What to Expect When Non-Small Cell Lung Cancer Spreads

How Is Metastatic NSCLC Diagnosed and Treated?

A number of tests are used to diagnose NSCLC, see if it has spread, and look for signs that the cancer might be recurring after treatment, according to the ACS. Your doctor will likely start with a chest X-ray. If there are any suspicious masses, they may follow up with a CT (computed tomography) scan, MRI (magnetic resonance imaging), or PET (positron emission tomography) scan, which can help your doctor tell if the cancer has spread to the bones, brain, liver, other organs, or spinal cord.

Once a doctor determines there is reason to suspect cancer, the actual diagnosis is made by conducting a biopsy (a procedure in which cells, tissue, or fluids are removed to be examined in a lab). Sample cells can be collected by a syringe needle, surgery, or fluid removal from the area around the lungs. Doctors may also use mucus samples to conduct tests. Procedures to diagnose NSCLC include:

• Bronchoscopy A lighted flexible or rigid tube with a camera is inserted through the nose or mouth to help doctors see inside the airways and collect samples for testing.
• Mediastinoscopy An endoscope (a thin tube with a light and camera) is inserted through a small surgical opening in the chest to look behind the breastbone (the sternum) and take tissue samples from the lymph nodes along the windpipe and major bronchial tube areas.
• Mediastinotomy When lymph nodes can’t be reached using mediastinoscopy, a surgeon may use this, which is the same procedure but with a slightly larger incision between the ribs, next to the breastbone.
• Thoracoscopy A thin, flexible tube with a camera and light, called a thorascope, is inserted through an incision near the lower end of the shoulder blade, between the ribs, to allow doctors to see into that area.

Current treatments don’t cure metastatic NSCLC for most people. But they can ease your symptoms and help you live longer and feel better, according to Taofeek Owonikoko, MD, a thoracic medical oncologist and executive director of the University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, in Baltimore.

Treatment options depend on many factors, including where the cancer has spread and the 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 biomarker testing (also called molecular or genomic testing), which looks for changes in the tumor’s DNA. Biomarker testing can be done on tissue samples, blood, or other bodily fluids, such as urine or sputum (known as a liquid biopsy). This can help doctors plan personalized 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, brain, liver, or elsewhere, might require conventional cancer treatments, such as radiation therapy or chemotherapy. In some cases, surgery may be done to remove tumors that have spread to the brain.

The Outlook for Metastatic NSCLC

How long you’ll live — and what kind of life you’ll have — are related to the particular mutations present in your tumor cells, which 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.