First-Line Treatment for Lung Cancer

When you are diagnosed with lung cancer, the preferred initial treatment is called the first-line treatment. It may also be referred to as induction therapy or primary treatment. First-line treatment is usually considered to be the best treatment for the type of cancer diagnosed. It is given first to provide the best outcome.

This article will review the types of lung cancer and the first-line treatments recommended for each.

Types of Lung Cancer

There are two main types of lung cancer—small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC). Knowing the type of lung cancer as well as the stage of the cancer are critical pieces of information the oncologist (a specialist in diagnosing and treating cancer) needs to make treatment decisions. 

Small Cell Lung Cancer

Small cell lung cancer begins growing in the cells of the lung, and can quickly grow and begin to spread into other areas of the body, such as the brain, bones, or liver. SCLC tends to be more aggressive than NSCLC. An estimated 13% of newly diagnosed lung cancers are SCLC. 

Non-Small Cell Lung Cancer

NSCLC is the most common type of lung cancer, estimated to be over 80% of newly diagnosed lung cancers. NSCLC can be further classified into three subtypes, shown here in order of most to least common:

• Adenocarcinoma
• Squamous cell carcinoma
• Large-cell carcinoma

Treatment Options

There are several first-line treatments for lung cancer that may be used individually or in combination with one other. These include:

• Surgery
• Chemotherapy
• Radiation therapy
• Immunotherapy

Surgery

Surgical removal of the lung tumor and nearby lymph nodes is most often used to treat lung cancer when the tumor is small and unlikely to have spread into nearby tissue. Lung cancer surgery can involve removing only one lobe of the lung or may involve removing an entire lung.

Chemotherapy

Chemotherapy is medication that kills cancer cells. It works by targeting cells during specific times in their reproductive cycles in order to stop the cells from growing. Different chemotherapy medications work at varying points in a cell cycle. It is considered a systemic therapy as it affects cells throughout the body.

Radiation Therapy

Radiation works by damaging the DNA (hereditary material) inside of the cancer cell so that it is not able to continue to replicate and grow. It's given by a specialized machine that directs beams of radiation to the prescribed area. Radiation is a local therapy, treating only the area where the beam is directed.

Immunotherapy

Immunotherapy is another systemic treatment for cancer, but works much differently than chemotherapy. It includes various treatments that help the immune system recognize cancer cells and stop their growth or spread. These treatments include:

• Checkpoint inhibitors such as Keytruda (pembrolizumab), Tecentriq (atezolizumab), Libtayo (cemiplimab), Imfinzi (durvalumab), and Imjudo (tremelimumab)
• Monoclonal antibodies such as Avastin (bevacizumab) Cyramza (ramucirumab), and Portrazza (necitumumab)

Targeted Therapy

Some lung cancers have specific mutations (genetic changes) that are partly responsible for the abnormal growth of the cancer cells. Some of these mutations have medications that are available to specifically target them, to help stop or slow the growth of the cancer.

First-Line Treatment for Small Cell Lung Cancer

The first-line treatments for SCLC depend upon the stage of the cancer, meaning how far advanced the cancer is. SCLC is categorized as either limited stage or extensive stage. The first-line treatment for limited-stage SCLC can include:

• Chemotherapy and radiation therapy given together
• Chemotherapy alone, which can include a combination of medications
• Surgery, followed by chemotherapy
• Surgery, followed by chemotherapy and radiation

Extensive-stage SCLC may be treated by:

• Combination of chemotherapy and immunotherapy
• Chemotherapy alone
• Radiation to specific areas where cancer is causing symptoms, followed by chemotherapy alone or with immunotherapy

First-Line Treatment for Non-Small Cell Lung Cancer

NSCLC treatment is also based upon its stage, ranging from 1 to 4.

Stage 1

The following treatment options can be used for stage 1 NSCLC:

• Surgery alone
• Surgery, followed by targeted therapy
• Radiation alone

Stage 2

The following treatment options can be used for stage 2 NSCLC:

• Surgery alone
• Chemotherapy, followed by surgery
• Surgery, followed by chemotherapy
• Surgery, followed by targeted therapy
• Radiation alone

Stage 3

The following treatment options can be used for stage 3 NSCLC:

• Chemotherapy, followed by surgery
• Chemotherapy and radiation together, followed by surgery
• Surgery, followed by chemotherapy
• Surgery, followed by targeted therapy
• Surgery, followed by chemotherapy and radiation therapy, followed by immunotherapy
• Surgery, followed by radiation
• Chemotherapy and radiation together, followed by immunotherapy
• Radiation alone

Stage 4

Stage 4 NSCLC treatment options include:

• Combination of chemotherapy medications
• Chemotherapy combined with targeted therapy
• Chemotherapy alone
• Targeted therapy alone, based upon results of genomic testing
• Immunotherapy alone

When First-Line Treatment Doesn’t Work

Regardless of the type of lung cancer, first-line treatments are given with the expectation that those treatments offer the best chance of curing the cancer or keeping it from growing and spreading. If cancer does not respond to the treatment that was used, different types of treatment or different chemotherapy agents may be needed.

The types of chemotherapy that are used after first-line treatments may not be as effective or work for as long as the initial treatments did. Further testing of the cancer may be needed, such as molecular testing, to see if any targeted therapy can be used. 

Molecular or genomic testing looks at the genes inside cancer cells to identify the presence of biomarkers (substances produced by cancer cells or other cells in response to cancer). Biomarkers are different for each person’s cancer, and if certain biomarkers are present in lung cancer, additional treatment options may be available.

These targeted medications are often not chemotherapy but are medications that target a specific biomarker, affecting how the cancer grows.

Summary 

First-line treatments for lung cancer are those given as the initial treatment after diagnosis. The first-line treatments for lung cancer depend upon the stage of the cancer as well as the type. For SCLC, chemotherapy is a standard first-line treatment. For NSCLC, first-line treatment may consist of chemotherapy, radiation and/or surgery. 

A Word From Verywell

Getting a diagnosis of lung cancer can be a time of anxiety and uncertainty. Sometimes it can feel like forever for scans to get done and results to be return, but these these are necessary, as they allow the oncologist to develop the best treatment plan for you.