An Overiew of Stage 3 Lung Cancer

Symptoms, Staging, and Treatment of Stage III Lung Cancer

Doctor talking to patient in hospital
What are the symptoms and treatments for stage 3 lung cancer?. Portra Images/Taxi/Getty Images

Stage 3 Lung Cancer - Definition

Stage 3 non-small cell lung cancer is a broad and diverse category of lung cancers that is further broken down into stage 3A and stage 3B

Stage 3 - Locally Advanced vs Advanced Lung Cancer

It's easier to describe the diversity of stage 3 lung cancers by breaking down all lung cancers into two primary categories.

  • Locally advanced lung cancer - Stage 3A is considered locally advanced lung cancer. These tumors have not spread to distant regions of the body, but have spread to lymph nodes on the same side of the body as the tumor. Stage I to stage 3A lung cancers are considered "operable" meaning that surgery offers a chance for a cure.
  • Advanced lung cancer - Along with stage 4 lung cancer, stage 3B lung cancer is considered advanced lung cancer .These tumors have spread to a degree such that surgery is not possible (unless, and sometimes, after treatment with chemotherapy and radiation therapy.) These tumors are "inoperable" and not usually curable, but they are treatable, and many new treatments have been approved in recent years.

How Common is Stage 3 Lung Cancer?

Roughly 30 percent of people have stage 3 lung cancer at the time of diagnosis, leaving 30 percent of individuals diagnosed at an earlier stage (stage 1 or stage 2 disease) and 40 percent having already progressed to stage 4 (metastatic) lung cancer at the time of diagnosis.

Staging of Non-Small Cell Lung Cancer

Lung cancer staging is a very important step in choosing the best treatment options, especially making the distinction between stage 3A and stage 3B. Stage 3 lung cancer is best described by separating the stages into stage 3A and stage 3B separately.

Stage 3A lung cancer includes tumors that are large and have spread to nearby lymph nodes, or tumors of any size that have spread to lymph nodes that are further away but still on the same side of the body as the cancer.

Stage 3B lung cancer is defined as a tumor of any size that has spread to distant lymph nodes or has invaded other structures in the chest (such as the heart or esophagus.) Tumors involving a malignant pleural effusion (fluid build-up containing cancer cells in the pleural cavity between the layers lining the lungs) were changed from stage 3B to stage 4 in 2009.

Oncologists use the TNM system to further define stages of lung cancer. A simplified description of the TNM system includes:

T refers to tumor size:

  • T1 – A tumor is less than 3 cm (1 ½ inches) in size.
  • T2 –The tumor is greater than 3 cm.
  • T3 – The tumor can be any size, but is near the airway or has spread to local areas such as the chest wall or diaphragm.
  • T4 – The tumor is any size, but is located in the airway or has invaded local structures such as the heart, or the esophagus.

N refers to lymph nodes:

  • N0 – No nodes are affected.
  • N1 – The tumor has spread to nearby nodes on the same side of the body.
  • N2 – The tumor has spread to nodes further away but on the same side of the body.
  • N3 – Cancer cells are present in lymph nodes on the other side of the chest from the tumor, or in nodes near the collarbone or neck muscles.

M represents metastatic disease:

  • M0 – No metastases are present.
  • M1 – The tumor has spread (metastasized) to other regions of the body or the other lung.

Using the TNM System, stage 3A lung cancer is described as:

  • T1N2M0 – The tumor is less than 3 cm in size and has spread to lymph nodes further away but on the same side of the body as the tumor.
     
  • T2N2M0 – The tumor is larger than 3 cm and has spread to lymph nodes further away but on the same side of the body.
     
  • T3N1M0 – The tumor is any size but is near an airway or has spread locally to an area like the chest wall or diaphragm, and nearby lymph nodes are affected.
     
  • T3N2M0 – The tumor is any size but is near an airway or has spread locally to an area like the chest wall or diaphragm, and lymph nodes that are further away but on the same side of the body are affected.

Using the TNM System, stage 3B is described as:

  • Any T, N3, M0 – A tumor of any size that has spread to lymph nodes on the other side of the chest from the tumor or to nodes near the collarbone or neck muscles, but has not spread to distant regions of the body.
     
  • T4, Any N, M0 – A tumor of any size that is located in the airways, or has invaded local structures such as the heart or esophagus. Nodes may or may not be involved, and when affected, can be near the tumor or further away in the chest or neck, but the tumor has not spread to distant regions of the body.

Symptoms of Stage 3 Lung Cancer

Stage 3 lung cancer symptoms are variable since stage 3 includes a wide spectrum of cancers. Symptoms due to cancer in the lungs such as a persistent coughshortness of breath, and repeated infections such as pneumonia or bronchitis, are common.

Spread to areas such as the chest wall and diaphragm can result in pain in the chest, ribs, shoulders, and back.Tumors located near the airways can cause hemoptysis (coughing up blood) and wheezing. When the tumor involves areas such as the esophagus and other chest structures, dysphagia (difficulty swallowing) and hoarseness can occur. Pain in the back, chest, and ribs is common if a pleural effusion is present, and this can result in increasing shortness of breath.

General symptoms of cancer such as fatigue and unintentional weight loss may be present as well.

Treatment of Stage 3 Lung Cancer

The treatment of stage 3 lung cancer is the most controversial of all lung cancer stages, partly because this group is so varied. Due to the poor survival rate, the National Cancer Institute states that everyone with stage 3 lung cancer should be considered a candidate for clinical trials –- studies that evaluate new treatments or combinations of treatments for lung cancer.

Stage 3A Treatment

For some stage 3A lung cancers, surgery can be performed to remove the tumor and is usually followed up with adjuvant chemotherapy (chemotherapy after surgery). Surgery offers a chance for a cure but is not always possible with tumors of this size. The risk of lung cancer recurrence is also fairly high for people with stage 3A lung cancer.

For those that are relatively healthy, a combination of chemotherapy or chemotherapy and radiation therapy is often recommended. If individuals are unable to tolerate chemotherapy, radiation therapy can be used alone to treat symptoms such as pain and shortness of breath.

It's now recommended that molecular profiling (gene testing) be done for everyone with non-small cell lung cancer, especially lung adenocarcinoma. Medications have been approved for people with driver mutations such as EGFR mutations, ALK rearrangements, and ROS1 rearrangements, and these targeted therapies can sometimes result in excellent control of the disease. Resistance often develops in time, but next generation medications are currently approved and being tested in clinical trials for when this occurs. For those with squamous cell carcinoma of the lungs, anti-EGFR antibodies may be used. Clinical trials are also studying medications which address other genetic changes in lung cancer.

Two new immunotherapy drugs were approved in 2015 for the treatment of lung cancer. These medications work by essentially enhancing the ability of our own immune systems to fight cancer. While they do not work for everyone, some people have achieved long-term disease-free control of their cancer.

Stage 3B Treatment

Stage 3B cancers, unlike stage 3A, cannot usually be treated with surgery. In other words, they are inoperable—but  not untreatable. Treatments may include chemotherapy, radiation therapy, targeted therapies, and immunotherapy as with stage 3A disease.

In some cases, the use of chemotherapy and radiation therapy is able to decrease the size of a tumor so that surgery is then possible. Chemotherapy used in this way is referred to as "neoadjuvant chemotherapy."

For people with stage 3 lung cancer, treatments can also be used as palliative treatment., meaning that the focus of treatment is relieving symptoms such as pain and shortness of breath rather than trying to control the cancer. It's actually been found that palliative therapy for people with lung cancer may improve survival.

Prognosis

The overall 5-year survival rate with stage 3A lung cancer is 14 percent, but it can vary widely. The 5-year survival rate with stage 3B lung cancer is sadly only about 5 percent  It's important to keep in mind that these statstics are based on how people do with lung cancer in the past. Since there have been more medications approved for the treatment of lung cancer between 2011 and 2015 than during the four decades preceding 2011, these statistics are fairly unreliable in estimating how you will do with lung cancer today. This following article goes into more detail.

What Can I Do to Help Myself?

Studies suggest that learning what you can about your cancer helps with the outcome. Ask questions. Involve your loved ones and encourage them to ask questions as well. Consider joining a support group. Learn about clinical trials that might be appropriate for your particular situation. Learning about your cancer and going through treatment can take a tremendous amount of time. Ask for and allow your loved ones and friends to help and encourage you in your journey. Don’t lose hope—even if that hope is only to be as comfortable as possible while you enjoy the company of your loved ones.

Sources:

American Cancer Society. Lung Cancer (Non-Small Cell.) Non-Small Cell Lung Cancer Survival Rates by Stage. 05/16/16. http://www.cancer.org/cancer/lungcancer-non-smallcell/detailedguide/non-small-cell-lung-cancer-survival-rates

American Joint Committee on Cancer. Lung Cancer Staging. 7th Edition. Accessed 06/07/16. https://cancerstaging.org/references-tools/quickreferences/Documents/LungMedium.pdf

Edge, S. et al (Eds.). AJCC Cancer Staging Manual. 7th Edition. Springer. New York, NY. 2010.

Faithi, A. and J. Brahmer. Chemotherapy for advanced stage non-small cell lung cancer. Seminars in Thoracic and Cardiovascular Surgery. 2008. 20(3):210-6.

National Cancer Institute. Non-Small Cell Lung Cancer Treatment (PDQ) - Health Professional Version. Updated 07/07/16.

Santos, E. et al. Controversies in the management of stage IIIA non-small-cell lung cancer. Expert Review of Anticancer Therapy. 2008. 8(12):1913-29.

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