Chemotherapy for Lung Cancer

Chemotherapy refers to the use of cytotoxic (cell-killing) medications to kill cancer cells. It's often used to treat lung cancer either alone or in conjunction with other modes of treatment. Chemotherapy for lung cancer may be given before or after surgery, along with immunotherapy medications or radiation, or as a means of managing metastatic lung cancer and extending life.

How Chemotherapy Works

Chemotherapy medications work by killing rapidly dividing cells. Since cancer cells divide quicker than most cells, they are particularly susceptible to these drugs.

Different chemotherapy medications work at different stages of cell division. For this reason, two or more medications are often given at the same time to kill as many cancer cells as possible. This is known as combination chemotherapy.

Combining chemo medications offers several benefits. These chemo combinations can:

• Decrease the chance that tumors will become resistant to treatment
• Attack the cancer with everything early on rather than waiting to see which one drug will be most effective
• Target different aspects of the cancer cells all at once
• Address the fact that cancer cells continually change and different cells may respond to different drugs
• Be more powerful together than one drug used alone

Using Chemotherapy for Lung Cancer

Unlike surgery and radiation therapy, which are considered local treatments (targeting the tumor directly at its location), chemotherapy is a systemic treatment, meaning that it works to kill cancer cells throughout the body.

Chemotherapy for lung cancer is often recommended to:

• Kill cells remaining after surgery: Known as adjuvant chemotherapy, this treatment is used after tumors have been removed to kill any cancer cells that may have spread but are undetectable by scans. It is often recommended for people with stage 2 and stage 3A non-small cell lung cancer (NSCLC) to reduce the risk of recurrence.
• Be used in combination with radiotherapy in patients with stage 3B and 3C lung cancer who are not surgical candidates.
• 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.
• Prolong life: In cases of advanced lung cancer, chemotherapy can extend life by reducing the size of a tumor or preventing additional growth. This is referred to as maintenance chemotherapy.
• Relieve cancer symptoms: When a tumor is causing symptoms such as pain or shortness of breath, chemotherapy may be able to reduce the size of the tumor to decrease symptoms. 
• Help immunotherapy drugs work: Immunotherapy drugs (checkpoint inhibitors) stimulate the immune system to fight cancer, but sometimes cancer cells can hide. Chemotherapy drugs break the cells down so the immune system can identify them and target malignancies.
• Put cancer into remission: Lung cancer is rarely ever fully cured. However, when chemo is combined with immunotherapy drugs, some people may experience full or partial remission and long-lasting control of their cancer.

First-Line Therapy

First-line therapy refers to the first treatment given for advanced lung cancer (beyond stage 3), including any combination of medications. These drugs are considered the "gold standard" of treatment and are most likely to be effective. Increasingly, immunotherapy drugs such as Keytruda (pembrolizumab) are being used, either alone or in combination with chemotherapy, as first-line therapy for NSCLC.

Some genetic mutations, such as KRAS G12C, are implicated in lung cancer and can be specifically targeted with drugs that are appropriately called targeted therapies. That's why oncologists now routinely order genetic testing before deciding which options to use as first-line treatments.

Second-Line Therapy

For patients that start with targeted therapy, chemotherapy may be brought in as a second-line choice either because the cancer is continuing to grow or because side effects from other treatments cannot be tolerated.

In other cases, chemotherapy may be combined with a targeted therapy drug as a second-line treatment. For instance, chemo is sometimes used with Cyramza (ramucirumab), which stops the formation of new blood vessels so a tumor can't survive.

Second-line treatment is less likely to be effective than first-line treatment, but it can offer a longer and better quality of life. Many people living with lung cancer now receive further therapies (third-line, fourth-line treatment, and so on).

Chemotherapy Drugs and Delivery

Many different medications are used to treat lung cancer. Most commonly, NSCLC treatment begins with either cisplatin or carboplatin (these are known as "platinum" drugs) combined with another medication. Common medications used in lung cancer include:

• Platinol (cisplatin)
• Paraplatin (carboplatin)
• Taxotere (docetaxel)
• VePesid or Etopophos (etoposide)
• Gemzar (gemcitabine)
• Taxol (paclitaxel)
• Alimta (pemetrexed)
• 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).

How They Are 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.

A combination of drugs that work at different phases of cell division increases the chance of treating as many cancer cells as possible. Since different cells are all on different timing in the process, repeated sessions also increase the chance of treating more cancer cells.

Side Effects of Chemotherapy

Many side effects of chemotherapy are related to the "normal" effect of chemotherapy on rapidly dividing cells. Cells that divide most rapidly include those in bone marrow, hair follicles, and the digestive tract, so chemotherapy has a significant impact on these areas.

Everyone responds to chemotherapy differently. However, some side effects are common:

• Fatigue (the most common side effect)
• Nausea and vomiting
• Mouth sores
• Taste changes
• Loss of appetite, which can place you at risk for cancer cachexia (weight loss and muscle wasting that's responsible for nearly 20% of cancer deaths)
• Anemia, low red blood cell count
• Hair loss 
• Skin changes 
• Fingernail changes
• Depression
• Chemobrain
• Peripheral neuropathy
• Fertility problems
• Kidney problems
• Thrombocytopenia, or low blood platelet count

Another problem is neutropenia, a low white blood cell count seen in a majority of cancer patients. Having a low white blood cell count can predispose you to infections and sometimes cause very serious health concerns that, as a chemo patient, you should watch for and discuss with your healthcare provider.

Coping and Supporting Your Body

Good nutrition is an essential part of staying strong during chemo treatments. Some people include complementary treatments such as nutritional supplements into their diets.

Discuss any supplement use while undergoing chemo with your oncologist before doing so. Certain supplements can decrease the effectiveness of chemotherapy drugs for lung cancer, while others may make the medication toxic.

As for side effects, you may have few or you may have severe reactions to your medication(s). These can improve 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.

Some ways to manage side effects include:

• Anti-nausea medications: These are given preventatively with some chemo drugs so that you may never feel sick to your stomach. Other times they are offered on an as-needed basis.
• Good oral hygiene: This is imperative to manage mouth sores and prevent oral infections.
• Iron supplements: These may be prescribed to offset anemia and fatigue, but the first course of treatment is to get rest and alter your lifestyle. Fighting cancer will require you to slow down.
• Brain exercises: To combat the hazy-mind feeling and forgetfulness that can occur with chemobrain, some people make an effort to keep their mind engaged by doing crossword puzzles or other stimulating activities.

The management of chemo side effects has improved significantly in recent years. If you're struggling with the effects of these drugs, it may be helpful to join a cancer support group where you'll have the opportunity to talk to others who are experiencing similar challenges in their lives.

Why Can't Chemo Cure Lung Cancer?

Healthcare providers rarely use the word "cured" in relation to lung cancer. Even if you go into remission and have no evidence of cancer for years, the risk of dying from some cancers may persist for 15 years.

The reason chemotherapy does not cure lung cancer for good is that tumors become resistant to the drugs over time. Cancer cells are, in a way, "smart." They constantly change and develop methods for escaping the treatments healthcare providers send their way.

Resistance is one reason why, when a tumor has started to grow again while someone is on chemotherapy, an oncologist may choose different drugs the next time around.

A Word From Verywell

It's a lot to process when learning about the effectiveness of lung cancer treatments and their possible side effects. When chemotherapy for lung cancer is recommended, it can be a significant physical and emotional undertaking, especially at the beginning. It may help to remember that the chemo of today is not the same as it was in the past, and that many side effects people once endured are less common due to improved treatments.

Chemotherapy is still challenging, though, so you will need to build a strong support network to help you through the tough times. Surround yourself with those who can help you cope with all the phases and facets of treatment.