What Is Lung Cancer Recurrence?

Treatment and Prognosis When Lung Cancer Comes Back

In This Article

Lung cancer recurrence is generally defined as lung cancer that returns after treatment and following a period of more than three months of remission (in which there is no evidence of the disease). A recurrence may be the same cancer type or occur in the same location as before, or the type and location may be different. Also referred to as relapse, lung cancer recurrence occurs far more often than you might expect—even with early-stage tumors and despite modern cancer therapies.

Lung cancer recurrences can sometimes be brought back into remission with appropriate treatment, but those that develop rapidly or are more advanced and widespread are generally hard to treat.

Types of Lung Cancer Recurrence

A lung cancer recurrence can be defined by where it occurs:

  • Local recurrence is when cancer comes back in the lung near the site of the original tumor.
  • Regional recurrence is when cancer recurs in the lymph nodes near the site of the original tumor.
  • Distant recurrence is when lung cancer recurs far away from the original tumor, such as in the bones, brain, adrenal glands, or liver.

How Often Does Lung Cancer Recur?

The chance that lung cancer will recur depends on many factors, including the type of cancer involved, the stage of cancer at the time of diagnosis, and how the original malignancy (cancer) was treated.

Most lung cancers that recur tend to do so between two and five years of the original diagnosis, depending on the type of cancer involved.

Recurrence vs. Disease Progression

If the lung cancer remission period does not reach three months, the cancer is regarded as disease progression rather than recurrence, meaning that the disease was still active even if tests were unable to detect it.

Non-Small Cell Lung Cancer

Among people with non-small cell lung cancer (NSCLC), the most common form of the disease, between 30% and 55% will experience recurrence. The risk of recurrence varies by the stage of cancer, of which NSCLC has five (stage 0 through stage 4). Around three in 10 people will experience relapse with stage 1 NSCLC, increasing to roughly seven in 10 by stage 4.

Recurrence typically occurs within five years with earlier stages of NSCLC, decreasing to two years by stage 4.

Small Cell Lung Cancer

By contrast, around seven in 10 people with small cell lung cancers (SCLC) will experience recurrence, usually within one to two years.

As a disease with only two stages—limited and extensive—SCLC generally has worse outcomes than NSCLC and a greater risk of recurrence. Not surprisingly, people with extensive SCLC (in which cancer has spread beyond the confines of one lung) are more like to relapse.

Small cell lung cancers can be further classified: Refractory cases are those that return within 60 days of chemotherapy, while sensitive ones have a longer sustained period of remission. As a general rule, sensitive cases tend to respond better to second-line treatment than refractory ones.

Interestingly, the recurrence of small cell lung cancer after five years of disease-free survival is rare.

Symptoms of Lung Cancer Recurrence

Symptoms of a lung cancer recurrence depend on where it occurs.

Location of Lung Cancer Recurrence Possible Symptoms
Local or in lymph nodes near the original tumor •Persistent cough
Coughing up blood
Shortness of breath
Wheezing
Pneumonia
Bones •Deep pain in the chest, back, shoulders, or extremities
Brain •Dizziness
•Impaired vision
Double vision
•Weakness on one side of the body
•Loss of coordination
Liver

•Abdominal pain
Jaundice (yellowing of the skin and eyes)
•Itching
•Confusion

More generalized symptoms of cancer, such as fatigue and unintentional weight loss, may also signal a recurrence.

With NSCLC, around 83% of recurrences will be metastatic—i.e., occur in distant parts of the body rather than near the site of the original tumor. Because of this, the symptoms can vary depending on where the metastatic tumor is located (most commonly the liver, brain, or bones).

With SCLC, similar patterns will develop wherein the majority of cases will be extensive rather than limited stage disease. Where symptoms can differ is in the development of paraneoplastic syndromes—a set of conditions in which the immune system responds abnormally and attacks normal cells of the central nervous system, causing the loss of fine motor skills, slurred speech, difficulty walking or swallowing, memory loss, and seizures. These disorders are far more common with SCLC than NSCLC.

Causes

Most lung cancer recurrences are caused by the spread of the original malignancy. Even after the initial curative treatment, there may be lingering cells that survive and fall below the detection levels of imaging tests. These cells can potentially "seed" a new tumor at the original site or be transported via the bloodstream or lymphatic system to distant parts of the body.

Less commonly, the treatments used to kill cancer may increase your risk of an entirely new and different cancer. A typical example involves radiation therapy in which exposure to high-dose radiation may cause you to develop an entirely new type of cancer in the irradiated tissues.

Referred to as radiation-induced secondary malignancies (RISM), these "new" tumors tend to develop within five years of exposure and may require different forms of treatment.

The risk of recurrence can increase if you don't change the modifiable risk factors that contributed to lung cancer in the first place. Moderate to heavy smoking alone can increase the risk of recurrence more than seven-fold compared to survivors who quit cigarettes.

Treatment

Treating a lung cancer recurrence depends largely on where the cancer recurs and the type of cancer involved. Know, however, that once lung cancer recurs, there is little chance of the malignancy being cured.

With that said, treatments are available that may increase both survival time and quality of life. Among them:

  • Surgery is not commonly used to treat lung cancer recurrence but may occasionally be used to resect a localized tumor or larger isolated tumors in the brain or liver.
  • Chemotherapy is usually the mainstay of treatment for lung cancer recurrence. Second-line drugs will be used, in large part because recurrent cancers tend to mutate and become resistant to previous medications.
  • Targeted therapies may be useful for people with advanced or recurrent lung cancer who have certain mutated strains. Genetic tests can help determine if you have at treatable gene mutations, such as the EGFR mutationALK-positive lung cancer, or ROS1-positive lung cancer.
  • Radiation therapy is generally used sparingly if previously prescribed. If your lifetime dose is relatively low or the benefits of treatment outweigh the risks, it may still have a place in treatment. Stereotactic body radiotherapy (SBRT) is a form of radiation used to ablate (remove) small secondary tumors in places like the brain or liver.
  • Immunotherapy involves the use of medications that stimulate the immune system to fight the disease. These drugs don't work for everyone but have provided long-term control for some people with lung cancer recurrence.

Once lung cancer recurs, it is by definition stage 4. According to the National Cancer Institute, people with stage 4 lung cancer should consider clinical trials as a means to access experimental treatments that may extend life.

Prognosis

The prognosis of recurrent lung cancer will depend on many factors, including the site of the recurrence, the cancer type, your general health, and the treatments used. Even though recurrence lowers a person's expected life expectancy, some people have been known to enjoy a good quality of life for many years.

The prognosis generally varies by whether NSCLC or SCLC is involved.

When NSCLC recurs, the majority of cases will be metastatic. According to a 2014 study in Translational Lung Cancer Research, 44% will occur in distant sites, while 39% will involve both local and distant sites. Even so, the median survival time for people with NSCLC recurrence is around 21 months, with some people living for eight years.

The outcomes with SCLC, on the other hand, tend to be poor. Most people with SCLC recurrence live two to three months if untreated; many others will die within six even with treatment, according to a 2016 study in the Journal of Thoracic Disease.

On the plus side, people with NSCLC and SCLC who do not experience another recurrence within five years are likely to remain cancer-free for another five.

A 2019 study commissioned by the American Cancer Society tracked lung cancer survivors with a five-year history of sustained remission and found that 87% made it another five years cancer-free.

Even so, the risk of recurrence never completely returns to zero.

Coping

Coping with a cancer recurrence can be difficult, as all of the emotions of the original diagnosis can not only return but are often amplified. For some people, the disappointment can be overwhelming and lead to depression and anxiety over a battle they thought they had won. While these emotions are entirely normal, try not to let them overwhelm you to the extent that you just give up.

It is important to remember that survival times are based on studies involving all sorts of people, each of whom have different health concerns. Try to focus less on how you long you may or may not live and instead work with your doctor so that your goals are clearly understood—whether it be to fight the disease with all available options or to forego lung cancer treatment so you can maintain the highest quality of life with whatever time is left. There is no wrong or right answer.

Ask questions. Talk about your options. Pull together a support network of loved ones and friends. Join a support group or seek counseling if you have difficulty coping.

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