When considering treatment options for non-small cell lung cancer like adenocarcinoma, we evaluate the patient’s stage (I-IV) and if appropriate, molecular profile. Staging is dependent on the size, location, and number of lymph nodes involved in the lung cancer. Types of treatments include radiation therapy, surgery, and systemic therapy (which is further divided into chemotherapy, targeted therapy, and immunotherapy).
Stage IA lung cancers can be managed surgically if the patient is able to undergo an operation, and if the tumor is in a location that is surgically accessible. Radiation treatment alone may also be used.
For stage IB, II, and IIIA patients, surgery, radiation alone or with chemotherapy may also be used. These decisions depend on lymph nodes involved by the cancer, how healthy the patient is, and if the surgery had clean resection margins (meaning there was no cancer at the edges of the tumor).
Stage II and III patients with cancer that has spread to the lymph nodes also benefit from immunotherapy postoperatively.
Stage IIIB lung adenocarcinoma is treated with chemotherapy, radiation, and followed with an immunotherapy called durvalumab.
In patients with Stage IV, metastatic lung adenocarcinoma, we must first consider the performance status of the patient to ensure that our treatments will not cause undue harm. Surgery is rarely used in Stage IV lung cancer, and only if there are very few locations of metastasis in an otherwise healthy patient. Molecular testing including EGFR, ALK, ROS1, BRAF mutations and PD-L1 percentage are standard of care in this group of patients. In patients with cancers that harbor the aforementioned mutations, targeted, oral therapies are used. Chemotherapy and immunotherapy can be considered when the tumor develops resistance to these treatments. If PD-L1 status is greater than 50%, immunotherapy, namely pembrolizumab, is appropriate first line therapy. In the absence of mutations or high PD-L1 levels, chemotherapy, with or without immunotherapy, is front line treatment. Immunotherapy, other types of chemotherapy, and clinical trials represent options after chemotherapy.
Special considerations must also be taken for patients who have lung cancer that has metastasized to their brain. These cancers are treated with surgery and radiation, though some will have responses to chemotherapy or targeted therapy. We are not certain how effective immunotherapy is in patients with brain metastasis from lung cancer, but studies are ongoing.