Optimizing the treatment of inoperable lung cancer

By Carl Gay, MD, PhD, as told to Hallie Levine

When patients hear the phrase “inoperable lung cancer,” they often think it means their cancer is incurable. But thanks to advances in treatment in recent years, this diagnosis is not a death sentence. There are many treatments to slow the spread and sometimes even get you into full remission.

There are a few reasons why a patient might have inoperable lung cancer:

• Her cancer has spread. If you have stage III or IV lung cancer, it may have spread (metastasized) beyond your lungs to your chest wall, heart, and even other, more distant organs.
• You have small cell lung cancer (SCLC). This is a rarer form of lung cancer, accounting for about 14% of all cases. Usually, by the time doctors find it, SCLC has spread.
• It’s hard to remove the cancer. If the tumor is near a blood vessel or other organ, your doctor may not want to risk it.
• You have another high-risk health condition. If you already have a lung condition, such as chronic obstructive pulmonary disease (COPD), or are otherwise in very poor health, your doctor may worry that you may not be strong enough to endure surgery.

Regardless of why your lung cancer is inoperable, there are safe and effective treatments for it. This will ensure you get the most out of your therapy.

Watch out for game-changing therapies

In the past, we have always treated patients with inoperable lung cancer with chemotherapy and radiation at the same time. This usually shrinks the cancer, although it may not be enough to allow a patient to go into full remission. But over the past decade, we’ve developed several revolutionary new tools to add to our arsenal. The most important is the use of immunotherapies, drugs that help a person’s own immune system recognize and destroy cancer cells more effectively. Some examples are:

durvalumab (Imfinci). This is a drug that binds to a specific protein, PD-L1, and helps your immune system kill cancer cells. It is used either alone or with other drugs to treat adults with unresectable small cell and non-small cell lung cancer. A 2022 study found that the 5-year survival rate for patients with non-small cell lung cancer who received durvalumab and chemotherapy was 42.9%, compared with just 33.4% for patients who received chemotherapy alone .

osimertinib (Tagrisso). Another promising option is the use of a drug known as a tyrosine kinase inhibitor (TKI) after chemotherapy and radiation. This seems to have the best results in patients suffering from a specific form of lung cancer known as EGFR-positive cancer. EGFR is a protein found on cells that helps them grow. If you have an EGFR gene mutation, your cells can go haywire and overgrow, causing cancer. It appears to offer significant benefits for patients with late-stage EGFR-positive cancers, but investigation is ongoing to determine whether it also has benefits for non-surgical early-stage cancers.

If you are told you have inoperable lung cancer, your doctor is your best source for advice on treatment. You might also want to ask your doctor about a clinical trial, which is a type of trial that tests new lung cancer therapies before they’re available to everyone. Your doctor can tell you if there is one that might be right for you.

manage side effects

The side effects of treating inoperable lung cancer are quite unique due to the double whammy of chemotherapy and radiation. Early-stage lung cancer usually requires surgery, followed by a short course of radiation, which can cause minor side effects, such as skin irritation. But inoperable lung cancer requires higher doses for longer periods of time. This can cause side effects like lung irritation – which it usually does

causes shortness of breath and/or coughing – and even irritation of the esophagus which can make swallowing quite painful. Chemotherapy can cause side effects like fatigue, anemia, hair loss and, worse, a higher risk of serious infections due to decreased blood counts.

With all these nasty side effects, one would expect that patients would have trouble sticking to their treatment. Surprisingly, they aren’t. I think one reason is that patients fall into an almost natural routine – radiation every day Monday through Friday and chemotherapy every week. You don’t have time to think about it. But I always stress to my patients that you don’t have to be a hero. Many of our patients can be on the stoic side. Her instinct is to go with the flow and not bring up problems.

If you’re receiving chemotherapy and radiation for your inoperable lung cancer, it’s very important to see your doctor regularly. Tell them about any side effects at the first sign. For example, if you start to notice pain when swallowing, don’t wait until you can barely eat or drink anything to tell your doctor. There are medications that we can prescribe to alleviate some of these symptoms and make the whole process easier. This, in turn, makes it easier for you to stick to your overall treatment plan.

Realize that there is hope for all patients

Inoperable cancer is not always metastatic cancer. But sometimes it can be. What I always emphasize to my patients in these cases is the increasing personalization of the therapy. We can now do a genetic analysis of a person’s tumor and treat them based on how likely they are to respond to a particular targeted therapy.

Patients are often thrown by the numbers, and for good reason: the current 5-year survival rate for metastatic lung cancer, for example, is only about 8%. But I remind my patients that these numbers are based on people diagnosed at least 5 years ago. If you’re diagnosed with metastatic, inoperable lung cancer today, improved treatments may improve your outlook.