为什么强调肺癌要进行综合治疗？

    肺癌分为早期、中期和晚期。简单地讲，直径小于3cm的肿瘤、没有外侵，并且没有肺门和纵隔淋巴结转移的肺癌，我们称之为“早期肺癌”；

    一旦侵及胸膜，或出现肺门淋巴结转移，我们就把它定义为“早中期肺癌”；

如果肺部肿瘤转移至纵隔淋巴结，或肿瘤侵犯了胸壁、膈肌、心包和纵隔等结构，我们称之为“局部晚期肺癌”

    如果肺癌患者出现了肺外转移，如颅脑转移、骨转移、腹腔脏器转移，就属于"晚期肺癌"。

    肺癌患者一旦发生了淋巴结转移，就意味着癌细胞已经进入了淋巴循环系统，并极有可能通过血液循环系统播散到全身。所以肺癌的治疗不能仅仅局限于“一把刀”。

肺癌治疗除了外科手术，还有放疗、靶向治疗、中医药治疗。近年来临床广泛应用的还有伽玛刀、氩氦刀、射频消融、冷冻治疗和热疗、光动力治疗等多种治疗手段。医生可以根据病人具体病情、综合科学合理地应用现有的治疗手段，以期达到根治或延长患者生存、改善生活质量的目的。

国际的数据资料和我国的数据资料都显示：即使手术治疗的早期肺癌的五年生存率也不足90%。中晚期肺癌的局部复发和远处转移率就更加令人不满意了！

值得强调的是：“话疗”，心理治疗的重要性！

Radiation therapy, or radiotherapy, refers to carefully aimed doses of radiation (high energy x-rays) intended to kill cancer cells. If you need radiation therapy, you will be asked to see a specialist called a radiation oncologist. Like surgery, radiation therapy cannot be used to treat widespread cancer. Radiation only kills cancer cells directly in the path of the radiation beam. It also damages the normal cells caught in its path, and for this reason, it cannot be used to treat large areas of the body. Patients with lung cancer treated with radiation therapy often experience fatigue and loss of appetite. If radiation therapy is given to the neck, or center of the chest, patients may also develop a sore throat and have difficulty swallowing. Skin irritation, like sunburn, may occur at the treatment site. Most of the side effects of radiation therapy go away after the treatment ends.

If the radiation therapy irritates or inflames the lung, patients may develop a cough, fever, or shortness of breath months and sometimes years after the radiation therapy ends. This condition occurs in about 15% of patients and is called radiation pneumonitis. If it is mild, radiation pneumonitis does not require treatment and resolves on its own. If it is severe, radiation pneumonitis may require treatment with steroid medications, such as prednisone. Radiation therapy may also cause permanent scarring of the lung tissue near the site of the original tumor. Typically, the scarring does not lead to symptoms. Widespread scarring can lead to permanent cough and shortness of breath. For this reason, radiation oncologists carefully plan the treatments using CT scans of the chest to minimize the amount of normal lung tissue exposed to the radiation beam.

Chemotherapy

Chemotherapy refers to the use of drugs to kill cancer cells throughout the body. Chemotherapy is given by a medical oncologist. Most chemotherapy used for lung cancer is injected into a vein (called intravenous, or IV injection). Although these drugs kill cancer cells, they may also cause side effects, such as nausea, vomiting, and fatigue. Nausea and vomiting are often avoidable; read the ASCO Patient Guide: Preventing Nausea and Vomiting Caused by Cancer Treatment for more information.

Chemotherapy may also damage normal cells in the body, including blood cells, skin cells, and nerve cells. This may result in low blood counts, an increased risk of infection, hair loss, mouth sores, and/or numbness or tingling in the hands and feet. Your medical oncologist can often prescribe drugs to help provide relief from many side effects. Hormone injections are also used to prevent white and red blood cell counts from becoming too low.

Newer chemotherapy treatment plans cause fewer side effects and are as effective as older treatments. Chemotherapy has been shown to improve both the length and quality of life in people with lung cancer of all stages.

Talking with your doctor is often the best way to learn about the medications you've been prescribed, their purpose, and their potential side effects or interactions with other medications. Learn more about your prescriptions through Cancer.Net's Drug Information Resources, which provides links to searchable drug databases.

Targeted therapy

Targeted therapy fights lung cancer by stopping the action of abnormal proteins that cause cancer cells to grow uncontrollably. These abnormal proteins are present in unusually large amounts in certain lung cancer cells. Two types of drugs target abnormal cells.

Monoclonal antibodies interfere with how the abnormal proteins actually enter the normal cell; they stop the entrance on the cell surface, which is like the doorway of the cell. Bevacizumab (Avastin) is a monoclonal antibody given in combination with chemotherapy. Drugs like bevacizumab block the formation of new blood vessels (also called angiogenesis), which is necessary for a tumor to grow and spread. The risk of serious bleeding for patients taking bevacizumab is about 2%.

Erlotinib (Tarceva) is a drug approved by the U.S. Food and Drug Administration (FDA) for locally advanced and metastatic NSCLC. It blocks the epidermal growth factor receptor (EGFR), a protein that helps lung cancer cells grow and multiply. This medication is a pill that can be taken by mouth. The side effects of erlotinib include rash that looks like acne and diarrhea.

Gefitinb (Iressa) is another drug that works like erlotinib. It is available only to people who were already taking it, had taken it in the past and had a good effect, or as part of a clinical trial.

Combining treatments

Most patients with lung cancer are treated by more than one specialist with more than one type of treatment. For example, chemotherapy can be prescribed before or after surgery, or before, during, or after radiation therapy. Patients should have a sense that their doctors have a coordinated plan of care and are communicating effectively with one another. If patients do not feel that the surgeon, radiation oncologist, or medical oncologist is communicating effectively with them or each other about the goals of treatment and the plan of care, patients should discuss this with their doctors or seek additional opinions before treatment.

Treatment of NSCLC

Stage I and II. In general, stage I and II NSCLC are treated with surgery. Surgeons cure many patients with an operation. Before or after surgery, a patient may be referred to a medical oncologist. Some patients with a large tumor or evidence of spread to lymph nodes may benefit from neoadjuvant chemotherapy (chemotherapy before the surgery, also called induction chemotherapy) or adjuvant chemotherapy to reduce the chance the cancer will return. Radiation therapy is recommended to treat and cure a lung tumor in people for whom surgery is not advisable.

Stage III. Stage III NSCLC has spread to the point that surgery or radiation therapy alone is not enough to cure the disease for most people. Patients with stage III disease have a high risk of the cancer returning, either in the same place or at a distant location, even after successful surgery or radiation therapy. For this reason, doctors generally do not recommend immediate surgery, and sometimes suggest chemotherapy with surgery to follow.

After chemotherapy, patients with stage IIIA NSCLC may still undergo surgery, especially if the chemotherapy is effective in killing or shrinking the cancer. Because chemotherapy travels throughout the body, if it is killing the cancer the doctors can see, it may also be killing the invisible cancer cells that may have escaped the original tumor. Following effective chemotherapy, surgeons can be more confident that removing a stage IIIA NSCLC will result in a cure.

Some patients with stage IIIA NSCLC are not treated with surgery. Instead, patients with stage IIIA disease may be treated with a combination of chemotherapy and radiation therapy with the intent to cure. The chemotherapy may be delivered either before or at the same time as the radiation therapy. This method has shown to improve the ability of radiation therapy to shrink the cancer and to decrease the risk of the cancer returning. Chemotherapy delivered at the same time as radiation therapy is more effective than chemotherapy delivered before radiation therapy, but it results in more side effects. Patients who have received both chemotherapy and radiation therapy for stage IIIA disease may still go on to have surgery. However, there is debate among doctors whether surgery is necessary for patients effectively treated with radiation therapy and if radiation therapy is needed in patients whose tumors are completely removed following treatment with chemotherapy.

For the majority of patients with NSCLC, the tumor is unresectable (cannot be removed by surgery). This may be because they have stage IIIB lung cancer, or the surgeon feels that an operation would be too risky, or that the tumor cannot be removed completely. For patients with unresectable NSCLC, with no signs of spread of cancer to distant sites or in fluid around the lung, a combination of chemotherapy and radiation therapy can still be used to try to cure the patient.

Stage IIIB with pleural effusion and Stage IV NSCLC. Patients with stage IV NSCLC or stage IIIB due to malignant pleural effusion (cancer cells in the fluid around the lung) are typically not treated with surgery or radiation therapy. Rarely, doctors recommend that a brain or adrenal metastasis be removed surgically if that is the only place the cancer has spread. Radiation therapy can also be used to treat a single site of metastasis, such as in the brain. However, patients with stage IV disease, or stage IIIB with a pleural effusion, are at very high risk for the cancer spreading or growing in another location. Most patients with these stages of NSCLC are only treated with drugs.

The goals of chemotherapy are to shrink the cancer, relieve discomfort caused by the cancer, prevent further spread, and lengthen life. Rarely, chemotherapy can make metastatic lung cancer disappear. However, doctors know from experience that the cancer will return. Therefore, patients with stage IV disease, or stage IIIB with a pleural effusion, are never considered "cured" of their cancer no matter how well the chemotherapy works. These patients must be followed closely by their doctors and require lifelong chemotherapy to control their disease. Chemotherapy has been proven to improve both length and quality of life for patients with NSCLC.

For more information about NSCLC treatment that cannot be removed by surgery, read the ASCO Patient Guide: Advanced Lung Cancer Treatment.

Treatment of small cell lung cancer

As with NSCLC, the treatment of small cell lung cancer depends on stage. Small cell lung cancer spreads quickly, so systemic chemotherapy is the primary treatment for all patients. The most commonly used chemotherapy regimen is etoposide (VePesid, Etopophos, Toposar) plus cisplatin (Platinol) or carboplatin (Paraplatin). Patients with limited stage small cell lung cancer are best treated with simultaneous chemotherapy plus radiation therapy to the chest given twice a day. Radiation therapy is best when given during the first or second month of chemotherapy. Patients with extensive stage cancer are treated with chemotherapy only. Chemotherapy is given for three to six months. Surgery is rarely appropriate for patients with small cell lung cancer and is only considered for patients with very early-stage disease, such as a small lung nodule. In those cases, chemotherapy, with or without radiation therapy, is given afterwards.

In patients whose tumors have diminished after chemotherapy, radiation therapy to the head cuts the risk that the cancer will spread to the brain. This preventative radiation to the head is called prophylactic cranial irradiation (PCI) and has been shown to extend the lives of these patients.

Like patients with advanced NSCLC, patients with small cell lung cancer of any stage face the risk that their cancer can return, even when it is initially controlled. All patients with small cell lung cancer must be followed closely by their doctors with x-rays, scans, and check-ups.

Stopping smoking

Even after lung cancer is diagnosed, it is still not too late to benefit from stopping cigarette smoking. People who stop smoking have an easier time with all treatments, feel better, live longer, and have a lower risk of developing a second lung cancer. Stopping smoking is never easy and even harder when facing the diagnosis of lung cancer and treatment. People who smoke should seek help from family, friends, smoking cessation programs, and health care professionals. None of the smoking cessation aids available interfere with cancer treatment.

Controlling physical symptoms caused by lung cancer

Chemotherapy is not as effective as radiation or surgery to treat lung cancer that has spread to the brain. For this reason, lung cancer that has spread to the brain is treated instead with radiation therapy, surgery, or both. Most patients with brain metastases from lung cancer are treated with radiation therapy to the entire brain. This can cause side effects such as hair loss, fatigue, and redness of the scalp. With a small tumor, a type of radiation therapy called stereotactic radiosurgery can focus radiation only on the tumor in the brain and minimize side effects.

Radiation therapy or surgery may also be used to treat metastases that are causing pain or other symptoms.

• A tumor in the chest that is bleeding or blocking the lung passages can be shrunk by radiation therapy.
  
• During a bronchoscopy (See Diagnosis), lung passages blocked by cancer can be opened to improve breathing.
• Surgeons can use a laser to burn away tumor or place a mechanical stent (support) to prop open an airway passage.
• Bone metastases that weaken important bones can be treated with surgery and reinforced using metal implants. Bone metastases can also be treated with radiation therapy.

Medications can also help treat the symptoms of lung cancer.

• Medications are used to treat cancer pain. Most hospitals and cancer centers have pain control specialists that design pain-relief treatments even for very severe cancer pain. Many drugs used to treat cancer pain, especially morphine, can also relieve shortness of breath caused by cancer.
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• Medications can be used to suppress cough, open closed airways, or reduce bronchial secretions.
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• Prednisone or methylprednisolone (Medrol, Meprolone) can reduce inflammation caused by lung cancer or radiation and improve breathing.
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• Extra oxygen from small, portable tanks can help make up for the lung's reduced ability to extract oxygen from the air.
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• Medications called bisphosphonates strengthen bones, lessen bone pain, and can help prevent future bone metastases.
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• Appetite stimulants and nutritional supplements can improve appetite and lessen weight loss.