Treatments for stage 3 non–small cell lung cancer

The following are treatment options for stage 3 non−small cell lung cancer. Your healthcare team will suggest treatments based on your needs and work with you to develop a treatment plan.

Chemotherapy and external radiation therapy may be given together before surgery for stage 3 non–small cell lung cancer. You need to be well enough to have this treatment. Chemoradiation may also be given if you won't be having surgery and are well enough to have this treatment.

The chemotherapy drug combinations most often used with chemoradiation are cisplatin with etoposide (Vepesid).

Surgery may be offered after chemoradiation if the chemoradiation shrinks the tumour enough to make removing it possible.

A lobectomy removes the lobe of the lung where the tumour is. A bilobectomy is a type of lobectomy that removes 2 of the 3 lobes of the right lung.

A sleeve resection removes a tumour from one of the airway tubes of the lung (the bronchi) along with a margin of healthy tissue around the tumour.

A pneumonectomy removes the whole lung.

An extended pulmonary resection removes the muscles, nerves, blood vessels and other tissues near the lung. During the surgery, a wide area of tissue surrounding the lung is taken out to remove as much of the cancer as possible. Surgery for cancer that has grown into the bones of the spine is done using 2 surgeries, one to support the spine with rods followed by another surgery to remove the tumour.

A chest wall resection removes the muscles, bones and other tissues of the chest wall.

For stage 3A non–small cell lung cancer, you may be offered surgery after chemoradiation if the cancer has responded to chemoradiation. You need to be healthy enough to have surgery.

For stage 3B and 3C non–small cell lung cancer, you will not be offered surgery because surgery will not help given where the cancer has spread. You will be offered other treatments.

The chemotherapy drug combinations that may be used to treat non−small cell lung cancer are:

• cisplatin with vinorelbine or etoposide – most common 2 combinations

• cisplatin (or carboplatin) and gemcitabine

• cisplatin (or carboplatin) and docetaxel (Taxotere)

• carboplatin (or cisplatin) and paclitaxel

• gemcitabine and docetaxel

• gemcitabine and vinorelbine

• carboplatin (or cisplatin) and pemetrexed (Alimta) – not used for squamous cell carcinoma of the lung

For stage 3A non–small cell lung cancer, you may have chemotherapy before surgery if you cannot be given radiation therapy. Chemotherapy may also be given after surgery if no chemotherapy was given before surgery or if the cancer responded to chemotherapy given before surgery.

For stage 3B and 3C non–small cell lung cancer, you may have chemotherapy by itself if you are not well enough to have chemoradiation or radiation therapy.

Targeted therapy may be used to treat stage 3 non−small cell lung cancer. The type of targeted therapy you have will depend on the type of genetic change (mutation) found during diagnosis using cell and tissue studies and whether there is treatment based on that mutation.

Epidermal growth factor receptor (EGFR) is a receptor on the surface of cells that sends signals to cells that allow them to grow and divide. A mutation in the EGFR gene can cause cancer cells to grow and divide more than normal. Cancer cells that have the EGFR mutation are called EGFR positive (EGFR+).

EGFR-positive stage 3B and 3C non−small cell lung cancer may be treated with targeted therapy instead of chemotherapy. Drugs that may be used are:

• erlotinib (Tarceva)

• gefitinib (Iressa)

• osimertinib (Tagrisso)

Erlotinib may also be given as maintenance therapy for stage 3 non−small cell lung cancer after 4 cycles of chemotherapy with cisplatin or carboplatin.

The EGFR exon 20 insertion mutation happens when a small piece of genetic material gets added (inserted) into the area of the EGFR gene called the exon 20.

Targeted therapy drugs used for other EGFR mutations don't work for the exon 20 insertion mutation.

Amivantamab (Rybrevant) may be offered for stage 3B or stage 3C non–small cell lung cancer with the EGFR exon 20 insertion mutation if it doesn't respond to, or stops responding to, chemotherapy with cisplatin or carboplatin.

Anaplastic lymphoma kinase (ALK) is a protein that helps with cell growth and division. It is controlled by the ALK gene. A very small number of non–small cell lung cancers have a change (mutation) in the ALK gene. Cancer cells that have the ALK mutation are called ALK positive (ALK+).

ALK-positive stage 3 non−small cell lung cancer may be treated with crizotinib (Xalkori). If you can't take crizotinib, other drugs that may be given are:

• ceritinib (Zykadia)

• alectinib (Alecensaro)

• brigatinib (Alunbrig)

KRAS G12C is a common genetic mutation found in people with non–small cell lung cancer. A tumour that has the KRAS G12C mutation is called KRAS G12C-positive.

Sotorasib (Lumakras) is a targeted therapy drug that can be used to treat people with stage 3 KRAS G12C-positive non–small cell lung cancer that have received at least one other systemic treatment.

The ROS1 gene makes a protein that is responsible for signals in cells and helps with cell growth. A mutation in the ROS1 gene can cause cancer cells to grow and divide more than normal. Cancer cells that have the ROS1 mutation are called ROS1 positive (ROS1+).

ROS1-positive stage 3 non−small cell lung cancer may be treated with crizotinib.

Entrectinib (Rozlytrek) may be offered for ROS1-positive stage 3 non–small cell lung cancer, if you have not been given crizotinib as a treatment.

MET exon 14 skipping mutations (METex 14) is a mutation that has been found in a small number of non–small cell lung cancer tumours.

Tepotinib (Tepmetko) or capmatinib (Tabrecta) may be used in people who have stage 3 non–small cell lung cancer that has METex 14 mutations, and can't be removed with surgery.

The RET gene makes a protein that is responsible for signals in cells and in cell growth. A very small number of non–small cell lung cancers have a change in the RET gene. Cancer cells that have changes in the RET gene are called RET–positive (RET+).

RET+ stage 3 non–small cell lung cancer that can't be removed with surgery may be treated with Gavreto (pralsetinib), instead of chemotherapy.

Bevacizumab (Avastin, MVASI, Zirabev) is a type of targeted therapy called an angiogenesis inhibitor. It targets a protein called vascular endothelial growth factor (VEGF), which helps new blood vessels grow. Bevacizumab is combined with the chemotherapy drugs carboplatin and paclitaxel. This combination may be offered for stage 3 non−small cell lung cancer.

Immunotherapy with different types of PD-L1 checkpoint inhibitors may be used to treat stage 3 non−small cell lung cancer.

Durvalumab (Imfinzi) may be used if you can't have surgery to treat non–small cell lung cancer that has stopped growing when it has been treated with chemoradiation. Durvalumab is given until the cancer starts to progress (grow again).

Cemiplimab (Libtayo) is used for non−small cell lung cancer tumours that make a lot PD-L1, but don't have changes to other genes such as EGFR, ALK or ROS-1. You may be given cemiplimab if you can't have surgery or chemoradiation.

Atezolizumab (Tecentriq, Tecentriq SQ) may be offered by itself for stage 3A non–small cell lung cancer that has been completely removed with surgery, and that hasn't progressed after chemotherapy given after surgery is finished.

External radiation therapy by itself may be given as the main treatment if you have stage 3 non–small cell lung cancer and are not well enough to have surgery, chemotherapy or chemoradiation as treatment.

External radiation therapy may be delivered by 3D conformal radiation therapy (3D-CRT) or intensity modulated radiation therapy (IMRT).

Talk to your doctor about clinical trials open to people with non−small cell lung cancer in Canada. Clinical trials look at new ways to prevent, find and treat cancer. Find out more about clinical trials.