It used to be that all patients diagnosed with non-small-cell lung cancer automatically got chemotherapy. These days, most peoples’ tumors are first tested to see if they have mutations or markers that suggest they’ll respond well to targeted therapies or immunotherapy. As a result, nearly half of patients with non-small-cell lung cancer are treated first with targeted therapy or immunotherapy. The majority of the remaining patients, if they’re physically able to tolerate therapy, will receive a combination of chemotherapy and immunotherapy. Many patients, upon hearing about this course of action, have questions. Here are some of the most common ones. What combination will I get? People who are found to carry a targetable mutation, such as an ALK mutation, will receive a drug, such as Xalkori (crizotinib), that targets that mutation as their first line of treatment. If you don’t have a mutation, but your tumor is found to have high levels of a protein called PDL1 on its surface, you will receive Keytruda (pembrolizumab) as a first line of treatment. Patients whose tumors do not carry a targetable mutation and who have a low number of PDL-1 markers on their tumor will receive chemotherapy plus Keytruda. RELATED: What You Need to Know About Testing for Tumor Mutations in Metastatic Non-Small-Cell Lung Cancer Is chemo used before or after surgery? This will depend on the stage of the cancer and other factors. Doctors might recommend chemotherapy before surgery, sometimes along with radiation therapy, to shrink a tumor before trying to remove it. Chemo is also commonly given after surgery to kill any residual cancer cells that might be left behind. In certain situations, especially if there is concern that some tumor may have been left behind, radiation will also be recommended following chemotherapy. Chemotherapy along with radiation may be the primary treatment strategy for advanced cancers that have grown into nearby structures and can therefore not be surgically removed. What drugs will I get? In non-small-cell lung cancer, oncologists look at what kind of cells are involved, such as squamous cells, adenocarcinoma cells, or unspecified large cells, then tailor the treatment to them. Drugs can be taken orally or intravenously. For lung cancer, they’re usually given intravenously. There are several regimens of chemotherapy used for lung cancer, says David Graham, MD, a medical oncologist at The Levine Cancer Institute in Charlotte, North Carolina. Chemotherapy drugs commonly used to treat non-small-cell lung cancer include:
Platinol (cisplatin)Paraplatin (carboplatin)Alimta (pemetrexed)Taxotere (docetaxel)Taxol (paclitaxel)Gemzar (gemcitabine)Albumin-bound paclitaxel (nab-paclitaxel, Abraxane)Vinorelbine (Navelbine)Etoposide (VP-16)
Usually, a combination of two chemotherapy drugs is given to treat early-stage lung cancer (cancer that can be removed with surgery). This combo often includes cisplatin or carboplatin along with another drug. In cases of advanced lung cancer that cannot be removed surgically, doctors may recommend a single drug, especially for people who are in poor health or can’t tolerate a combination therapy regimen, according to the American Cancer Society. Some people with advanced lung cancer might also receive targeted therapy or immunotherapy along with chemotherapy. RELATED: Speaking Cancer: A Glossary of Formal and Informal Terms Used to Describe Cancer Tests, Treatment, Patients, and More What side effects will I experience? Chemotherapy drugs can be tough to take. They work by killing off cancer cells, but can kill off normal cells in other parts of the body as well, which can lead to unpleasant side effects. These may include:
Upset stomach Queasiness, nausea, and vomiting are the most common side effects of chemotherapy, says Dr. Graham. Sometimes an upset stomach can lead to loss of appetite or weight loss. “But we are much better at controlling that now,” says Graham. Zofran (ondansetron) is commonly prescribed to combat these side effects. “This drug really revolutionized how we are able to give chemotherapy,” he says. “Before Zofran, we had to put people in the hospital and basically sedate them to give them their chemotherapy.” Many other antinausea medications have been developed in the last few decades that can control nausea should Zofran not work.Hair loss This tends to be more prevalent with Taxotere or paclitaxel, says Graham. “But it’s just temporary and [the hair] often comes back before chemotherapy ends.”Mouth sores These sores can form on the inside lining of the mouth or on the lips. They can be painful and interfere with talking, eating, and swallowing. Kidney damage This can happen with cisplatin, particularly if the patient doesn’t get enough fluid during treatment. “We make sure they are watched closely, and we keep the tank full,” said Graham. “We can do that intravenously.”Neutropenia Chemotherapy can be hard on the bone marrow, causing low platelet counts and a depletion of white blood cells. If counts get too low, there is an increased risk of infection. “Blood counts may be checked mid-cycle during the first cycle but not usually after that,” says Graham. “There are some folks who tell patients to avoid crowds [and other potentially infectious situations], but I do not,” he says. “Most infections that occur from a too-low white count come from bacteria already inside a person. It’s not from someone who sneezes across the mall or in church.”Neuropathy Numbness or weakness in the fingers and toes can happen with some of the platinum drugs and the taxanes (docetaxel and paclitaxel), which can also damage nerves. “It can be a problem, and it can take a long time for the nerves to grow back and heal, says Graham. “The neuropathy can feel like the hands or feet have ‘fallen asleep,’ and it can lead to trouble holding onto or grabbing things, as well as trouble walking.” At this time, “we do not have any good treatments for neuropathy.”Hearing loss This one isn’t very common, but it can happen. Graham says occasionally a couple will come to him and say, “He or she doesn’t listen to me any longer,” says Graham. “I’ve occasionally had to intervene between spouses and say ‘I have to take the blame for that.’”
Doctors may prescribe different medicines, exercises, or supplements to help patients manage these side effects.
Word to the Wise: Don’t Isolate Yourself
If you are experiencing health issues that you think are related to chemotherapy, speak up. Let your doctor’s office know when you have problems. “We can’t help with something we don’t know about,” said Graham. Also, rely on your support system at home, whether you have family or friends to help you. “A lot of people think they can’t be around anyone and can’t go out when they are undergoing chemo, but getting that support is a valuable thing,” said Graham. Additional reporting by Julie Marks.
