Thoracic & Esophageal Cancer

Non-Small Cell Lung Cancer

University Hospitals Seidman Cancer Center is a national leader in screening, diagnosing and treating non-small cell lung cancer (NSCLC). Ranked as one of the best cancer hospitals in the country by U.S. News & World Report for over 20 consecutive years, UH Seidman Cancer Center is part of the National Cancer Institute (NCI)-designated Case Comprehensive Cancer Center at Case Western Reserve University School of Medicine – one of an elite group of 51 such comprehensive cancer hospitals in the U.S.

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Our lung cancer experts are ready to help in your fight against cancer. To make an appointment today, call 216-844-3951.

What Is Non-Small Cell Lung Cancer (NSCLC)?

Cancer is a disease in which cells divide uncontrollably and spread into surrounding tissues. In lung cancer, cancer cells form in one or both lungs. Of the two main types of lung cancer – non-small cell lung cancer (NSCLC) and small cell lung cancer – NSCLC cells appear larger than small cell lung cancer cells when viewed under a microscope. The more common and slower-growing of the two types, NSCLC accounts for approximately 80 to 85 percent of lung cancer diagnoses.

NSCLC is further divided into three main subtypes, which are also grouped together because their treatment and prognoses (the most likely course and outcome of the disease) are often similar:

Adenocarcinoma: starts in the cells that line the alveoli (the tiny air sacs in the lungs that facilitate rapid gaseous exchange) and produce substances such as mucus
Squamous cell carcinoma: also called epidermoid carcinoma, this type of NSCLC forms in the thin, flat cells lining the inside of the lungs
Large cell carcinoma: begins in several types of large cells within in the lungs

Additionally, the NSCLC category includes certain less common cancers, among them adenosquamous carcinoma, sarcomatoid carcinoma, salivary gland carcinoma, carcinoid tumor and unclassified carcinoma.

What Are Non-Small Cell Lung Cancer Symptoms?

Signs and symptoms of NSCLC are common to all lung cancers and include the following:

A cough that doesn’t go away or worsens over time
Shortness of breath
Wheezing
Chest discomfort or pain
Blood in sputum (mucus coughed up from the lungs)
Hoarseness
Weight loss for no known cause
Loss of appetite
Fatigue
Trouble swallowing
Swelling in the face and/or veins in the neck

Most of these symptoms are more likely to be caused by conditions other than lung cancer, including common illnesses. If you experience any of these problems, see your doctor to determine their cause. Also, in its early stages, NSCLC may not cause any signs or symptoms. Instead, the disease may be found during a chest x-ray taken for treating another issue.

What Causes Non-Small Cell Lung Cancer?

Smoking cigarettes and exposure to secondhand smoke is a primary risk factor for NSCLC. However, some people who have never smoked develop the disease. Other risk factors for getting NSCLC include:

Exposed to asbestos, arsenic, chromium, beryllium, nickel, soot, tar or other chemicals in the workplace or home
Radiation therapy to the breast or chest
Exposure to radon in the home or workplace
Living in areas with high levels of air pollution
Having a family history of lung cancer

Non-Small Cell Lung Cancer & Smoking: We Are Here to Help and Heal, Not Judge

It is not uncommon for current or former smokers who are diagnosed with NSCLC to experience feelings of shame or guilt regarding their condition. Know that the UH Seidman Cancer Center care team is here to help and heal – not judge – and that we provide the same compassionate care to all our patients that we would give to our own family members.

Also know that it’s never too late to quit smoking. Studies have shown that smokers who quit smoking after their lung cancer diagnosis are more likely to respond better to treatment and live longer than lung cancer patients who continue to smoke during treatment.

How Is Non-Small Cell Lung Cancer Diagnosed

If non-small cell lung cancer is suspected after a physical exam, your doctor will order one or more imaging tests to identify any abnormalities in or around your lungs. These tests include chest x-ray, computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET) scan and bone scan. Your doctor may also order a sputum cytology, which is procedure in which a pathologist views a sample of sputum (mucus coughed up from the lungs) under a microscope to check for cancer cells.

While important, imaging tests alone are not sufficient for an official diagnosis. If the results of imaging tests indicate the possibility of NSCLC, your doctor will use one or more procedures to collect a tissue sample in order to make the diagnosis. These procedures include:

Needle Aspiration/Core Biopsy: In this procedure, the doctor uses a thin needle to remove a sample of tissue from the lung for later examination under a microscope by a pathologist. The doctor will often use a chest CT scan or special x-ray machine called a fluoroscope to guide the needle. A core biopsy typically obtains a larger tissue sample than a needle aspiration biopsy.
Bronchoscopy: In this procedure, a surgeon or a pulmonologist passes a bronchoscope (a thin, flexible tube with a light attached to the end) into the mouth or nose and down through the main windpipe into the lungs. The bronchoscope allows the doctor to see inside the lungs. Tiny tools inside the bronchoscope can take fluid or tissue samples for later examination by a pathologist. Patients are given mild anesthesia during a bronchoscopy.
Thoracentesis: After numbing the skin on the chest, a doctor inserts a needle through the chest wall and into the space between the lung and chest wall to extract a fluid sample. A pathologist examines the sample later for the presence of cancer cells.
Thoracoscopy: Through a small cut in the skin of the chest wall, a surgeon inserts a special instrument and a small video camera to examine the inside of the chest. This procedure is performed in the operating room with the patient under general anesthesia. Thoracoscopy is also referred to as video-assisted thoracoscopic surgery (VATS).
Mediastinoscopy: In this procedure, a surgeon makes an incision at the top of the breastbone through which a mediastinoscope (a thin, tube-like instrument with a light and a lens for viewing) is inserted into the chest. The instrument may also be fitted with a tool to remove lymph node or other tissue samples, which are examined later under a microscope for signs of cancer. The procedure requires general anesthesia and is performed in an operating room.
Thoracotomy: In a thoracotomy, a surgeon makes an incision in the chest to examine the lung(s) directly and takes tissue samples for testing. Performed in an operating room with the patient under general anesthesia, a thoracotomy is the procedure most often used to remove entire lung tumors.

Early diagnosis of NSCLC provides the best prognosis, which is the most likely course of the disease and chance of recovery. However, NSCLC and other lung cancers can be difficult to diagnose because they often cause symptoms that are mistaken for those of common illnesses or the effects of long-term smoking. As a result, approximately 80 percent of people diagnosed with NSCLC have already progressed to advanced stages of the disease, where it is more difficult to treat. Annual screenings are therefore recommended if you are between the ages of 55 and 80 and have a long history of smoking tobacco.

Staging Non-Small Cell Lung Cancer

Staging is the process used to find out if the cancer has spread within the lungs or to other parts of the body (metastasis). Some of the same tests used to stage the disease are used to diagnose it and, as such, are carried out at the same time as diagnostic procedures using the most advanced diagnostic equipment available. Information gathered from the staging process determines the stage of the disease. Proper staging of the cancer is essential for the doctor to be able determine the best treatment plan and provide the most accurate prognosis.

NSCLS is classified into the following stages based on the size and location of the tumor, whether the cancer has spread to the lymph nodes and/or other parts of the body, and other factors:

Occult (Hidden) Stage

Cancer cells are found in sputum or bronchial washings (a sample of cells taken from inside the airways that lead to the lungs), but cancer cannot be seen by imaging or bronchoscopy. Cancer may have spread to other parts of the body.

Stage 0

A tumor is found in the top layers of cells lining the air passages, but has not spread deeper into other lung tissues. The cancer has not spread to nearby lymph nodes or to distant parts of the body.

Stage 1

A small tumor is present, but the cancer has not spread to the nearby lymph nodes, making it possible for a surgeon to remove it completely. Stage I is divided into 2 substages based the tumor’s size:

Stage IA: Stage IA tumors are 3 centimeters (cm) in diameter or less in diameter. Stage IA tumors may be further divided into stages IA1, IA2, or IA3 based on the size of the tumor.

Stage II

Stage II lung cancer is divided into two substages:

Stage IIA: The tumor is larger than 4 centimeters (cm) but less than 5 cm in diameter. The cancer has not spread to nearby lymph nodes.
Stage IIB: The tumor is 5 cm or less in diameter and has spread to the lymph nodes. The Stage IIB designation also describes a tumor that is more than 5 cm wide and has not spread to the lymph nodes.

In some cases, Stage II tumors can be removed with surgery. Other times, more treatment is needed.

Stage III

Stage III lung cancer is divided into three substages – IIIA, IIIB and IIIC – based on the size of the tumor and to which lymph nodes the cancer has spread. Stage III cancers have not spread outside of the lungs and nearby lymph nodes. With stage IIIA and stage IIIB cancers, the tumor may be difficult or impossible to remove using surgery. Stage IIIC cancers cannot be removed with surgery. Stage III cancers that cannot be treated with surgery can be treated successfully with chemotherapy and radiation therapy.

Stage IV

Stage IV describes lung cancer that has spread to more than one area in the other lung, the fluid surrounding the lung or the heart, or distant parts of the body via the bloodstream. Once cancer cells enter the bloodstream, the cancer can spread to anywhere else in the body, though NSCLC is more likely to spread to the brain, bones, liver or adrenal glands. Stage IV NSCLC is classified into 2 substages:

Stage IVA: The cancer has spread within the chest and/or has spread to one area outside of the chest.
Stage IVB: The cancer has spread outside of the chest to more than one place in one organ or to more than one organ.

Surgery is usually not an option for most stage IIIB, IIIC or IV lung cancers. Surgical removal of lung that has spread to the lymph nodes above the collarbone is also not possible. Surgical removal may also not be an option if the cancer has grown into vital structures within the chest, including the heart, large blood vessels or the main breathing tubes leading to the lungs. In these situations, the doctor will prescribe other treatment options.

Non-Small Cell Lung Cancer Treatment

UH Seidman Cancer Center’s highly skilled surgeons and oncologists are experts at treating NSCLC, offering patients the complete range of current treatment options. In addition to offering all current NSCLC treatments, UH Seidman Cancer Center participates in clinical trials exploring the newest treatments for NSCLC, always on the lookout for a cure for the disease and ways to improve patients’ quality of life.

Current NSCLC treatments include the following:

Surgery

Our skilled thoracic surgeons have advanced training in minimally invasive techniques. We use a less-invasive approach in the most of our surgeries to that patient experience less pain, quicker recovery and improved outcomes. The four main surgical procedures used to treat NSCLC are:

Wedge resection: surgical removal of a tumor and some of the normal tissue surrounding it; removal of a slightly larger amount of tissue than normal is called a segmental resection
Lobectomy: surgical removal of a whole lobe (section) of a lung
Pneumonectomy: surgical removal of an entire lung
Sleeve resection: surgical removal of a part of a main bronchus (one of the two large airways that lead from the windpipe to the lungs)

Radiation Therapy

Radiation therapy uses high-energy x-rays or other types of radiation to kill cancer cells or prevent them from growing. The two primary types of radiation therapy used in NSCLC treatment are:

External radiation therapy: radiation is directed at the area of the body with the cancer from a machine situated outside the body
- Among the external radiation therapies used at UH Seidman Cancer Center to treat NSCLC is stereotactic body radiation therapy, in which the patient is placed in the same position for each radiation treatment with the use of special equipment. Once a day for several days, a radiation machine directs a larger than usual dose of radiation at the tumor. Because the patient is in the same position for each treatment, less damage occurs to healthy tissue surrounding the tumor. This therapy is also called stereotactic external-beam radiation therapy and stereotaxic radiation therapy.
Internal radiation therapy consists of the use of a radioactive substance sealed in needles, seeds, wires or catheters placed directly into or near the cancer. For example, in tumors located in the airways, radiation can be given directly through an endoscope, which is flexible, lighted tube used to look inside the body.

Chemotherapy

Chemotherapy (chemo) is a cancer treatment that uses drugs to halt the growth of cancer cells by killing the cells or by preventing their division. Chemotherapy drugs are either injected into a vein or taken orally. The drugs move through the bloodstream to reach most parts of the body. Chemotherapy may be given before and/or after surgery or under other circumstances depending on the stage of the cancer and other factors. The chemotherapy drugs most often used to treat NSCLC are:

Cisplatin
Carboplatin
Paclitaxel (Taxol)
Albumin-bound paclitaxel (nab-paclitaxel, Abraxane)
Docetaxel (Taxotere)
Gemcitabine (Gemzar)
Vinorelbine (Navelbine)
Etoposide (VP-16)
Pemetrexed (Alimta)

Targeted Therapy

Targeted therapy is a treatment in which drugs or other substances are used to identify and attack specific cancer cells. This treatment approach typically causes less harm to normal cells than radiation therapy or chemotherapy. Examples of targeted therapies used to treat advanced, metastatic or recurrent NSCLC include monoclonal antibodies, tyrosine kinase inhibitors and mammalian target of rapamycin (mTOR) inhibitors.

Genomics, which is the branch of medicine that analyzes gene sequences in a person’s DNA and uses that information to customize medical care to the patient’s genetic makeup, is important in the development of targeted therapies for NSCLC. To date, at least several genomic abnormalities have been identified in NSCLC. UH Seidman Cancer Center has developed specific targeted therapies against these mutations, either already approved or available through clinical trials.

Immunotherapy

Immunotherapy refers to treatments that seek to fight cancer using the patient’s own immune system. In this type of therapy, substances produced by the body or in a laboratory are used to boost, direct or restore the body’s natural defenses against cancer. Immune checkpoint inhibitor therapy is an example of an immunotherapy used to treat some patients with advanced NSCLC.

Other Treatments

Other NSCLC treatment include:

Proton therapy: Proton therapy delivers high doses of radiation directly into the tumor. This advanced form of radiation targets the cancer without affecting surrounding healthy tissue and vital organs.
Laser therapy: This treatment uses a laser beam (a narrow beam of intense light) to kill cancerous cells.
Photodynamic therapy (PDT): In PDT, a patient is given a drug that collects in higher concentrations in cancer cells than in normal cells. Fiberoptic tubes are then used to deliver laser light to the cancer cells, where the drug becomes active upon exposure to the light and kills the cells.
Cryosurgery: In this treatment, the surgeon uses an instrument to freeze and destroy cancer tissue in the body.
Electrocautery: Electrocautery uses a probe or needle heated by an electric current to destroy cancer cells.

Many patients diagnosed with NSCLC should consider taking part in a clinical trial. Participation in clinical trials can extend patients’ lives and, in some cases, provide access to life-saving treatments and procedures. Some clinical trials are open only to patients who have not started treatment.

Pioneering Clinical Research Leads to New Opportunities in Care

University Hospitals is an affiliate of Case Western Reserve University School of Medicine, a nationally recognized leader in clinical research. UH Seidman Cancer Center conducts a number of clinical trials for patients with lung cancer and other cancers, offering access to the newest and most innovative therapies and treatment options. Clinical research in NSCLC treatment includes trials exploring new chemotherapy and immunotherapy drugs used by themselves and in combination with other medications and radiation therapies such as stereotactic radiation and proton therapy.

Learn More About Our Available Clinical Trials

Supportive Care for Non-Small Cell Lung Cancer

In addition to its world-class core diagnostic and treatment services, UH Seidman Cancer Center offers a range of Supportive Oncology Services designed to provide comprehensive care for the physical, emotional and spiritual needs of cancer patients and their families. The focus of our Supportive Oncology Services is to prevent or ease symptoms caused by lung and other types of cancer, aiming to improve patients’ quality of life during all phases of treatment, regardless of prognosis or stage of the disease. A compassionate care team that includes doctors, nurses, nutritionists, social workers and other health professionals provides these services.

Supportive Oncology Services include the Symptom Management and Supportive Care Clinic at UH Seidman Cancer Center’s Robinson Family Pavilion in Cleveland, Ohio. The expert team operating the clinic sees cancer patients for pain symptoms, non-pain symptoms (nausea, constipation, fatigue, anorexia, shortness of breath, etc.), anxiety, depression and delirium, as well as both patients and families for coping assistance.

Compassionate, Highly Trained Team of Experts

A compassionate, experienced, multidisciplinary team evaluates and reviews every cancer case so that diagnosis and treatment decisions are based on the group’s combined expertise. Together, we work through every step of cancer care, always with a cure in mind. Our care team comprises:

Oncologists
Surgical oncologists
Pathologists
Radiation oncologists
Radiologists
Pulmonologists
Medical geneticists
Genetic counselors
Nurse navigators
Nurse practitioners
Social workers

At UH Seidman Cancer Center, each patient’s case is presented at weekly tumor board meetings, where our team conducts a disease-specific tumor board review to ensure that all treatment options are considered.

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