Misconceptions About Stage 4 Treatments for Lung Cancer

The Truth about Chemotherapy and Radiation for Stage 4 Lung Cancer

patient receiving chemotherapy
What are the misconceptions about chemotherapy for stage 4 lung cancer?. National Cancer Institute, Rhoda Baer (photography)

What Can You Expect from Stage 4 Lung Cancer Treatments?

If you're living with stage 4 lung cancer your oncologist has likely discussed the purpose of the treatments you have been offered. Yet we are learning that what people may expect from some forms of therapy differs from what oncologists are expecting. What is the truth about chemotherapy and radiation therapy for stage 4 lung cancer and what are some misconceptions?

Stage 4 Lung Cancer Hope and False Hope and Prognosis

There is much more hope for those with stage 4 lung cancer than in the past. It's important to note right up front that the prognosis for people with stage 4 lung cancer is improving; new treatments are becoming available, and survival rates are improving. There are many people who are considered "long term" survivors of stage 4 lung cancer, and that number is increasing each year.

That said, the prognosis for stage 4 lung cancer is still not what we would wish, and some treatments do not work as well as we would like them to. In discussing these treatments, there is a fine balance between instilling hope and delivering false hope.

False hope about treatment options may lead people to undergo therapies which have a heavy cost with regard to quality of life. False hope may also keep people from pursuing different treatment options which may work better.

True hope, in contrast, involves honestly weighing whether a treatment is worthwhile, but a way in which you can feel empowered in making choices for your life.

Goals of Physicians vs Expectations of Patients with Stage 4 Lung Cancer

Until fairly recently we had assumed that physicians and patients were on the same wavelength when it came to expectations about stage 4 lung cancer treatments.

A few studies, however, have broken that bubble, at least with respect to expectations related to chemotherapy and radiation therapy. (Targeted therapies, immunotherapy, and one particular type of radiation therapy are another story and will be discussed further below.) Let's take a look at what we have learned.

Chemotherapy for Stage 4 Lung Cancer - Results vs Expectations

In a 2012 study, researchers set out to see whether the expectation of patients and oncologists were in synch with regard to expectations related to chemotherapy for stage 4 lung cancer. The results of the study were sobering.

In all, 69 percent of stage 4 lung cancer patients (and 81 percent of stage 4 colorectal cancer patients) didn't understand that chemotherapy was not at all likely to cure their cancer. In other words, the majority of these people with lung cancer were carrying a false hope that chemotherapy might cure their disease.

Another study done in 2015 confirmed that these differences in expectations persisted, in that around two-thirds of patients with stage 4 lung or colon cancer didn't understand that chemotherapy was not at all likely to cure their cancer.

Chemotherapy, when used for people with stage 4 lung cancer may extend survival.

People treated with these drugs live, on average, a few weeks or a few months longer. Chemotherapy may also be used as a palliative therapy, reducing symptoms such as shortness of breath. Yet chemotherapy only rarely results in a cure for lung cancer.

Radiation Therapy for Stage 4 Lung Cancer

As with chemotherapy, it appears that many people have misconceptions about the benefit of radiation therapy for stage 4 lung cancer. In a 2012 study, it was found that 64 percent of people did not realize that radiation was not likely to cure their cancer.

Radiation therapy, as with chemotherapy, may extend life, or help with the symptoms of cancer, but only rarely results in long-term survival.

In contrast to chemotherapy, however, radiation may be very helpful in controlling bleeding or obstruction of the airways due to a lung cancer, or treating bone metastases which can cause pain or fractures.

There is one type of radiation therapy which is sometimes used with hopes of long-term survival among those with stage 4 lung cancer. If a person has one or only a few metastases to the brain, for example, stereotactic body radiotherapy (SBRT) also known as CyberKnife, has sometimes resulted in long-term control of the disease.

The Impact of False Hope with Stage 4 Lung Cancer

It's been argued at times that having false hope with cancer is better than no hope. Yet when questioned, it appears that the majority of people would rather not be given false hope. False hope denies people the opportunity to fully make their own decisions or be their own advocates in their care. There are two opposing reasons why this false hope can be detrimental to people living with advanced lung cancer.

One reason is that false hope gives people who want to do everything possible to treat their disease the illusion that this is already being done. We do have treatments now in addition to chemotherapy, surgery, and radiation therapy which may offer more hope or a greater possibility of survival for some people. Since some of these newer treatments have only recently been approved or are only available in clinical trials. Since some of these newer treatments have only recently been approved or are only available in clinical trials, carrying a false hope that chemotherapy may be a cure might prevent people from pursuing options more likely to meet their expectations.

A different reason, however, is that a person may commit to a treatment which decreases their quality of life thinking it will increase the quantity when that is unlikely. In this way, false hope denies people the choice to honestly choose how they would wish to spend their last days.

Patient/Physician Communication

Looking at the discrepancy between expectations between patients and physicians you might think that communication was the problem. Instead, however, it was found that patients who said they had good communication with their physicians were more likely to carry the false hope that chemotherapy could be curative. Though the reasons for this aren't known, it could be that oncologists are afraid that sharing the truth about chemotherapy may remove hope. 

Targeted Therapies for Stage 4 Lung Cancer

Everyone with stage 4 non-small cell lung cancer should have molecular profiling (gene testing) one on their tumors. For those who have EGFR mutations, ALK rearrangements, ROS1 rearrangements, or other mutations, specific targeted therapies may result in control of their cancer beyond what could be expected with chemotherapy.

While cancers usually become resistant to these drugs in time (often around a year but sometimes many years), another (second or third generation) medication may then be an option. For example, an EGFR positive lung tumor which is controlled for awhile on Tarceva (erlotinib) but develops resistance, may be sensitive to a 3rd generation medication. In this way, lung cancer, at least lung cancers with specific mutations, is becoming closer to being treated like a chronic disease: not curable, but controllable for a significant amount of time.

Immunotherapy for Stage 4 Lung Cancer

In 2015, two new immunotherapy drugs were approved for the treatment of lung cancer. Immunotherapy works by using the principles of our own immune systems to fight off cancer cells. While many people do not respond to these drugs, those who do respond may sometimes obtain long-term control of their cancer. In other words, people who respond to these medications, such as Keytruda (pembrolizumab) or Opdivo (nivolumab) may live much longer than they would have expected to live if treated with chemotherapy or radiation therapy alone.

Discussions About End of Life Care

Aside from the possibility of using newer treatments which may be more effective than chemotherapy, we noted that chemotherapy or radiation therapy—if someone is using these treatments expecting that they may cure their advanced lung cancer—may decrease the chance of having an honest discussion with their oncologist about end-of-life issues.

We are learning that palliative care (palliative care can be used even if someone is expected to be cured) not only substantially improves quality of life for people with advanced lung cancer, but may increase survival as well. Hospice care is one form of palliative care, and sadly, many people opt for this care only very late in their disease and wish they had done so earlier due to the support that comes with this choice.

If you are considering stopping your treatment, check out this article on when should you stop cancer treatment. Learn more about coping with terminal cancer

Source:

Chen, A., Cronin, A., Weeks, J. et al. Expectations about the Effectiveness of Radiation Therapy among Patients with Incurable Lung Cancer. Journal of Clinical Oncology. 2013. 31(21):2730-5.

Mack, J., Walling, A., Dy, S. et al. Patient Beliefs that Chemotherapy may be Curative and Care Received at the End of Life Among Patients with Metastatic Lung and Colorectal Cancer. Cancer. 2015. 121(11):1891-7.

Weeks, J., Catalano, P., Cronin, A. et al. Patients' Expectations about Effects of Chemotherapy for Advanced Cancer. The New England Journal of Medicine. 2012. 367:1616-1625.

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