First-Line Treatment for Cancer

First-Line vs Second-Line Therapy for Cancer

gloved hand drawing up a chemotherapy drug from a vial

What exactly is first-line treatment? How is it different than second-line treatment options, and what else do you need to know?

First-line treatment simply refers to the initial, or first treatment recommended for a disease or illness. With many conditions, including cancer, there are many possible treatments which could be effective. First-line treatment is the one that, for most people, is expected to provide the best results with the fewest side effects.

First line treatments change all of the time with cancer. As newer studies find better options, whether it involves surgery, radiation therapy, targeted therapy, or immunotherapy, the "first-line" treatment recommendations for a disease are continually changing.

What Exactly Is First-Line Treatment?

First-line treatment is usually the standard treatment (the "gold standard") given when someone is diagnosed with a particular disease or condition, such as lung cancer. In other words, it is likely the treatment most oncologists would first choose in treating someone. That said, there are no general "rules" stating which treatment has to absolutely come first, and in addition to that, it's important to work with your oncologist to choose the treatment that is best for YOU. Only you can be your own advocate and select the treatments which offer you the best outcomes while minimizing the side effects you are willing to tolerate.

With regard to cancer, first-line treatment may actually be a combination of treatments, such as surgery, chemotherapy, and radiation therapy, given in succession. Therefore, a better term would probably be "first-line treatment regimen or protocol."

In contrast to first-line treatment, second-line treatment is usually a treatment which is chosen after first-line treatment has failed to achieve your goal, or has side effects requiring you to stop using that treatment. Second-line treatments are often inferior to first-line treatments but not always. For example, with metastatic breast cancer, second-line therapy tends not to control cancer for as long a period of time as first-line therapy.

In addition to first and second line treatments, there are often further options. For example, with metastatic breast cancer, you might hear your oncologist talk about fourth-line therapy. This therapy might be tried when first, second, and third line treatments are no longer working to control cancer.

It Can Vary for the Same Cancer

Every cancer is different, and it is important to keep this in mind if you hear about another treatment for your type of cancer. First line treatment for one cancer of a type and stage may be different than the first line treatment of another person's cancer of the same type and stage but a different molecular profile.  In addition to that, other factors such as age, general health, and co-existing conditions may make what is a first line treatment for one person as second-line therapy for another.

First-Line Treatment Is a Choice

We are entering an era known as "participatory medicine" in which patients are much more involved in their health care. Decisions are made as a team, rather than the paternalistic relationship between physicians and patients of the past.  After a discussion, and learning as much as you can about your cancer, you will likely have a choice between different approaches. 

Questions to Ask 

When you and your doctor consider a first-line treatment or first-line treatments, think through these questions.

  • Clarify the type and stage and molecular profile of your tumor.  Is there any further testing that should be done?
  • What is your goal in receiving this treatment?
  • What side effects are you willing to tolerate?
  • What is a second line treatment if this treatment doesn't work. How about third-line, fourth-line, and more?
  • Are there any clinical trials available that may better suit your needs? Ask about these, or research these right away, as some first-line treatments may disqualify you from some clinical studies.
  • What is the cost to you of the treatment(s)?
  • What is the average success rate of the treatment(s)?
  • What are some possible risks?
  • How soon will you need to begin treatment?
  • Where would you recommend I have a second opinion?

A Note About Alternative Treatments

It's important when talking about treatment to clarify what is meant by "alternative treatments." Most people now use the phrase alternative treatments to refer to complementary treatments that are offered by some cancer centers. In this setting, therapies such as acupuncture, meditation, massage, and yoga are used in an integrative fashion - that is, they are used along with traditional treatments such as chemotherapy. These complementary treatments may help some people cope with the side effects of cancer and cancer treatments.  

There has been some interest (and many internet scams) with alternative approaches which substitute another treatment for conventional treatments. These are dangerous, and there are currently no alternative treatments which would be considered a first-line treatment for cancer.

Bottom Line

First-line treatments are those which you and oncologist will choose as the best first choice for your particular cancer. There are often several different options available, yet first-line treatments are those which are most expected to control your disease with the fewest side effects in the process. Whether second-line therapies with your cancer are inferior, or instead interchangeable, with first-line therapy will depend on many different factors. Take time to learn about your cancer so you can make an educated choice on which therapies should be the first-line treatments for you. 

Also Known As: first-line therapy, primary therapy, primary treatment, induction therapy

Examples: Dan's oncologist recommended chemotherapy as first-line treatment for his lung cancer. He told us he would consider a form of targeted therapy as a second-line treatment if Dan did not respond to the treatment.

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