Treatment outline of stage 4 of lung cancer (non small cell carcinoma): Rapidly evolving field

Lung cancer is amongst the most common malignancies in India. Risk factors for lung cancers are prevalent in the society like smoking, pollution, etc. Unfortunately, we don’t have good screening techniques to detect it early. Hence majority cases are detected in an advanced stage. Most of them are detected in stage 4.

Treatment for such stage has evolved in the last decade. A decade back we were unable to offer treatment to majority patients. And those whom we were treated, used to succumb in about 6 months. Things have changed a lot. This has happened due to advancement in science. We are able to detect different subgroups in this population who requires treatment differently. Now we are seeing 5-year survival in lung cancer stage 4 which was unheard of before.

Chemotherapy, targeted therapy and immunotherapy are major armamentaria with us to tackle this disease. We generally divide stage 4 cancers into small cell and non-small lung cancers. Again non-small cancers are divided into squamous carcinoma, adenocarcinoma and other rare variants. Adenocarcinoma is the most common.

Non-small cell carcinoma is now divided into mutations positive and mutation-negative tumors. For all adenocarcinoma, we at least test EGFR, Alk, Ros1 molecular tests on the biopsy sample which was taken for your diagnosis.  These molecular tests are very important for patient management. For those who are positive, we can offer oral targeted therapy. This treatment has lesser side effects and better results as compared to chemotherapy. And for patients whose testing is negative, it won’t work at all. Hence this testing is of prime importance. We have different drugs for each mutation. Hence to consult medical oncologist for such treatment is a must.

For those patients who are mutation negative, we have options of chemotherapy alone, immunotherapy alone or combination of both. PDL1 testing is needed at baseline to decide on which way to go. Again with the addition of immunotherapy we see better results for this group too. Side effect profile for immunotherapy is completely different as compared to chemotherapy. You should consult your medical oncologist to decide whether immunotherapy will help in your case or not.

Currently, many-targeted therapy and immunotherapy are very costly restricting its use in a larger population. We hope that this cost will come down with time. There are many patient assistance programs from pharmaceutical companies to help in procuring this drug. Your medical oncologists can guide you on the same.

Dr. Rushabh Kothari | Consultant Medical Oncology | Narayana Multispeciality Hospital Ahmedabad.