LUNG CANCER
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Treatments for Lung Cancer

Treatment Overview

Surgery, radiotherapy and chemotherapy may be used separately or together to treat people with lung cancer. This booklet discusses separately the treatments for small cell lung cancer and non-small cell lung cancer. This is because they can be quite different.

Your doctor will plan your treatment by taking into account a number of things, including:

your general health
the type of lung cancer (small cell or non-small cell)
the size and position of the tumour
whether it has spread beyond the lung (the stage of the cancer).

If you have any questions about your treatment, don't be afraid to ask your doctor or the nurse looking after you. It often helps to make a list of questions, and to take a friend or relative with you.

Treatment for Small cell lung cancer

Chemotherapy is the main treatment for people with small cell lung cancer. In many people, chemotherapy will enable them to live for longer, with better control of symptoms. Chemotherapy may be given on its own, or before radiotherapy. Sometimes chemotherapy and radiotherapy are given at the same time; this is known as chemoradiation.

Surgery is not usually used to treat people with small cell lung cancer, except if the cancer is found very early. This is because the cancer has usually spread to other parts of the body before being diagnosed, even if it can't be seen on a scan.

If an operation is possible, chemotherapy or radiotherapy may be given after surgery to help reduce the risk of the cancer coming back. Giving treatment in this way is known as adjuvant treatment.

The scans and tests you had to diagnose the cancer may be repeated later, to see how well you are responding to treatment.

Radiotherapy is sometimes given to the head (known as prophylactic cranial radiotherapy) to reduce the risk of the cancer spreading to the brain. This may be done for people with small cell lung cancer, if chemotherapy has worked very well or if they have had surgery to remove the tumour.

Radiotherapy may also be used effectively in people with advanced small cell lung cancer, to relieve symptoms such as pain.

Treatment for Non-small cell lung cancer

People with non-small cell lung cancer are given different types of treatment depending on the stage of their cancer.

Stage 1 Non-small cell lung cancer can often be removed with surgery. If people have other medical problems, or are not fit enough to have surgery, radiotherapy may be given to the lung tumour instead. Chemotherapy is sometimes used after surgery (adjuvant chemotherapy), to reduce the risk of the cancer coming back. Chemotherapy is also sometimes given before surgery and/or radiotherapy. This is called neo-adjuvant chemotherapy.

Occasionally radiofrequency ablation (RFA) may be used. This is only likely to be suggested if other treatments are not suitable for you. RFA is only available at some cancer centres.

Stage 2 It may be possible to remove stage 2 non-small cell lung cancer with surgery. Radiotherapy may be used for people who are not fit enough for surgery or choose not to have it. Chemotherapy is often given following surgery or radiotherapy, to reduce the risk of the cancer coming back.

Stage 3 Non-small cell lung cancer can sometimes be removed with surgery, although this is often not possible because it may have spread too far. Chemotherapy, either on its own or combined with radiotherapy, may sometimes be given before an operation (neo-adjuvant treatment). If surgery is not possible, radiotherapy can be given instead. Sometimes chemotherapy given on its own, or in combination with radiotherapy, will be the only treatment used.

Stage 4 If non-small cell lung cancer has spread to other parts of the body, or is affecting more than one lobe of the lung, radiotherapy may be used to shrink the cancer and reduce symptoms. Sometimes chemotherapy may be given before or after the radiotherapy and may shrink the cancer and improve well-being for some people. The aim is to control symptoms and maintain a good quality of life for as long as possible. Radiotherapy may also be very effective in relieving symptoms.

How treatment is planned

If your tests show that you have lung cancer, you will be looked after by a multidisciplinary team. This is a team of staff who specialise in treating lung cancer and in giving information and support. It will normally include:

  • surgeons who are experienced in lung surgery
  • specialist nurses who are experienced in the treatment and care of people with lung cancer
  • oncologists – doctors who have experience in lung cancer treatment using chemotherapy, radiotherapy and other cancer treatments
  • radiologists who help to analyse x-rays and scans
  • pathologists who advise on the type and extent of the cancer.

Other staff will also be available to help you if necessary, such as:

  • physiotherapists
  • counsellors and psychologists
  • social workers.

Together they will be able to advise you on the best course of action and plan your treatment, taking into account a number of factors. These include your age, general health, the type of lung cancer and the stage.

If two treatments are equally effective for your type and stage of cancer your doctors may offer you a choice of treatments. Sometimes people find it very hard to make a decision. If you are asked to make a choice, make sure that you have enough information about the different treatment options, what is involved, and the side effects you might get, so that you can decide on the right treatment for you.

Remember to ask questions about anything that you don't understand or feel worried about. You may find it helpful to discuss the benefits and disadvantages of each option with your doctor, or specialist nurse.

Giving your consent

Your doctor will explain the aims of any treatment before you have it. They will usually ask you to sign a form saying that you give your permission (consent) for the hospital staff to give you the treatment. No medical treatment can be given without your consent, and before you are asked to sign the form you should be given full information about:

  • the type and extent of the treatment you are advised to have
  • the advantages and disadvantages of the treatment
  • any other treatments that may be available
  • any significant risks or side effects of the treatment.

If you don't understand what you have been told, let the staff know straight away so that they can explain again. Some cancer treatments are complex, so it's not unusual for people to need repeated explanations.

It„s often a good idea to have a friend or relative with you when the treatment is explained, to help you remember the discussion more fully. You may also find it useful to write down a list of questions before you go to your appointment.

People often feel that hospital staff are too busy to answer their questions, but it's important for you to be aware of how the treatment is likely to affect you. The staff should be willing to make time for you to ask questions.

You can always ask for more time if you feel that you can't make a decision when the treatment is first explained to you.

You are also free to choose not to have the treatment. The staff can explain what may happen if you don't have it. It is essential to tell a doctor or the nurse in charge, so that they can record your decision in your medical notes. You don't have to give a reason for not wanting to have treatment, but it can be helpful to let the staff know your concerns so that they can give you the best advice.

Benefits and disadvantages

Many people are frightened at the idea of having cancer treatments, because of the side effects that can occur. Although many of the treatments can cause side effects, these can usually be controlled with medicines.

Treatment can be given for different reasons, and the potential benefits will vary depending on the individual situation. In people with early-stage lung cancer, surgery can sometimes be done with the aim of curing the cancer. Occasionally, additional treatments are also given to reduce the risk of it coming back.

If the cancer is at a more advanced stage the treatment may only be able to control it, reducing symptoms and helping to improve quality of life. For some people in this situation however, the treatment will have no effect upon the cancer, and they will go through the treatment's side effects with little benefit.

Treatment decisions

If you've been offered treatment that aims to cure your cancer, deciding whether to accept the treatment may not be difficult. However, if a cure is not possible and the treatment is being given to control the cancer for a period of time, it may be more difficult to decide whether to go ahead with it.

Making decisions about treatment in these circumstances is always difficult, and you may need to discuss in detail with your doctor whether you wish to have treatment. If you choose not to, you can still be given supportive care (also known as palliative care) with medicines to help control any symptoms. Some cancer treatments, such as radiotherapy, can also be used to help treat symptoms.

Second opinion

Usually, a number of cancer specialists work together as a team and they use national treatment guidelines to decide on the most suitable treatment for each person. Even so, you may want to have another medical opinion. Either your specialist or GP can refer you to another specialist for a second opinion, if you feel it will be helpful. Getting a second opinion may cause a delay to the start of your treatment, so you and your doctor need to be confident that it will give you useful information.

If you go for a second opinion, it may be a good idea to take a friend or relative with you, and to have a list of questions ready so that you can make sure your concerns are covered.

Surgery for lung cancer

The operation

Surgery is most commonly used for non-small cell lung cancers that are small in size and haven't spread. Before any operation you may need to have further tests to assess your ability to cope with the surgery.

There are three main types of surgery for lung cancer; lobectomy, pneumonectomy and wedge resection. The type of operation will depend upon the size and position of the tumour.

Removal of a lobe of the lung, as shown in the diagram below, is called a lobectomy. Removal of two lobes is called a bi-lobectomy.

Figure: Lobectomy

Removal of a whole lung, as shown below, is called a pneumonectomy.

Figure: Pneumonectomy

Occasionally, in people who have very early lung cancer, a very small amount of the lung is removed. This is called a wedge resection (shown below).

Figure: Wedge Resection

A segmentectomy operation removes a slightly larger part of the lung. These operations are not done very often.

People are often worried that they won't be able to breathe properly if their lung has been removed. However, it's quite possible to breathe normally with only one lung.

People who had breathing difficulties before the operation may continue to be breathless afterwards. Breathing tests, to measure how well your lungs work, will be done to help you and your doctor to decide whether an operation is right for you.

Before any operation, make sure that you have discussed it fully with your doctor so that you understand what it involves.

Surgery is sometimes combined with radiotherapy or chemotherapy.

After your operation

It can take many weeks to recover fully from a lung operation, although some people recover more quickly than others. There are things you can do to help speed up your recovery. After your operation you will be encouraged to start moving about as soon as possible. This is an essential part of your recovery. Even if you have to stay in bed, it's important to keep up regular leg movements to help your circulation and prevent blood clots. A physiotherapist will visit you regularly on the ward to help you with breathing exercises to prevent chest infections and other possible complications.

X-rays will be taken regularly to make sure your lung is working properly.

Drips and drains

A drip (intravenous infusion) will be used to give you fluids for a couple of days, until you're able to eat and drink normally again.

You will also have drainage tubes in your wound. These are usually taken out about 2–7 days after your operation, depending on your recovery. The wound will usually be around the side of your chest between two ribs. It will be covered by a dressing, which the nurses will check.

Pain

It is quite normal to have some pain or discomfort after your operation. This can usually be controlled with painkillers. Let your doctor or one of the nurses know if you have any pain, so they can treat it as soon as possible. It's important to be as comfortable as possible so that you can breathe properly. This can reduce your risk of developing chest infections.

Mild discomfort or pain in your chest can last for several weeks, and you will be given some painkillers to take home with you. Some people find that they have pain that starts some weeks or months after their operation. This is usually because nerve endings which have been damaged during the operation have started to grow back. Talk to your specialist if you start to have pain some time after your operation.

Going home

You will probably be ready to go home about 5–10 days after your operation. If you think that you might have problems when you go home – if you live alone, for example, or have several flights of stairs to climb – it's important to tell one of the nurses or the hospital social worker when you're admitted to the ward.

They can arrange for help when you go home. When you go home, you will need to exercise gently to build up your strength and fitness. It's a good idea to check with your doctor or physiotherapist which types of exercise would be suitable for you. Walking and swimming are good exercises that are suitable for most people after treatment for lung cancer.

Radiotherapy for lung cancer

Radiotherapy treats cancer by using high-energy x-rays to destroy the cancer cells, while doing as little harm as possible to normal cells. The treatment is given in the hospital radiotherapy department. The number of treatments you have, and the length of time they take, will depend on the type of cancer as well as its size and position.

When it is given

Radiotherapy is usually given by aiming high-energy x-rays at the lung from a radiotherapy machine. This is known as external beam radiotherapy.

Radical radiotherapy: Radiotherapy can be given with the aim of curing the cancer (radical radiotherapy). This may be instead of surgery. There are different ways of having radical radiotherapy.

You may have treatment every week day with a rest at the weekend. The treatment will be given for 3–7 weeks.

Sometimes radical radiotherapy will be given using CHART (Continuous Hyperfractionated Accelerated Radiotherapy). The dose of radiotherapy is divided so that more than one treatment, or fraction, is given each day. People having CHART are given treatment every day, including weekends, until the course is over. The course usually lasts 12 days.

Palliative radiotherapy: Radiotherapy may also be used to control symptoms (palliative radiotherapy). Often only one or two treatments are given. Sometimes a higher dose of radiotherapy is given over two weeks if the doctor thinks this may be helpful. Treatment is given each weekday with a rest at the weekend.

Sometimes a type of internal radiotherapy called endobronchial radiotherapy or brachytherapy may be used. This type of radiotherapy may be given when the tumour is blocking one of the airways and has made the lung collapse. It is a simple way of opening up the airway. If you have this type of radiotherapy, you usually need only one session of treatment.

External radiotherapy

To make sure that the radiotherapy works as well as possible, it has to be carefully planned. Before you start your treatment you will have pictures taken with a special CT scanner and measurements will be taken by the therapy radiographers. The information will be used to work out the details of your radiotherapy. Treatment planning is a very important part of radiotherapy, and it may take a couple of visits. The doctor who plans and supervises your treatment is known as a clinical oncologist.

Marks may be drawn on your skin to help the radiographer (who gives you your treatment), to position you accurately and to show where the rays are to be directed. It's important not to wash or rub them off until the treatment is finished. Occasionally, tiny permanent marks (tattoos) are made on the skin in case further treatment is needed later. At the beginning of your radiotherapy you will be given instructions on how to look after your skin in the area to be treated.

Before each session of radiotherapy the radiographer will position you carefully on the couch, either sitting or lying, and make sure that you are comfortable. During your treatment you will be left alone in the room, but you will be able to talk to the radiographer who will be watching you. Radiotherapy is not painful and only takes a few minutes, but you do have to stay still while the treatment is being given.

Figure: The radiographer watches on a monitor while treatment is given.

Radiotherapy to the brain

Some people with small cell lung cancer are given radiotherapy to the brain. This is because there is a risk that the cancer cells will spread to the brain. Giving radiotherapy in this way is known as prophylactic cranial radiotherapy (PCR).

A soft clamp is used to hold your head still to make sure that the correct area of the head is treated. Sometimes a see-through plastic mask is made to help keep your head in the right position during treatment. PCR is usually given daily, Monday to Friday. The number of sessions will vary depending on the individual situation.

Internal radiotherapy

If you are having endobronchial radiotherapy, a thin tube (catheter) will be temporarily put inside your lung using a bronchoscope. Then a small piece of solid radioactive material (the source) will be placed inside this tube, next to the tumour.

The radiotherapy is delivered directly to the tumour and healthy tissue will only be slightly affected. The source is left in place for a few minutes to give the treatment. The source and catheter are then removed. The treatment can be repeated two or three times, depending on the dose of radiotherapy you need.

Side effects of Radiotherapy

Radiotherapy can cause general side effects, such as tiredness. It can also cause chest pain or a few days of flu-like symptoms. You may notice that you develop a cough and produce more sputum (phlegm), which may have flecks of blood in it. This is quite normal. These side effects can be mild or more troublesome, depending on the strength of the radiotherapy dose and the length of your treatment. Your radiotherapist will be able to advise you about what to expect.

Problems with swallowing

After two to three weeks of treatment, the main problem you are likely to notice is difficulty in swallowing. This may be very uncomfortable. You may also have heartburn and indigestion. This happens because the radiotherapy can narrow your gullet (oesophagus). Tell your doctors if you have problems swallowing, as they can give you medicines to help. If you don't feel like eating, or have problems with swallowing, you can replace meals with nutritious, high-calorie drinks. These are available from most chemists and can be prescribed by your GP. Our booklet on diet has some helpful hints on how to eat well when you are feeling ill.

Tiredness

Radiotherapy can make you feel tired, so try to get as much rest as you can, especially if you have to travel a long way for treatment each day.

Skin care

Some people develop a skin reaction similar to sunburn. Pale skin may become red and sore or itchy; darker skin may develop a blue or black tinge. You will be given advice on how to look after your skin by the radiographer giving your treatment.

Hair loss

External radiotherapy will make your hair will fall out within the treatment area, including chest hair for men or head hair if you are given prophylactic cranial radiotherapy. The hair usually grows back, although occasionally the hair loss is permanent.

All the side effects should disappear gradually once your treatment is over, but it's important to tell your doctor if they continue.

Radiotherapy treatments for lung cancer do not make you radioactive. It is perfectly safe for you to be with other people, including children, throughout treatment.

Long-term side effects of Radiotherapy

Very rarely radiotherapy for lung cancer can cause long-term side effects such as inflammation, or hardening and thickening (fibrosis) of the lungs. This can cause symptoms such as shortness of breath and a cough. The gullet (oesophagus) may also be affected and become narrower, making swallowing difficult. The bones in the chest area may become thinner and more brittle.

Long-term side effects are very rare, but it's important that you are aware of them so that you can seek medical advice if you notice any symptoms.

CHART radiotherapy for non-small cell lung cancer

CHART is a particular way of giving radiotherapy. The initials stand for Continuous Hyperfractionated Accelerated Radiotherapy. CHART may be given to some people with a type of lung cancer called non-small cell lung cancer (NSCLC).

Studies have shown that CHART may work better for some people with inoperable non- small cell lung cancer (NSCLC) than standard daily radiotherapy does.

How CHART works?

Radiotherapy is the use of x-rays and similar rays (such as electrons) to treat disease. It works by damaging DNA (our genetic material) in the cancer cells. By damaging the DNA, the cancer cells are no longer able to divide and grow.

Each radiotherapy treatment is called a fraction. In standard radiotherapy for lung cancer, one fraction or treatment is given daily from Monday to Friday – usually for several weeks. In CHART, more than one fraction is given each day (hyperfractionation). Reducing the time between fractions means that there is less time between treatments for the fast growing cancer cells to recover.

Unlike standard radiotherapy, where there is a break from treatment at the weekend, people having CHART are given treatment every day including weekends. A modified type of CHART, called CHARTWEL, gives a break at the weekend.

In CHART, the number of treatments will be about the same as standard radiotherapy but the course will be completed sooner (accelerated treatment). The total dose of radiotherapy is similar to that given with standard radiotherapy.

When CHART is used?

At the moment, CHART radiotherapy is only available in some hospitals. Where it is available, it can be offered in particular situations to people with certain stages of NSCLC. The stage of a cancer is a term used to describe its size, position and whether it has spread beyond where it started in the body.

CHART radiotherapy can be offered to people with stage 1 and 2 NSCLC whose tumour can't be operated on, or who can't (or don't want to) have surgery. It can also be given to those with stage 3A or 3B NSCLC who aren't fit enough (or don't want) to have both chemotherapy and radiotherapy.

Stage 1A – the cancer is no bigger than 3cm (1¼in) in size.

Stage 1B is when either:

the cancer is larger than 3cm
the cancer is growing into the main airway of the lung (bronchus)
the cancer has spread into the inner covering of the lung (pleura).

Stage 2A the cancer measures 3cm (1¼in) or less in size and nearby lymph nodes are affected.

Stage 2B is when either:

the cancer is larger than 3cm (1¼in) and in the nearby lymph nodes,
there is no cancer in the lymph nodes, but the tumour has grown into the chest wall, the outer covering of the lung (pleura), or the muscle layer below the lungs (diaphragm).

Stage 3A is when either:

The cancer is of any size and has spread into the lymph nodes in the middle of the chest (mediastinum), but not to the other side of the chest.

The cancer has spread into tissue around the lung near to where it started. This can be into the:

chest wall
the covering of the lung
the middle of the chest (mediastinum)
other lymph nodes close to the affected lung.

Stage 3B is when either:

the cancer has spread to lymph nodes on either side of the chest or above the collar bone
the cancer has spread into another important area; such as the gullet (oesophagus), the heart, windpipe or a main blood vessel
there are two or more tumours in the same lung
there is a collection of fluid around the lung, containing cancer cells.

Sometimes it is not possible to give CHART; for example if the tumour is too near the spinal cord, or if the tumour and affected lymph nodes are too far apart.

How CHART radiotherapy is given?

Treatment planning

To make sure that the radiotherapy works as well as possible, it has to be carefully planned. On your first few visits to the radiotherapy department, you will be asked to lie under a machine called a simulator. This takes x-rays of the area to be treated. Sometimes, a CT scanner can be used for the same purpose. Treatment planning is a very important part of radiotherapy, and it may take a couple of visits.

Pinprick „tattoos' or marks may be drawn on your skin to help the radiographer, who gives you your treatment, to position you accurately, and to show where the rays are to be directed. These marks are often permanent because they must remain visible throughout your treatment, but occasionally they can be washed off once your radiotherapy is finished. At the beginning of your treatment, you will be given instructions on how to look after your skin.

CHART treatment

Before each session of radiotherapy, the radiographer will position you carefully lying on the couch and make sure that you are comfortable. You will be left alone in the room during your treatment (which only takes a few minutes), but will be able to talk to the radiographer, who will be watching you from the next room. Radiotherapy is not painful, but you do have to stay still for a few minutes while the treatment is being given.

A typical schedule would be to give treatment three times a day for 12 days in a row, including the weekends. Each treatment has to be given at least six hours apart. This is to allow the normal cells which have suffered damage to recover between treatments. This reduces the chance of long-term damage to normal tissues.

The first treatment is given early in the morning (about 8am) followed by one around lunchtime (about 2pm) and another in the early evening (about 8pm). This means that people usually have to stay in the hospital, or nearby, while having their radiotherapy.

Possible side effects of CHART radiotherapy

Giving radiotherapy over two weeks should allow the radiotherapy to be completed before side effects develop. However, there are a few side-effects which may develop towards the end of treatment or after it is finished.

Problems with swallowing: The main side effect of CHART is a sore gullet (oesophagitis). This may make swallowing more difficult. You might also have heartburn or indigestion if the gullet is narrowed during treatment. This tends to develop towards the end of treatment and may be at its worst during the first few weeks after treatment before gradually improving.

Let your doctor know if you're having problems swallowing, as they can give you medicine to help. Some liquid medicines may be helpful as they create a protective layer over sore areas and soothe the lining of the gullet. If you don't feel like eating, or have problems swallowing, you can replace meals with thick fluids (such as soups and puddings) or nutritious, high-calorie drinks. These drinks are available from most chemists and can be prescribed by your GP.

Tiredness: You may find that you feel tired during your radiotherapy. This may get worse as you go through treatment, but should improve over the first few weeks and months after it finishes. Pay attention to how you feel, and if necessary, allow yourself extra time to rest, perhaps by taking a nap in the afternoons.

Cough: Radiotherapy may irritate the chest. This means you may develop a cough during or after your treatment. You can ask your doctor for something to help with this. It usually improves when the treatment finishes.

Breathlessness: This may get slightly worse during treatment but usually improves when treatment is finished.

If you have any breathing problems which get worse after finishing your treatment it's important to let your doctors at the hospital know as soon as possible. This is because it could be due to inflammation of the lungs (known as pneumonitis) which may need immediate treatment.

Skin reaction: Some people may also find that they get a mild skin reaction (like mild sunburn) on the area being treated, although this is unusual. You will be given advice on how to look after your skin by the radiographer giving your treatment.

Long-term side effects of CHART radiotherapy

Lung fibrosis: Radiotherapy can cause some damage to the normal lung tissue around the tumour. This can sometimes result in scarring of the lung (fibrosis) which develops between 6–9 months after radiotherapy and can cause breathlessness.

The frequency of lung fibrosis is slightly higher in people having CHART radiotherapy compared to those having standard radiotherapy treatment.

Your feelings

You may have many different emotions, including anxiety and fear. These are normal reactions and are part of the process many people go through in trying to come to terms with their condition.

Everybody has their own way of coping with difficult situations; some people find it helpful to talk to friends or family, while others prefer to seek help from people outside their situation. Some people prefer to keep their feelings to themselves. There is no right or wrong way to cope, but help is available if you need it.

Chemotherapy for lung cancer

Chemotherapy is the use of anti-cancer (cytotoxic) drugs to destroy cancer cells. The chemotherapeutic drugs work by disrupting the growth of cancer cells.

How chemotherapy is given?

There are over 60 different chemotherapy drugs. Those most commonly used to treat lung cancer include cisplatin, carboplatin, gemcitabine (Gemzar®), vinorelbine (Navelbine®), paclitaxel (Taxol) and docetaxel (Taxotere®).

The drugs are often given in combination. For example:

carboplatin and Taxol
vinorelbine and cisplatin or carboplatin
gemcitabine with cisplatin or carboplatin
MIC (mitomycin, ifosfamide and cisplatin)
EC (etoposide and carboplatin or cisplatin).

The drugs are given by injection into a vein (intravenously), or sometimes as tablets. Each cycle of chemotherapy may last a few days. After having chemotherapy you will have a rest period of a few weeks, which allows your body to recover from any side effects of the treatment. The number of sessions you have will depend on the type of cancer you have and how well it is responding to the treatment.

Chemotherapy may be given to you in the outpatient department, or as tablets to take at home, but sometimes you will need to spend a night or two in hospital.

Doctors are always looking to improve the treatment of lung cancer, so you may be asked to take part in a clinical trial.

Side effects of Chemotherapy

Chemotherapy can cause unpleasant side effects. However, many people have few side effects, and those that occur can often be well controlled with medicine. The main side effects are described here, along with some of the ways they can be reduced.

Lowered resistance to infection: Chemotherapy can reduce the production of white blood cells by the bone marrow, making you more likely to get an infection. This effect can begin seven days after treatment and your resistance to infection usually reaches its lowest point 10–14 days after chemotherapy. Your blood cells will then increase steadily and will usually have returned to normal before your next course of chemotherapy is due.

Contact your doctor or the hospital straight away if:

Your temperature goes above 38ºC (100.5ºF)
You suddenly feel unwell (even with a normal temperature).

You will have a blood test before each cycle of chemotherapy, to make sure that your blood cells have recovered. Occasionally it may be necessary to delay your treatment if your blood count is still low.

Bruising or bleeding: The chemotherapy can also reduce the production of platelets, which help the blood to clot. Let your doctor know if you have any unexplained bruising or bleeding, such as nosebleeds, blood spots or rashes on the skin, or bleeding gums.

Anaemia (low number of red blood cells): While having chemotherapy, you may become anaemic. This may make you feel tired and breathless.

Feeling sick: Some of the drugs used to treat lung cancer may cause nausea (feeling sick) and vomiting. There are now very effective anti-sickness drugs (anti-emetics) to prevent or reduce nausea and vomiting. Your doctor will prescribe these for you.

Sore mouth: Some chemotherapy drugs can make your mouth sore and cause mouth ulcers. Regular mouthwashes can help to keep your mouth clean and relieve any soreness. Your nurse will show you how to use these properly. If you don't feel like eating, you could try a diet of soft food or replacing some meals with nutritious drinks. Our booklet on eating well might be of some help.

Hair loss: Hair loss is another common side effect of some – but not all – chemotherapy drugs. Ask your doctor if the drugs you are taking are likely to make your hair fall out. Most patients are entitled to a free wig from the NHS and your doctor or nurse will be able to arrange for a wig for you. Some people prefer to use hats or scarves rather than a wig. If your hair does fall out, it will grow back over a period of 3–6 months.

Tiredness: You may feel tired and have a general feeling of weakness. It is important to allow yourself plenty of time to rest.

Although they may be hard to bear at the time, these side effects will gradually disappear once your treatment is over.

Chemotherapy affects people in different ways. Some find they are able to lead a fairly normal life during their treatment, but many find they become very tired and have to take things much more slowly. Just do as much as you feel like and try not to overdo it.

Treating Lung Cancer with Cancer growth inhibitors

There are structures on the surface of many types of cancer cells, known as epidermal growth factor receptors (EGFRs). The receptors allow epidermal growth factor (a particular protein present in the body) to attach to them. When epidermal growth factor (EGF) attaches to the receptor, it causes chemical processes to occur inside the cell that make it grow and divide more quickly.

Drugs known as EGFR antagonists attach themselves to the EGF receptor inside the cell, and prevent the receptor from being activated. This can help to stop the cancer cells from growing so quickly.

Erlotinib (Tarceva®), is an EGFR (epidermal growth factor receptor) antagonist. It is sometimes used to treat people with non-small cell lung cancer whose cancer has come back after initial treatment, or has not responded to at least one course of chemotherapy. Erlotinib is given as a tablet. Side effects are generally mild and can include diarrhoea, a rash, nausea and tiredness.

The National Institute for Health and Clinical Excellence (NICE) in the UK is an independent body that was set up by the government. NICE assesses medicines and treatments and gives guidance to doctors on how they should be used in the NHS in England and Wales. The equivalent body in Scotland is the Scottish Medicines Consortium (SMC).

In November 2008 NICE assessed the use of erlotinib in the NHS. It recommends that erlotinib can only be used as an alternative to docetaxel, in people with non-small cell lung cancer who have already tried one chemotherapy course that has not worked. It can only be used if the drug company supplies it at the same cost as that of docetaxel. However, people who were already having erlotinib before the guidance from NICE came out can continue to have it.

In Scotland, erlotinib can be given to people with advanced non-small cell lung cancer who have had at least one course of chemotherapy.

Treating Lung Cancer with Radiofrequency ablation

Radiofrequency ablation uses heat to destroy cancer cells. A doctor will place a needle into the lung tumour. This is usually done using a CT scanner to make sure the needle is in the right place. Radiowaves are then passed down the needle into the tumour to heat, and so destroy, the cancer cells.

This treatment is usually only used when a person has a very early stage cancer and other treatments are not suitable.

There are very few side effects with this treatment although it is quite common for people to have some pain or discomfort and to feel tired. You usually need to stay in hospital overnight with this treatment.

Newer treatments for lung cancer

Cryosurgery

Cryosurgery, or cryotherapy, uses extreme cold to freeze and destroy cancer cells. Using a bronchoscope, the doctor puts an instrument, called a cryoprobe, close to the tumour. Liquid nitrogen is then circulated through the probe to freeze the tumour. Cryosurgery is still a relatively new treatment for lung cancer, and is not widely available in the UK.

Diathermy

Diathermy, which is sometimes known as electrocautery, uses an electrical current passed through a needle, to destroy cancer cells.

Photodynamic therapy (PDT)

Photodynamic therapy (PDT) uses laser, or other light sources, combined with a light- sensitive drug (sometimes called a photosensitising agent) to destroy cancer cells. The light-sensitive drug is given as a liquid into a vein. After waiting for the drug to be taken up by the cancer cells, the laser light is directed at the tumour using a bronchoscope.

PDT will make you temporarily sensitive to light and you will need to avoid bright light for between a couple of days and a few months, depending upon the photosensitising drug that is used. Other side effects include swelling, inflammation, breathlessness and a cough.

PDT is still being researched as a treatment for advanced lung cancer and is not suitable for everyone. It can also be used if the cancer is just growing into the wall of one of the main airways (endobronchial cancer) and is at a very early stage. Your doctor can give you more information. PDT is only available at some centres.

Antiangiogenesis drugs

Angiogenesis is the medical term for the growth of new blood vessels. Tumours need their own blood supply in order to grow. Drugs are available which can help stop the development of new blood vessels – these are known as antiangiogenesis drugs. They include bevacizumab (Avastin®) and thalidomide. Both these drugs are being studied to see if they may help people with lung cancer.

Controlling symptoms of lung cancer

Apart from the symptoms which led you to see your doctor in the first place, new symptoms can sometimes develop during your illness, such as breathlessness or a cough. These may be caused by the growth or spread of the lung cancer to other parts of the body, but they may have another cause. For example, some lung cancer cells produce hormones which can upset the body's chemical balance. If you have any new symptoms, tell your doctor straight away so that you can be given treatment for them, or perhaps be reassured that they are nothing to worry about.

Occasionally, cancer in the lung can cause fluid to build-up between the layers that cover the lung (pleural effusion). Your doctor can usually drain the fluid by inserting a needle (cannula), into the area. The needle is attached to a tube and the fluid passes into a drainage bag or bottle.

Some people with lung cancer have pain. This can usually be well controlled using painkillers and other methods of pain control. People may have pain if the cancer has spread to the bones. A study is looking at the use of a drug, ibandronate, with radiotherapy to see if it helps relieve bone pain.

In addition to treatments already mentioned in this booklet, there are some other treatments that can be given to help relieve symptoms.

Laser therapy

Sometimes, lung cancer causes breathlessness by blocking the windpipe (the trachea), or one of the main airways that take air from the windpipe into the lungs. If the blockage is caused by a tumour within the airway, it can often be relieved by laser therapy, which burns the tumour out of the airway. Laser therapy does not destroy the tumour completely, but it can help to reduce or get rid of the symptoms.

Laser therapy is usually carried out under a general anaesthetic. While you are asleep, a bronchoscopy will be done, and a flexible fibre is passed through the bronchoscope to aim the laser beam at the tumour. The laser beam burns away as much of the tumour as possible. The bronchoscope is removed, and you are brought round from the anaesthetic. Usually the anaesthetic is a liquid given into a vein, and recovery from it is very quick.

There are not usually any side effects from laser therapy. If the treatment has been straightforward you may be able to go home the same evening or, more often, the next day. If you have had an infection in your lung, it may be necessary for you to stay in hospital for a few days for antibiotic treatment and physiotherapy.

If the blockage in the airway comes back, laser treatment can be used again. Sometimes radiotherapy is given as well, to try to make the relief given by the laser therapy last longer.

Airway stents

Sometimes an airway can become blocked by pressure on it from the outside, which makes it close. This can sometimes be relieved using a small device, called a stent, which is put inside the airway to hold it open. The most commonly used stent is a small wire frame. It is inserted through a bronchoscope in a folded up position and as it comes out of the end of the bronchoscope it opens up, like an umbrella. This pushes the walls of the narrowed airway open.

Airway stents are usually put in under a general anaesthetic. When you wake up you will probably not be able to feel that it is there, but you will be able to breathe more easily. The stent can stay in your lung permanently and should not cause any problems.

Blood vessel stents

Stents may also be used if a large blood vessel, called the superior vena cava, has become blocked by the cancer, causing a feeling of pressure in the upper body. This can usually be relieved by radiotherapy, or by putting a stent in the blood vessel to keep it open. In this case the stent is a small tube which is inserted through a small cut in the groin and passed up through the blood vessels to the chest. The stent can usually be put in under local anaesthetic, while you are awake.

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