Which treatment for advanced lung cancer?

• A quick guide to what's on this page
• How your treatment is planned
• Treating a blocked airway
• Treating fluid on the lung (pleural effusion)
• Treatment if the fluid comes back

• Treating brain secondaries
• Treating superior vena cava obstruction (SVCO)
• New treatments
• Deciding about treatments

Chemotherapy or radiotherapy may be used to treat advanced lung cancer. They can shrink the cancer or stop it growing and so can help to reduce symptoms and keep you well for longer. A biological therapy called erlotinib (Tarceva) is sometimes used when chemotherapy is no longer working.

The treatment that is best for you depends on

• The type of lung cancer you have
• Where the cancer has spread to in the body
• The treatment you have already had
• Any other medical conditions you might have

If the cancer has spread to just one area - for example in one or two bones, you may have radiotherapy. If the doctor thinks the cancer is in more than one area of the body, you may have chemotherapy or biological therapy. This is because chemotherapy and biological therapy treat the whole body and radiotherapy treats only the area it is aimed at. Chemotherapy may be given as injections into a vein or as capsules that you swallow. You usually have biological therapy for lung cancer as a tablet.

If you have already had radiotherapy to a particular part of the body, it may not be possible to give any more to that area. This is because there is a maximum amount of radiation that can be given to each part of the body before it causes too many side effects. Your doctor may then suggest chemotherapy or biological therapy instead.

If the cancer is blocking, or partly blocking, an airway and making you breathless your doctor may suggest one of several treatment options. You may have internal radiotherapy (endobronchial radiotherapy), electrocautery, laser therapy, light treatment (photodynamic therapy) radiofrequency ablation, or treatment with a freezing probe (cryotherapy). These are all ways of destroying the cancer that is causing the blockage. If the tumour is squashing your airway and making it difficult for you to breathe comfortably, your doctor may suggest putting in a rigid tube to keep the airway clear. This tube is called a stent. There is detailed information about all these treatments on the page about treating a blockage in an airway.

It is quite common for people with lung cancer to develop a collection of fluid between the sheets of tissue covering the lung (the pleura). This is called a pleural effusion. It makes you breathless because it takes up space in your chest - space that your lung would normally fill when you breathe in.

The treatment is to drain off the fluid. This is called thoracentesis (thora-sen-tee-sis). Your doctor will ask you to sit comfortably, leaning forward onto a table or back of a chair. First, you have a local anaesthetic injection into one side of your back. When the anaesthetic has had time to work, the doctor makes a small cut in the area and puts in a needle called a cannula. This hollow needle is attached to a tube with a drainage bottle (or bag) at the end.

If you have more than a litre of fluid inside your chest, it needs to be drained off slowly. So the doctor will put in a stitch to hold the cannula in place. Once it is secure, you can walk around carrying the drainage bottle. You may stay in hospital for a day or two while the fluid drains. Once the drainage has stopped, you will have a chest X-ray to make sure the fluid has all gone and then the drain can be taken out. This takes a short time. Your nurse will put a dressing over the small wound site and then you can go home. If you had a stitch to hold the drain in, this will need to be taken out after about a week.

Some people can keep the tube in for weeks or months - this is called an indwelling catheter. Sometimes the pleura stick together again after a while and the fluid stops building up and the tube can then be removed.

Remember - if your tube is connected to a bag or bottle, don't raise it above the level where the tube goes into your chest. If you do, you could allow the fluid back in.

Unfortunately, the fluid can build up again. You can have it drained more than once. But it isn't a good idea to keep on doing it, as you are likely to get an infection there in the end. If the fluid keeps building up, or your doctor thinks that it will, you may have treatment to try to stop it. This treatment is called pleurodesis (ploo-ro-dee-sis). The fluid collects between the two pleural membranes that cover the lung. Pleurodesis aims to stick the two pleura together, so there is no space for the fluid to collect. This won't make your breathing worse in any way.

The procedure is the same as for draining a pleural effusion. Sometimes it is carried out using video assisted thorocoscopy. But after the fluid has drained off, your doctor injects a powder or fluid through the cannula. The injection is a substance that irritates the pleura and makes them stick together. It may be plain talc, or an antibiotic or a chemotherapy drug called bleomycin. Once the talc or drug is in, the doctor clamps off the tube for an hour or so. Your doctor may ask you to shift position every 10 minutes or so (side to side and front to back). This helps to move the drug or talc around inside so that it coats the pleura all over. After the hour is up, your doctor may connect a suction tube, which helps the pleura to stick to each other.

You may have a bit of chest pain after the procedure. Do ask for painkillers if you need them. Then the tube can come out, the stitch is pulled together and a dressing put on. Once again, the stitch will need to come out after about a week. There is detailed information about pleurodesis in the lung cancer questions section.

Small cell lung cancer more often spreads to the brain than non small cell lung cancer. Cancer spread to the brain may make you drowsy and confused. Or you may have severe headaches and sickness. It is most likely to be diagnosed with a brain scan - either a CT scan or MRI scan. The treatment is usually radiotherapy to the head, together with steroid tablets to control symptoms. The treatment can cause short term side effects that include tiredness, headaches and feeling or being sick for a few weeks. Your doctor can give medicines to reduce these effects. If you are very tired you may need to rest a lot and have help and support from your family or friends.

There is detailed information about dealing with the side effects of brain radiotherapy in the brain tumour section. If you go to the brain tumour section you will need to use the back button at the top left of your screen if you want to come back to the lung cancer section.

SVCO can sometimes occur with advanced lung cancer. The vena cava is a large vein that carries blood from the brain, head and arms back to the heart. If the cancer squashes or blocks this vein, there is a build up of pressure behind the blockage so that fluid seeps out from the bloodstream and collects in the tissues of the face. People developing SVCO might notice swelling around their eyes, particularly first thing in the morning. SVCO can happen quite quickly or may take several weeks to develop.

Treatments are aimed at reducing the blockage of the vein and relieving symptoms. Steroids, such as prednisolone or dexamethasone, are often used to reduce swelling. Other treatments depend on the type of lung cancer you have. Chemotherapy might be used for small cell lung cancer and radiotherapy for non small cell lung cancer. Sometimes doctors put a metal tube (stent) inside the vein to keep it open. They might use this if SVCO develops rapidly, particularly if the cancer has not yet been fully diagnosed. Or if chemotherapy or radiotherapy does not help to relieve symptoms.

Trials of experimental treatments are going on and you may be able to take part in one. Some trials are for new chemotherapy drugs or new combinations of drugs.

Some biological therapies are being researched in advanced lung cancer. Some types stop cancers from making new blood vessels. These drugs are called antiangiogenesis drugs. Without its own blood supply, a cancer cannot continue to grow. Bevacizumab (also called Avastin) is an antiangiogenic monoclonal antibody (MAB) being used in trials for advanced non small cell lung cancer. It is sometimes combined with chemotherapy or other biological therapies.

You may want to look at the lung cancer research page for information about other areas of research. If you would like to find a particular trial, or see which trials are open, you can look at our clinical trials database in the cancer research section of CancerHelp UK.  Pick 'lung' from the drop down menu of cancer types. There is information about the clinical trial process , including information about taking part in trials.

It can be difficult to decide which treatment to try, or whether to have treatment at all, when you have an advanced cancer. You will need to consider your quality of life while you are having the treatment. This includes the possible side effects as well as stresses such as travelling back and forth to the hospital. Most importantly, you will need to understand what can be achieved with the treatment you are being offered.

Your doctor will discuss the treatment options with you. There may also be a counsellor or specialist nurse at the hospital you could chat to. You may also want to talk things over with a close relative or friend.

If you would like to talk to someone outside your own friends and family, look on our cancer information organisations page for counselling organisations. To find out more about counselling look in what is counselling?