What To Ask Your Doctor
- Should I have genetic or molecular testing?
- Do I have any genetic mutation that would change the course of my treatment?
- Am I eligible for immunotherapy? Am I more, or less, likely to respond to this treatment?
- How aggressively should we treat my cancer?
- Are there clinical trials which might be relevant for me?
As Dr. Raja Flores, chair of the Department of Thoracic Surgery at Mount Sinai Hospital, “you have to realize stage 4, again, does not mean death. You can have stage 4s who are alive 8, 9, and 10 years later. There are people out there who are walking around who have had brain metastases, but it’s kept quiet.”Read More
Stage four lung cancer symptomsPatients with stage IV lung cancer may experience symptoms as the disease progresses. Some symptoms may include:
- Coughing up blood (hemoptysis)
- Hoarseness (change your voice into a raspier tone)
- Shortness of breath
- Loss of appetite
- Dizziness and loss of balance
- Jaundice (yellowish in eyes or skin)
- Lymph nodes swelling
- Bone pain
Lung cancer treatment optionsSome people who have stage 4 lung cancer may not need treatment right away, while others might need it right away depending on how much the tumor has grown and spread at diagnosis. The decision on whether to start treatment depends on many factors, including:
- The type of lung cancer you have; for example, small cell carcinoma tends to spread quickly but be responsive to chemotherapy
- Your overall health condition; for example: if you have other serious illnesses like heart disease or diabetes mellitus
- How well your body responds to certain types of treatment
Similarly, the treatment recommended will depend on several factors, including whether the cancer is a squamous cell or non-small cell, what biomarkers are present, your underlying health, and many other factors unique to each person.
Lung cancer types
Lung cancer can be classified into two main types: small cell lung cancer (SCLC), which accounts for 15%, and non-small cell lung cancer (NSCLC), which accounts for 85% percent of all lung cancers. NSCLC is more common than SCLC, but SCLC tends to be more difficult to treat because it’s more likely to spread to other parts of the body and recur after treatment.
NSCLC, on the other hand, can be subdivided into three subtypes:
- Adenocarcinoma, which starts in the cells producing mucus
- Squamous cell lung carcinoma, which affects the lining of the lungs and accounts
- Large cell carcinomas can be very hostile and start anywhere in the lungs
Traditional Stage 4 lung cancer treatment
In the past, chemotherapy–which attempts to kill all fast-growing cells in the body–was considered the treatment standard for stage four lung cancer, but treatment methodologies are rapidly changing nowadays.
Next to chemotherapy, there is also radiotherapy which uses high-energy rays to kill cancerous cells. Also, there’s surgery that can be done if the tumor is accessible — where it removes part or all of an organ for treatment, or sometimes it can be done for advanced diagnostic testing.
“The way we plan Stage 4 lung cancer today is using precision therapy,” Dr. Geoffrey Oxnard, a thoracic oncologist at Boston University School of Medicine, told SurvivorNet. “It’s the idea of moving away from just chemotherapy for all into finding the right medicine for the right patient.”
These advances involve testing your cancer for the presence of genetic mutations or molecular features, which might be targeted for relatively new medications. For some people, these medications are extending life in remarkable ways.
Lung cancer biomarker testing
Biomarker testing is one of the first steps in developing a treatment for stage 4 lung cancer. The way this works is you take a sample from your tumor or do a blood test and identify if there are any genetic mutations —alterations or changes in the genes or proteins— that have developed your cancer.
Generally, a gene produces a protein that’s responsible for a specific role inside the cell (for example, growth or building of blood vessels). Thus, when a mutation occurs, this protein is produced excessively in a way that makes a cancer cell stronger and able to spread faster. The goal of biomarker testing and targeted therapies is to identify these genes or proteins and give medications that specifically target these pathways. By providing this targeted therapy cancer cells may be killed while causing less damage to surrounding normal cells that do not express the same biomarkers.
This is what’s called a lung cancer genetic test — to test for the presence of a mutated or altered gene or protein (biomarker) that caused the cancer. There are multiple biomarkers that can be tested. Some of the more common biomarkers tested in lung cancer include the following:
- EGFR gene mutation
- ALK gene mutation
- KRAS gene mutation
- BRAF gene mutation
- NTKR gene mutation
- MET gene mutation
- RET gene mutation
For each of these biomarkers, there is a specific available therapeutic drug targeting and inhibiting it.
Recent Stage 4 lung cancer treatment
Targeted therapies (Precision medicine)
Targeted therapies for lung cancer are medications designed specifically for certain genetic mutations that have contributed to causing the cancer. Many researchers believe that targeted therapeutic drugs or precision medicine are simply put, attempting to match your treatment to your tumor’s biology and characteristics is the way forward.
Some examples include trastuzumab (Herceptin), EGFR inhibitors, ALK inhibitors, KRAS inhibitors, ROS1 inhibitors, MET inhibitors, RET inhibitors, and NTRK inhibitors. Getting genetic and molecular testing is, as we said, the key first step to determining if you are eligible for targeted therapy and deciding which one you’ll get.
For example, if your cancer is over-expressing epidermal growth factor receptor (EGFR)–a protein that makes cells grow and divide–drugs blocking EGFR may be used.
Other mechanisms like packing a specific toxic drug to an antibody that can bind to the target protein and destroy it are also available; these are called antibody-drug conjugates.
The advent of precision medicine is that we’re able to target specific genetic mutations in your tumor, which means that your treatment will be more effective and less toxic than ever before. The reason for this reduced toxicity is that targeted therapy seeks out very specific cancer cells and leaves the healthy cells alone. At the same time, chemotherapy tends to cause a lot of collateral damage because it kills all fast-growing cells–both healthy and cancerous.
Immunotherapies are drugs that recruit the immune system to fight cancer cells. With advanced non-small cell lung cancer, you may be eligible for a type of immunotherapy called a checkpoint inhibitor. These play a dual role in the human body.
They act as a label to make the immune system cells able to differentiate between normal and cancer cells. As such, when the immune system sees a cell with a checkpoint protein on its surface, it binds to it and deems it as a normal cell. However, in case there’s a cell that doesn’t hold this checkpoint protein, the immune system will switch on and deem it as a foreign cell (either from an infection or cancer cell) and goes on to attack and destroy it.
The problem is that sometimes cancer cells can trick the immune system into believing they are normal cells by having these checkpoints and binding to the immune cells and switching them off. Thus, checkpoint inhibitors were made; the way they work is by binding to the checkpoint to prevent the immune system from being tricked by the cancer cells.
For stage 4 lung cancer, there are two main checkpoint inhibitors, and these are PD-1/PDL-1 and CTLA4 inhibitors. Widely used checkpoint inhibitors include the drugs Keytruda (pembrolizumab), Opdivo (nivolumab), Tecentriq (atezolizumab), Yervoy (ipilimumab), and Libtayo (cemiplimab-rwlc) and Imfinzi (durvalumab).
Sometimes these drugs are given as monotherapy and others work better coupled with additional treatments like chemotherapy. Your treatment team will decide how these drugs should be given to you based on your unique situation. However, it is important to understand that these drugs do not work for everyone and can sometimes stop working after some time.
Your doctor will give you all your options regarding the best option for your treatment. In fact, Dr. Flores reiterates the importance of each of these treatments for metastatic lung cancer patients. He shared with SurvivorNet, “It’s very important to take things step by step. So usually, with stage 4, it’s chemotherapy. And I never take surgery off the table.” He also added, “When you have a stage 4 patient, it’s important to make sure that they understand that chemotherapy is something that they have to look at, but it’s not the only option.”
This only confirms that even though a diagnosis of late-stage lung cancer can be overwhelming, it’s not a death sentence. Actually, there are multiple options to treat this disease, and they are all applicable but vary depending on the patient’s medical care and overall health.
Palliative care focuses on symptoms such as pain management and other problems that are not directly related to cancer itself but can affect the quality of life during treatment and after it’s over (for example, shortness of breath, nausea, depression, or fatigue). Even if you are receiving treatment for your lung cancer palliative care can play an important role in managing your symptoms and improving your quality of life.
You may have many questions about your treatment options, prognosis, and ongoing care. It might seem overwhelming to ask these questions, but it’s important to talk with your doctor about what you want to know. They can help you figure out what information you’d like to know and how best to get it.
The Bottom Line
It’s safe to say we’ve entered a new era of treating metastatic cancers with options like immunotherapy, molecular profiling, genetic testing, and precision medicine.
Remember, no matter what treatment you end up choosing, there are many things you can do to help manage your cancer and improve your quality of life. You can start by reaching out to fellow cancer patients that can share their experiences — or you can also look up alternative treatments that may provide relief from cancer symptoms like fatigue, muscle pain, and depression.