Lung Cancer Treatment

Overview

Lung cancer treatment has changed a great deal in the past decade. A biopsy used to tell doctors one main thing, the cell type. Today the same small piece of tissue is also tested for gene changes and proteins that show whether a targeted tablet or immunotherapy (drugs that help your own immune system attack the cancer) could work. Two people with tumours of the same size can end up on completely different plans.

For a family, this means the first week abroad is mostly about getting the right information. The treatment itself might be an operation to remove part of a lung, a course of radiation, drug therapy, or a combination. A tumour board recommends which. That is a meeting where chest surgeons, medical and radiation oncologists, pulmonologists (lung specialists), radiologists and pathologists review each case together.

The treatment plan is the hospital's to make; our part is the practical arrangements around it. Because the molecular results can take one to two weeks, we book a stay near the hospital that can be extended without moving you.

Who needs it

Lung cancer is divided into two main groups:

• Non-small cell lung cancer (NSCLC), the more common type, which includes adenocarcinoma and squamous cell carcinoma.
• Small cell lung cancer (SCLC), which tends to grow quickly and is treated mainly with drugs and radiation.

The plan depends on the stage. Staging describes the size of the tumour, whether lymph nodes in the chest are involved, and whether the cancer has spread to places such as the brain, bones, liver or the other lung. Broadly:

• Early stage (I and II): surgery is the main treatment for people fit enough to have it. Those who are not fit may be offered stereotactic radiation.
• Locally advanced (stage III): usually a combination. Some patients have chemotherapy with radiation, followed by immunotherapy. Others have drug treatment first and then surgery.
• Advanced (stage IV): treatment is mainly with drugs chosen according to the molecular results, with radiation for specific problems such as pain from cancer in a bone.

Fitness matters as much as stage. Breathing tests, heart checks and how active you are day to day all help the team decide whether an operation is safe.

To prepare a quote, hospitals generally ask for the chest CT scan (the images on a disc or download link, not only the report), any PET-CT, the biopsy report and, if done, molecular test results. Bring the biopsy blocks if your laboratory will release them. You can name the country you prefer on the quote form, or let hospitals in several countries quote so you can compare.

How it is done

Completing the tests

A typical first week includes some of these:

• PET-CT: a CT scan combined with an injection of slightly radioactive sugar that highlights active cancer anywhere in the body.
• MRI of the brain, because lung cancer can spread there without causing symptoms.
• Biopsy, if the existing sample is not enough. This might be a CT-guided needle biopsy through the chest wall, or an EBUS (endobronchial ultrasound), where a thin camera passed through the mouth takes samples from lymph nodes in the centre of the chest.
• Molecular tests for gene changes such as EGFR, ALK and ROS1, and a PD-L1 test, which helps predict whether immunotherapy is likely to help.
• Pulmonary function tests, breathing tests that show how much lung you can safely lose.

Molecular results can take one to two weeks. This wait is normal, and your coordinator plans accommodation around it.

Surgery

The usual operation for early NSCLC is a lobectomy, removal of the lobe of the lung that holds the tumour, along with nearby lymph nodes. A smaller operation (segmentectomy) suits some small tumours. Many centres now do these as keyhole surgery, either VATS (video-assisted thoracoscopic surgery, through a few small cuts with a camera) or robotic surgery. A larger open operation (thoracotomy) is still needed for some tumours. You wake up with a chest drain, a tube that lets air and fluid escape while the lung settles.

Radiation

Stereotactic body radiotherapy (SBRT) delivers very precise, high doses to a small tumour in a few sessions, usually over one to two weeks. Conventional radiation for stage III disease runs every weekday for about six weeks, often with chemotherapy at the same time.

Drug treatment

Chemotherapy is given in cycles, often every three weeks. Targeted drugs for EGFR or ALK changes are mostly tablets taken daily at home. Immunotherapy is a drip given every three to six weeks. Some patients now receive chemotherapy plus immunotherapy before surgery, and some take targeted drugs or immunotherapy after it.

Recovery and how long you stay

After keyhole lobectomy, many patients spend three to five days in hospital. Open surgery or complications can mean a week or more. Walking on the first day and breathing exercises with the physiotherapist help the lung re-expand and lower the risk of chest infection. Tiredness and some breathlessness are common for several weeks.

A realistic plan for surgery abroad is three to five weeks in total. That covers about a week of tests and decisions, the hospital stay, and then a period in nearby accommodation until the surgeon is satisfied with your chest X-ray. Surgeons generally ask you to wait at least two weeks after an uncomplicated operation before flying, because pressure changes in the cabin can affect a healing lung.

If the plan is radiation with chemotherapy, expect about seven to eight weeks. For drug treatment of advanced disease, many patients stay for the first one or two cycles, review side effects with the oncologist, then continue at home if the same drugs are available there. Your coordinator keeps a copy of every report and asks the treating team for a written handover for your doctor.

Questions to ask your doctor

Ask these at the consultation, and ask the interpreter to repeat anything that is unclear.

• What type and stage of lung cancer is this?
• Which molecular tests have been done, and are any results still pending?
• Am I fit enough for surgery, and which tests showed that?
• Will the operation be keyhole or open, and how much lung will you remove?
• If surgery is not suitable, is stereotactic radiation an option?
• Will I need chemotherapy, immunotherapy or targeted drugs before or after the operation?
• When can I fly home safely?
• Which follow up scans will I need, how often, and can they be done in my country?

If your relative finds it hard to ask questions in front of the doctor, write the list down and give it to the interpreter before the appointment. It is a simple way to make sure nothing important is missed.

If breathlessness remains after treatment, ask the team early whether oxygen is needed on the flight home. Airlines want a medical form (often called a MEDIF) filled in by the treating doctor, usually several days before departure, and the doctor may want to check oxygen levels first.