Although there are subtypes of NSCLC, depending on which type of cell the cancer originated in, they are usually grouped together, because the treatment approach and prognosis are often similar. These subtypes include adenocarcinoma, squamous cell carcinoma, and large-cell carcinoma. Treatment of metastatic NSCLC has improved dramatically in the past decade or so, says David Graham, MD, an oncologist with the Levine Cancer Institute in Charlotte, North Carolina. Just a decade or two ago, “The chances of living two years with metastatic NSCLC were pretty small,” he says. Thanks to advancements in treatment, the outlook is “definitely a lot better than it was,” Dr. Graham adds.
Recognizing the Symptoms of Metastatic NSCLC
Many cases of NSCLC are not discovered until the cancer is in an advanced stage, often because people don’t experience symptoms or attribute their symptoms to another condition, such as an infection. Most NSCLC is diagnosed when a tumor grows and begins to make breathing more difficult or causes problems in parts of the body near the lungs. Symptoms of NSCLC include:
A cough that does not go awayCoughing up bloodChest pain that gets worse with deep breathing or laughingWeight loss, loss of appetite, shortness of breath, and fatigue (These are all possible indications of NSCLC but can also be caused by other conditions. Because none of these symptoms are specific to NSCLC, diagnosis might be delayed.)
As with many other cancers, the danger increases when NSCLC spreads. Tumor cells can break away in the lungs and travel through the bloodstream to other parts of the body. Metastatic NSCLC cells, Graham says, are most likely to spread to lymph nodes in the middle of the chest, the liver, adrenal glands, bones, and possibly the brain. Symptoms of metastatic NSCLC depend on where in the body the cancer has spread, according to the ACS. Here are a few possibilities.
Bones: bone pain in the back or hipsBrain: headaches, weakness, numbness of an arm or leg, dizziness, seizuresLiver: yellowing of the skin and eyesSkin or lymph nodes: lumps near the surface of the bodyAdrenal glands: often no symptoms, but possible dizziness, weakness, fatigue
The diagnosis is made in a lab by looking at lung cells from a biopsy of the tumor or fluids surrounding the lungs. These procedures can help doctors determine if the cancer has spread to nearby cells:
Bronchoscopy — a lighted flexible or rigid tube with a camera that’s inserted through the nose or mouth to see inside the airwaysMediastinotomy — a surgical opening of the space in the chest between the lungsMediastinoscopy — an endoscope inserted through a small notch at the top of the sternum to view this areaThoracoscopy — a thin, flexible tube with a camera and light that’s inserted through an incision near the lower end of the shoulder blade between the ribs to allow doctors to see into that area
While current treatments do not cure metastatic NSCLC for most patients, they can ease your symptoms and help you live longer and feel better. According to Taofeek Owonikoko, MD, chief of the division of hematology/oncology at UPMC Hillman Cancer Center in Pittsburgh, this is referred to as the quantity and quality of life. Treatment options depend on many factors, including where the cancer has spread and the particular characteristics of the cancer. “We want to find the specific alterations in the cancer cell,” says Dr. Owonikoko. “If there are mutations, the particular treatment would be dictated by that.” Today, doctors commonly order a test using a biopsy of tumor tissue (or sometimes blood , known as a liquid biopsy). This is for biomarker testing, which helps doctors personalize your treatment based on genetic mutations and your likely response to immunotherapy. The test looks for DNA from dead tumor cells present in the bloodstream to determine whether the cancer cells have mutations in specific genes, including EGFR, ALK, ROS1, RET, and BRAF. “We have targeted therapies that will take advantage of changes associated with those genetic markers,” says Graham. “They offer a treatment opportunity we wouldn’t have otherwise.” Each of those genes is associated with a pathway in the cells that spurs cancer growth. Targeted therapies can home in on certain gene mutations with drugs to block the pathways and slow the growth and spread of cancer cells. Such treatments are known as targeted therapies because they are directed at specific types of cancer cells and cause less damage to healthy cells. Your tumor may also be tested for a protein called PD-L1. High levels indicate that the cancer may respond to immunotherapy drugs, one of the most important advances in the treatment of metastatic NSCLC (and other cancers) and now a standard treatment for most patients with advanced lung cancer. Cancer cells have devised all kinds of clever biological tricks to hide from the body’s immune system, which would otherwise attack them. Immunotherapy, using drugs called checkpoint inhibitors, makes the cancer cells visible to the immune system, which is then mobilized. Treatment of lung cancer, as well as cancer that’s spread to the bones, liver, brain, or elsewhere, might require conventional cancer treatments, such as radiation therapy or chemotherapy. In some cases, surgery may be used to remove tumors that have spread to the brain.
The Outlook for Metastatic NSCLC
The length of time you will live — and what kind of life you’ll have — are related to the particular mutations present in your tumor cells, what kinds of treatments are available, and how well you respond to those treatments. Because of advancements in treatment, survival rates for people with metastatic NSCLC are improving. If you respond to treatment, you could live four or five years, says Owonikoko. “Overall, the prognosis has improved,” he says, “but it’s still not where we want it to be.” Clinical trials are constantly being conducted to find ways to improve treatments and quality of life for people with metastatic NSCLC. Ask your doctor whether you may be a candidate for such a trial. Additional reporting by Colleen de Bellefonds
