Chemotherapy for Lung Cancer

When Is Chemotherapy Used for People With Lung Cancer?

Young woman receiving chemotherapy, elevated view
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Chemotherapy is often used for lung cancer, and refers to the use of cytotoxic (cell-killing) medications to kill cancer cells. Not all medications used now for lung cancer are considered chemotherapy, and targeted therapies and immunotherapy drugs work by a different mechanism. Chemotherapy may be used as after surgery to treat any remaining cells (adjunct chemotherapy), or for metastatic lung cancer to extend life. It also now commonly used along with treatments such as immunotherapy to increase the effectiveness of these drugs. Since chemotherapy drugs kill all rapidly dividing cells, they can disrupt normal cells as well. This gives rise to the common side effects such as hair loss (hair follicles divide rapidly), nausea and vomiting, and bone marrow suppression.

How Chemotherapy Works

Chemotherapy medications work by killing rapidly dividing cells. Since cancer cells divide more frequently than most cells, they are particularly susceptible to these drugs. Some normal cells also divide continuously, such as hair follicles, the stomach lining, and the bone marrow that makes red and white blood cells. This accounts for many of the side effects experienced during chemotherapy, such as hair loss, nausea, and low blood cell counts. Different chemotherapy medications work at different stages of cell division. For this reason, often two or more medications are given at the same time to kill as many cancer cells as possible (combination chemotherapy). Understanding cancer cells, and how they differ from normal cells, can help you understand a little easier how chemotherapy works.

When Chemotherapy Is Used With Lung Cancer

Unlike surgery and radiation therapy, which are considered "local" treatments, chemotherapy is a "systemic treatment," meaning that it works to kill cancer cells anywhere in the body. This can be particularly helpful if cancer cells may have spread beyond the regions treated by surgery and radiation. Chemotherapy may be considered for several reasons:

  • As an adjunct (in addition) to surgery: In this case, chemotherapy is given after surgery to kill any cancer cells that may have spread beyond the cancer but are undetectable by scans. This is often referred to as adjuvant chemotherapy. Adjuvant chemotherapy is often recommended for people with stage II and stage IIIA non-small cell lung cancer to reduce the risk of recurrence.
  • To shrink a tumor before surgery: In some cases, chemotherapy is used before surgery to shrink a tumor and improve the chances that surgery will be effective. This method is often referred to as neoadjuvant chemotherapy.
  • To cure cancer: Rarely, lung cancer may be cured by chemotherapy alone, but this is much more common with cancers such as leukemia. When combined with immunotherapy drugs (checkpoint inhibitors), however, some people have achieved a durable response. meaning that the treatment resulted in long lasting control of their cancer.
  • To prolong life in those with advanced lung cancer: Often chemotherapy can extend life when a cure is not possible. When chemotherapy has been effective in reducing the size of a tumor, a smaller dose of chemotherapy is sometimes used in the hope that it will delay the recurrent growth of a tumor. This is referred to as maintenance chemotherapy.
  • To help with symptoms of cancer: When a tumor is causing symptoms such as pain or shortness of breath, sometimes chemotherapy can reduce the size of the tumor to decrease symptoms. 
  • To make immunotherapy drugs work better: Immunotherapy drugs work simplistically but stimulating the immune system to fight cancer. In order for these drugs to work, the immune cells need to be "familiar" with the cancer cells or recognize antigens (protein markers) on the surface. Cancer cells have ways of "hiding" so that they are not recognized. Chemotherapy drugs can break down cancer cells, releasing pieces into the circulation. The immune cells that are stimulated by immunotherapy drugs can then better recognize their targets. Researchers are looking into ways of maximizing the abscopal effect.

When chemotherapy is given for symptoms alone (to improve quality of life) and not with an intent to cure the disease or lengthen survival, it is referred to as palliative chemotherapy. If your doctor is offering chemotherapy in this way, make sure she discusses this carefully with you, as studies suggest many people are confused about the reason behind its use.

First and Second Line Therapy

You may hear your oncologist refer to your chemotherapy as first line or second line. First line therapy refers to the first treatment given including any combination of medications. These drugs are considered the "gold standard" of treatment and are most likely to be effective. Until 2018, chemotherapy drugs alone were recommended for first line therapy for those who do not have targetable mutations. Keytruda (pembrolizumab) replaced chemotherapy in 2018 as the recommended first line therapy for non-small cell lung cancer.

It's important to note that everyone who has non-small cell lung cancer should have genomic testing (preferably with next generation sequencing) for targetable mutations before starting chemotherapy or immunotherapy drugs.

For people who have targetable mutations (genetic changes in cancer cells that can be "targeted" by specific drugs, beginning chemotherapy or immunotherapy before genetic testing results are available could result in more harm than good.

That said, sometimes when a cancer progresses on targeted therapy (such as EGFR positive lung cancers), chemotherapy may be used in combination with a targeted therapy.

When progression occurs (or therapy is limited by side effects), the next treatment option would be considered second line treatment. Second line treatment is less likely to be effective than first line treatment. Many people living with lung cancer now receive further therapies (third line, fourth line treatment, etc.).

How Chemotherapy Is Given

Some chemotherapy medications are given as an oral pill, but most are given intravenously. If you will be having IV chemotherapy, you may be asked to make a choice between having an IV placed at each visit, or having a chemotherapy port placed. With a port, an intravenous line is threaded into the large blood vessels near the top of the chest, and a small metal or plastic device is placed under your skin. There are advantages and disadvantages to each method, yet a port (or sometimes a PICC line) can reduce the number of needle sticks necessary during treatment.

The initial treatment for lung cancer usually involves the use of 2 or more drugs (combination chemotherapy). These drugs are often given in cycles of 3 to 4 weeks at least 4 to 6 times. Using a combination of drugs which work at different phases of cell division increases the chance of treating as many cancer cells as possible. Since different cells are all in different places in the process of cell division, repeated sessions also increase the chance of treating as many cancer cells as possible.


Many different medications are used to treat lung cancer. Most commonly, treatment of non-small cell lung cancer begins with either cisplatin or carboplatin (a "platinum" drug) combined with another medication. Common medications used in lung cancer include:

  • Platinol (cisplatin)
  • Paraplatin (carboplatin)
  • Taxotere (docetaxel)
  • Adriamycin (doxorubicin)
  • VePesid or Etopophos (etoposide)
  • Gemzar (gemcitabine)
  • Ifex (ifosfamide)
  • Camptosar (irinotecan)
  • Taxol (paclitaxel)
  • Alimta (pemetrexed)j
  • Hycamtin (topotecan)
  • Oncovir (vinblastine)
  • Oncovin (vincristine)
  • Navelbine (vinorelbine)

With small cell lung cancer, first line treatment usually includes a combination of a platinum drug and VePesid (etoposide), often in combination with the immunotherapy drug Tecentriq (atezolizumab). Second line treatment may include either the immunotherapy drug Opdivo (nivolumab) or a single chemotherapy drug such as Taxol (paclitaxel) or Hycamtin (topetecan).

Non-Cytotoxic Cancer Medications

Not all medications used for lung cancer are considered chemotherapy. Medications such as Tarceva (erlotinib) and Xalkori (crizotinib) are targeted therapy drugs, medications designed to specifically treat cancer cells. A relatively new category of medications, called immunotherapy drugs, is now also being used for lung cancer. These drugs work simplistically by helping our immune systems fight cancer. Examples include Opdivo (nivolumab) and Keytruda (pembrolizumab).

Why Can't Chemotherapy Drugs Often Cure Lung Cancer?

If you are familiar with chemotherapy agents used for leukemia, which can often cure the disease, you may wonder why chemotherapy does not usually cure lung cancer. This can be even more confusing when you see that chemotherapy is often effective early on for lung cancer in that it can significantly shrink a tumor. This question is important to address as studies have found that many people feel chemotherapy has the strong potential to cure their cancer.

The reason why chemotherapy does not usually cure lung cancer is that tumors become resistant to the drugs over time. Cancer cells are "smart" in a way. They do not stay the same, but constantly change and develop methods for escaping the treatments we send their way. Resistance is one reason why—when someone has a tumor which has begun to grow again on chemotherapy—different drugs are often used the next time around.

Chemotherapy in Combination with Immunotherapy May Result in a Durable Response

Chemotherapy drugs are now frequently combined with immunotherapy drugs. With these combinations, some people have experienced partial or complete remission of their cancer, and though the word "cure" isn't yet used in this situation (instead, oncologists use the term durable response), some cancers may be controlled for a long period of time.

Supplements and Chemotherapy

Many people with cancer decide to use complementary treatments such as nutritional supplements. When going through chemotherapy it is very important to discuss any supplements you are using with your oncologist. Some supplements can decrease the effectiveness of chemotherapy, while others may make the medication toxic. It is also very important to talk to your doctor about the use of vitamins and minerals during chemotherapy, as some of these could interfere with your treatment.

Side Effects

Side effects of chemotherapy vary depending on the medications you are given, and other factors such as your age, sex, and general medical condition. Thankfully, management of these side effects has made tremendous strides over the past few decades. Everyone responds to chemotherapy differently. You may have few side effects or you may instead find the symptoms quite troubling. These side effects can improve over time or worsen over time. Sometimes a medication may need to be changed, but often there are medications and treatments that can control your symptoms and make you more comfortable. Make sure to share any symptoms you are experiencing with your health care team. 

Before beginning treatment, it's also important to understand the potential long term side effects of chemotherapy.

Coping With Side Effects

The particular side effects you may experience will depend on the particular medications you are prescribed. As noted, many of these side effects are related to the "normal" effect of chemotherapy on rapidly dividing cells. Cells in our bodies which divide most rapidly include those in our bone marrow (leading to low blood counts) our hair follicles, and our digestive tracts. The most common side effect of chemotherapy include:

  • Nausea and Vomiting: Nausea and vomiting are quite common on chemotherapy, but the management of these side effects have improved dramatically in recent years. It is now possible for many people to go through chemotherapy treatment with minimal or no nausea or vomiting. Often medications are given not only to treat nausea but given along with chemotherapy to prevent nausea.
  • Mouth Sores: Roughly half of people develop mouth sores on chemotherapy for lung cancer. These mouth sores are most often more of a nuisance, but secondary infections (thrush) may sometimes develop.
  • Taste Changes: An abnormal sense of taste, often referred to as "metal mouth" is common with lung cancer chemotherapy drugs. There are several things you can do (mentioned in the article this is linked to) that may help you better tolerate this symptom.
  • Loss of Appetite: Loss of appetite is extremely important to address, as getting adequate nutrition during chemotherapy can help your body heal. An inadequate intake of nutrients can also place you at risk of cancer cachexia — a syndrome of weight loss and muscle wasting that is directly responsible for nearly 20 percent of cancer deaths.
  • Fatigue: Fatigue is the most common side effect of chemotherapy, affecting nearly everyone at some point. Simply recognizing that fatigue is common, and learning to prioritize activities and accept help is often the best solution for coping with this annoying side effect.
  • Anemia (low red blood cell count): A low red blood cell count can lead to fatigue. Sometimes treatment is needed, but as with fatigue, often learning to ask for help and get more rest is all that is needed.
  • Neutropenia (low white blood cell count): A low white blood cell count (neutrophils are a type of white blood cell which fights infection) is often the most serious side effect of chemotherapy. Having a low white blood cell count can predispose you to infections. Make sure to talk to your doctor about this before you begin chemotherapy. She may recommend that you avoid situations in which you could be predisposed to infections — such as avoiding crowds and minimizing contact with people who are sick. Sometimes medications are used which stimulate the production of white blood cells after chemotherapy. If your white blood cell count is too low, your chemotherapy session may need to be delayed until it has returned to acceptable values.
  • Thrombocytopenia (low platelet count): A low platelet count may result in easy bruising or bleeding. This is not often a serious concern with chemotherapy for lung cancer, but your doctor will monitor your platelet count carefully throughout your treatment.
  • Hair Loss: Many of the chemotherapy drugs used for lung cancer can result in hair loss. Preparing ahead by purchasing a wig or other forms of head covers is often recommended. 
  • Skin Changes 
  • Fingernail changes
  • Depression
  • Chemobrain (cognitive changes after chemotherapy) - Chemobrain, or cognitive changes after chemotherapy has recently been recognized as a fairly common side effect of chemotherapy. Common symptoms include difficulty multitasking or mild forgetfulness - such as forgetting where you placed the car keys. Some people find that "brain exercises" such as doing crossword puzzles and other logic games is helpful if this becomes bothersome.
  • Peripheral Neuropathy: Peripheral neuropathy is quite common for people going through chemotherapy for lung cancer. Symptoms can include pain and tingling in what is called a "stocking and gloves" distribution. Research is ongoing looking for methods to not only relieve the symptoms of this side effect but to prevent it from occurring in the first place.

Support and Coping During Chemotherapy

Certainly, there are side effects with chemotherapy, but the management of these has improved significantly in recent years. Chemotherapy is one of those times when the adage "it takes a village" is as true as ever. Reach out to family and friends and allow people to help you. Many people find it helpful to join a cancer support group or support community and have the opportunity to talk to others who are experiencing similar challenges in their lives. Since most people have several chemotherapy sessions, and these sessions take some time, this can be a chance to reconnect with family and friends. Check out this list of what to pack for chemotherapy for ideas on how to make your chemotherapy sessions go as smoothly as possible.

A Word From Verywell

Hearing that chemotherapy is recommended for your lung cancer can be very frightening. Not only does this cause problems such as the dreaded hair loss, but many people associate these treatments with the awful side effects that were once so common. Chemotherapy is still challenging, and you will need your support system on board, but some symptoms such as nausea and vomiting are now very controllable.

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  1. Ninomiya K, Hotta K. Pembrolizumab for the First-Line Treatment of Non-Small Cell Lung CancerExpert Opinion on Biological Therapy. 2018. 18(10):1015-1021. doi:10.1080/14712598.2018.1522300

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