Stage 4 Non-Small Cell Lung Cancer

Symptoms, Treatment, and Prognosis

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Stage 4 non-small cell lung cancer (metastatic lung cancer) is the most advanced stage of lung cancer and refers to any lung cancer of any size that has spread (metastasized) to another region of the body, to another lobe of the contralateral lung, or is accompanied by a malignant pleural effusion.

Nearly 40% of people newly diagnosed with lung cancer already have stage 4 disease. Causes include smoking, radon exposure, asbestos exposure, and more, and it's important to note that people who have never smoked can develop lung cancer. The diagnosis may be suspected based on findings on a chest CT scan, but a biopsy is usually required to make the diagnosis.

This stage of lung cancer is not curable, but it is treatable. Several advances in recent years in treatments such as targeted therapies and immunotherapy have improved survival significantly. While the prognosis is still not what we would hope, there are people who have survived for years or even decades while being treated.

Symptoms

These may include:

Symptoms due to the presence of a tumor in the lungs such as:

Symptoms due to spread of the tumor to other regions of the body, for example:

  • Pain in the back, hips, or ribs if the tumor has spread to bone
  • Difficulty swallowing due to a tumor being near or invading the esophagus
  • Headaches, vision changes, weakness, or seizures if a tumor spreads to the brain
  • Jaundice (a yellowing of the skin) from tumor that has spread to the liver

And symptoms related to metastatic cancer in general:

Treatments

Because stage 4 lung cancer has spread beyond the lungs it is considered inoperable, that is, surgery would be unable to remove all of the tumor and offer a chance for a cure. But stage 4 lung cancer is treatable. In those that are able to tolerate chemotherapy, traditional chemotherapy, immunotherapy, and/or the newer targeted therapies may improve survival and help with the symptoms of lung cancer. Many clinical trials are in progress looking at new targeted therapies, combinations of chemotherapy and targeted therapies and also immunotherapy.”

Chemotherapy

Chemotherapy was once the mainstay of therapy, but this is changing. Mutation testing should be done first, and the first step should be targeted therapy if possible. In people who do not have any treatable genomic alterations, a combination of immunotherapy and chemotherapy is often the next step.

Radiation Therapy

Radiation therapy may be recommended as a palliative therapy — therapy that is done to control symptoms but does not result in a cure. This can be helpful for some people to control bone pain (due to tumors spreading to bone), bleeding from the lungs, tumors that are obstructing the airways and causing shortness of breath, or brain metastases that are causing significant symptoms, such as headaches or weakness.

Targeted Therapies

It's now recommended that all patients with advanced lung adenocarcinoma and some people with squamous cell carcinoma of the lungs should have genetic testing (molecular profiling) done on their tumor. For a subset of people with EGFR mutations, ALK rearrangements, or ROS1 rearrangements medications are available that can increase progression-free survival. It's now recommended that everyone with stage 4 lung adenocarcinoma have genetic testing, and of the methods available, next generation sequencing provides the most information, yet at the lowest cost in the long run. These results can take time to come back, up to four weeks at some centers, but it's recommended that people wait to begin treatment if at all possible until the results are available (especially never smokers).

Immunotherapy

Immunotherapy is another newer type of treatment for lung cancer, with the first medication in this category having been approved for lung cancer in 2015. While these drugs do not work for everyone, some people with advanced lung cancer have experienced long-term control of their disease with these drugs. People who have tumors that are PD-L1 positive and/or a high tumor mutational burden may respond best to these medications. Those who have genomic alterations (such as EGFR mutations) tend not to respond as well. Immunotherapy drugs are usually combined with chemotherapy ("the triplet").

It is important to discuss any treatment you are considering with your doctor and your loved ones, so you can carefully weigh the risks and benefits of treatment.

Prognosis

The overall 5-year survival rate for stage 4 lung cancer is only approximately at least 4% but can be much higher in certain populations. The median survival time (time at which 50% of patients are alive and 50% have passed away) is about 8 months.

What Can I Do to Help Myself?

Studies suggest that learning what you can about your lung cancer can improve your quality of life, and possibly even your outcome. Ask questions. Learn about clinical trials. Consider joining a support group. Many of us hesitate to talk about end-of-life issues, but discussing these with your doctor and your family — even if all of you are hoping for a cure — is associated with fewer feelings of loneliness and a better quality of life. Never lose hope, even if you have chosen not to pursue further treatment. Hope for quality time with loved ones, with good control of your symptoms. Hope for the future of your loved ones who will remain, with memories of you in their hearts.

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