EN Non Small Cell Lung Cancer Guide For Patients

Non-Small-
Cell Lung
Cancer
What is
Non-Small-Cell
Lung Cancer?
Let us answer some

of your questions.
ESMO Patient Guide Series

based on the ESMO Clinical Practice Guidelines esmo.org
Non-small-cell lung cancer
Non-small-cell lung cancer (NSCLC)

An ESMO guide for patients
Patient information based on ESMO Clinical Practice Guidelines
This guide has been prepared to help you, as well as your friends, family and caregivers, better understand
non-small-cell lung cancer (NSCLC) and its treatment. It contains information on the different subtypes of
NSCLC, the causes of the disease and how it is diagnosed, up-to-date guidance on the types of treatments that
may be available and any possible side effects of treatment.
The medical information described in this document is based on the ESMO Clinical Practice Guidelines for
NSCLC, which are designed to help clinicians with the diagnosis and management of early-stage, locally
advanced and metastatic NSCLC. All ESMO Clinical Practice Guidelines are prepared and reviewed by leading
experts using evidence gained from the latest clinical trials, research and expert opinion.
The information included in this guide is not intended as a replacement for your doctor’s advice. Your doctor
knows your full medical history and will help guide you regarding the best treatment for you.
Words highlighted in colour are defined in the glossary at the end of the document.
This guide has been developed and reviewed by:
Representatives of the European Society for Medical Oncology (ESMO): David Planchard; Silvia Novello;
Solange Peters; Raffaele Califano; Jean-Yves Douillard; Francesca Longo; Claire Bramley; and Svetlana Jezdic
Representatives of the European Oncology Nursing Society (EONS): Anita Margulies; Roisin Lawless
Patient advocate from Lung Cancer Europe (LuCE) and Women Against Lung Cancer in Europe
(WALCE): Stefania Vallone
2
WHAT’S
ESMO Patients Guide
INSIDE
2 An ESMO guide for patients

4 Lung cancer: A summary of key information
7 Anatomy of the lungs
8 What is lung cancer?
9 What are the symptoms of lung cancer?
10 How common is NSCLC?
12 What causes NSCLC?
14 How is NSCLC diagnosed?
17 How will my treatment be determined?
21 What are the treatment options for NSCLC?
23 Treatment options for early (Stage I-II) NSCLC
25 Treatment options for locally advanced (Stage III) NSCLC
27 Treatment options for metastatic (Stage IV) NSCLC
32 Clinical trials
33 Supplementary interventions
35 What are the possible side effects of treatment?
49 What happens after my treatment has finished?
52 Support groups
53 References
55 Glossary
3
Lung cancer: A summary of key information

This summary is an overview of the key information provided within the NSCLC guide. The following information
will be discussed in detail in the main pages of the guide.
Introduction to lung cancer

• Lung cancer arises from cells in the lung that have grown abnormally and multiplied to form a lump or tumour.
• Non-small-cell lung cancer (NSCLC) is a type of lung cancer, which is differentiated from small-cell lung
cancer (SCLC) because of the way the tumour cells look under a microscope. The three main types of
NSCLC are adenocarcinoma, squamous cell carcinoma, and large cell (undifferentiated) carcinoma
of the lung. They are diagnosed in the same way, but may be treated differently.
• Lung cancer is the third most common cancer in Europe; NSCLC represents 85–90% of all lung cancers.
Smoking is the biggest risk factor for the development of lung cancer.
• In Europe, there has been a decrease in lung cancer mortality among men, while it is increasing in women –
this reflects a difference in smoking trends between the sexes.
Diagnosis of NSCLC
• Lung cancer may be suspected if a person has symptoms such as persistent cough or chest infection,
breathlessness, hoarseness, chest pain or coughing up blood. Other symptoms may be fever, appetite loss,
unexplained weight loss and fatigue.
• Following a clinical examination, your doctor will arrange for an x-ray and/or computed tomography
(CT) scan (or might use other technologies, such as positron emission tomography [PET] CT scan or
magnetic resonance imaging [MRI]) to evaluate the position and extent of the cancer. Examination of a
biopsy (cells or tissue taken from the tumour) will confirm a diagnosis of NSCLC.
Treatment options for NSCLC

• Types of treatment include:
-- Surgery
-- Chemotherapy – the use of anti-cancer drugs to destroy cancer cells. Chemotherapy can be given
alone or with other treatments.
-- Targeted therapy – newer drugs that work by blocking the signals that tell cancer cells to grow.
-- Immunotherapy – a type of treatment designed to boost the body’s natural defences to fight cancer.
-- Radiotherapy – the use of measured doses of radiation to damage cancer cells and stop them growing.
• Combinations of different treatment types are frequently offered based on the stage and type of NSCLC and on
the patient’s condition and comorbidities (additional diseases or disorders experienced at the same time).
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ESMO Patients Guide
• Cancer is ‘staged’ according to tumour size, involvement of regional lymph nodes and whether it has
spread outside the lung to other parts of the body. This information is used to help decide the best treatment.
• Early-stage (Stage I-II) NSCLC
-- Surgery is the main treatment for early-stage NSCLC.
-- Chemotherapy may be given after surgery (adjuvant chemotherapy) in patients with Stage II and
Stage III NSCLC and in some patients with Stage IB disease.
-- Radiotherapy (either stereotactic ablative radiotherapy [SABR] or conventional radiotherapy)
is an alternative to surgery in patients who are unable or unwilling to have surgery.
-- Radiotherapy may be given after surgery (adjuvant radiotherapy) in patients with Stage II and Stage
III NSCLC.
• Locally advanced (Stage III) NSCLC
-- Treatment for locally advanced NSCLC is likely to involve different types of therapy (multimodal
therapy).
-- If it is possible to remove the tumour (i.e. the tumour is resectable), treatment options can include:
~~ Induction therapy (initial treatment[s] given to shrink the tumour before a second planned
treatment) consisting of chemotherapy with or without radiotherapy, followed by surgery.
~~ Surgery followed by adjuvant chemotherapy and/or radiotherapy.
~~ Chemoradiotherapy (i.e. chemotherapy and radiotherapy given at the same time or
sequentially).
-- The type of treatment – and sometimes the sequence of treatments – offered to patients with
resectable Stage III NSCLC will depend on the general health of the patient and any comorbidities,
as well as the extent and complexity of the surgery required to remove the tumour.
-- In unresectable Stage III NSCLC, chemoradiotherapy is the preferred treatment. Alternatively,
chemotherapy and radiotherapy can be given sequentially (i.e. one after the other) in patients
unable to tolerate concurrent treatment.
-- Immunotherapy may be offered to some patients with unresectable locally advanced NSCLC
following treatment with chemoradiotherapy.
• Metastatic (Stage IV) NSCLC
-- NSCLC is referred to as metastatic or Stage IV disease when it has spread beyond the lung which was
initially affected.
-- It is rarely possible to remove metastatic NSCLC with surgery or to treat it radically with radiotherapy.
-- Intravenous chemotherapy with a two-drug combination (with or without the addition of the
targeted therapy called bevacizumab) is the main treatment for patients with metastatic NSCLC.
-- The choice of drugs used will largely depend on the general health of the patient and the histological
subtype of the tumour.
5
-- Patients whose tumours express relatively high levels of programmed death-ligand 1 (PD-L1) protein
(determined by molecular testing using a tumour biopsy) may receive first-line immunotherapy with
pembrolizumab.
-- Patients whose tumours contain specific mutations (alterations) to the epidermal growth factor
receptor (EGFR), BRAF, anaplastic lymphoma kinase (ALK) or ROS1 genes (determined by
molecular testing using a tumour biopsy) are best treated with oral targeted therapies given
continuously.
-- After 4–6 cycles of doublet chemotherapy (i.e. two chemotherapy drugs given together), maintenance
treatment (treatment to help keep the cancer from coming back) with a chemotherapy drug called
pemetrexed, may be given to patients in good general health. The targeted therapy erlotinib may be
offered as maintenance treatment in patients whose tumours have EGFR mutations.
-- Should the cancer come back (relapse or recurrence), second- and third-line treatments may
be offered. Suitable second- and third-line treatments depend on which first-line treatment has
been received and on the general health of the patient. Treatment options include: chemotherapy
(pemetrexed or docetaxel), immunotherapy (nivolumab, pembrolizumab or atezolizumab),
when not given as first-line treatment, antiangiogenic therapy (nintedanib or ramucirumab) in
combination with docetaxel, and targeted therapies (afatinib, gefitinib, erlotinib, osimertinib,
dabrafenib in combination with trametinib, crizotinib, ceritinib, alectinib, brigatinib or lorlatinib)
for patients with molecular alterations.
~~ Patients whose tumours have EGFR mutations who have received first-line treatment with
erlotinib, gefitinib or afatinib, and who have a confirmed EGFR T790M mutation, may be
subsequently treated with osimertinib.
~~ Patients with a confirmed BRAF mutation who have received first-line treatment with
dabrafenib and trametinib may receive second-line platinum-based chemotherapy.
~~ Patients whose tumours have ALK rearrangements and who have received first-line treatment
with crizotinib may be treated with second-line ceritinib, alectinib, brigatinib or lorlatinib
if available.
Follow-up after treatment

• Patients who have completed treatment for Stage I–III NSCLC are typically followed-up with clinical and
radiological examinations every 6 months for the first 2 years and annually after that.
• Patients who have completed treatment for metastatic disease are typically followed up with radiological
examinations every 6–12 weeks (depending on their suitability for further treatment) so that second-line
therapy can be started if needed.
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ESMO Patients Guide
Anatomy of the lungs

The lungs form part of our respiratory (breathing) system, which includes:
• Nose and mouth.
• Trachea (windpipe).
• Bronchi (tubes that go to each lung).
• Lungs.
Anatomy of the respiratory system, showing the trachea, bronchi and lungs. As we breathe in, air passes from our nose or
mouth, through the trachea, bronchi and bronchioles, before it reaches tiny air sacs called alveoli – this is where oxygen
from the air passes into the bloodstream (see inset image).
7
What is lung cancer?

Lung cancers typically start in the cells that line the bronchi and parts of the lung such as the bronchioles or
alveoli. There are two main types of primary lung cancer:
• Small-cell lung cancer (SCLC): This type gets its name from the small size of the cells that it is composed of
when viewed under a microscope.
• Non-small-cell lung cancer (NSCLC): This is the more common type of lung cancer, and accounts for
80–90% of all lung cancers (Planchard et al., 2018).
-- This guide will focus exclusively on NSCLC.
What subtypes of NSCLC are there?

The three main histological subtypes of NSCLC are:
• Adenocarcinoma: About 40% of all lung cancers are adenocarcinomas. These tumours start in mucus-
producing cells that line the airways.
• Squamous cell carcinoma (SCC): About 25–30% of all lung cancers are SCC. This type of cancer
develops in cells that line the airways and is usually caused by smoking.
• Large cell (undifferentiated) carcinoma: This type makes up around 10–15% of all lung cancers. It gets
its name from the way that the cancer cells look when they are examined under a microscope.
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ESMO Patients Guide
What are the symptoms of lung cancer?

The most common symptoms of lung cancer, including NSCLC, are:
• Persistent cough. • Coughing blood.
• Chest infection that won’t go away • Chest or shoulder pain that won’t
or keeps coming back. go away.
• Difficulty breathing/breathlessness. • Hoarseness or lowering of the voice.
• Wheezing.
Other, non-specific symptoms, may include:
• Fever.
• Loss of appetite.
• Unexplained weight loss.
• Feeling extremely tired.
You should see your doctor if you experience any of these symptoms. However, it is important to remember that
these symptoms are common in people who do not have lung cancer; they may also be caused by other conditions.
9
How common is NSCLC?
Lung cancer represents the third most

common cancer in Europe
In 2018, the number of new cases of lung cancer diagnosed in Europe was estimated at more than 470,000
(Ferlay et al., 2018) :
• 312,000 new cases in men.

• 158,000 new cases in women.
In Europe, lung cancer is the second most common cancer in men (after prostate cancer) and the third most
common in women (after breast and colorectal cancer) (Ferlay et al., 2018). Incidence rates of lung cancer are higher
in more developed countries than in less developed countries; these variations largely reflect the differences in
the stage and degree of the tobacco epidemic (Torre et al., 2015).
In Europe, there has been a decrease in lung cancer mortality among men, while it is increasing in women – this
reflects the difference in smoking prevalence trends between the sexes (Malvezzi et al., 2016; Planchard et al., 2018).
The majority of cases of lung cancer are diagnosed in patients aged 65 years and over, and the median age at
diagnosis is 70 years.
NSCLC is the most common type of lung cancer,

representing 85–90% of all lung cancers
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ESMO Patients Guide
The map shows estimated numbers of new cases of lung cancer diagnosed in 2018 per 100,000 people of each region’s
population (Ferlay et al., 2018).
NORTHERN AMERICA EASTERN ASIA
CENTRAL AND
39.1 / 30.7 WESTERN EUROPE EASTERN EUROPE 47.2 / 21.9
43.3 / 25.7 49.3 / 11.9
NORTHERN EUROPE SOUTH EASTERN ASIA
CENTRAL AMERICA SOUTHERN EUROPE
43.1 / 15.7 34.0 / 26.9 26.3 / 9.6

7.2 / 4.5
MELANESIA
17.1 / 8.9
SOUTH
CENTRAL ASIA
CARIBBEAN
9.4 / 3.4
AUSTRALIA/
23.5 / 14.2 NEW ZEALAND
SOUTH AMERICA WESTERN AFRICA 28.4 / 24.0

16.8 / 10.2 2.4 / 1.2 WESTERN ASIA
MIDDLE AFRICA
38.8 / 7.8
3.8 / 2.3 EASTERN AFRICA
SOUTHERN AFRICA 3.4 / 2.2 POLYNESIA
26.0 / 8.9 52.0 / 24.6

NORTHERN AFRICA
male
female 16.9 / 3.4
11
What causes NSCLC?

Smoking is the biggest risk factor for developing lung
cancer. However, there are other risk factors that can
Smoking is the biggest risk
also increase the chances of developing lung cancer.
factor for lung cancer
It is important to remember that having a risk factor
increases the risk of cancer developing but it does not
mean that you will definitely get cancer. Likewise, not
having a risk factor does not mean that you definitely
won’t get cancer.
Smoking
Tobacco smoking is the leading cause of lung cancer. In
Europe, it is responsible for 90% of cases in men and
80% of cases in women (Novello et al., 2016). The number
of years that a person has been a smoker is more
important than the number of cigarettes smoked per
day; therefore, giving up smoking at any age can reduce
the risk of developing lung cancer more than cutting
down on the number of cigarettes smoked per day.
Passive smoking
Passive smoking, also referred to as ‘second-hand
smoke’ or ‘environmental tobacco smoke’, increases
the risk of developing NSCLC, but to a lesser extent
than if you are a smoker.
Radon
Radon is a radioactive gas that is produced during the
breakdown of naturally-occurring uranium in soil and
rocks, particularly granite. It can pass through from
the ground into homes and buildings. Exposure to
excessive levels of radon is thought to be a significant
causative factor in patients with lung cancer who have
never smoked. This may be particularly relevant for
underground miners who may be exposed to high
levels of radon if the mines in which they work are in a
particular geographical region.
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ESMO Patients Guide
Genetic susceptibility
It is thought that some people may be more likely to develop
lung cancer based on their genetic makeup (Bailey-Wilson et al.,
2004). Having a family history of lung cancer, or other types of
cancer, increases the risk of developing lung cancer to some
degree. In people who are genetically predisposed to lung
cancer, smoking further increases the risk.
Household and environmental pollutants

Other factors described as risk factors for the development
of NSCLC include exposure to asbestos and arsenic.
There is evidence that lung cancer rates are higher in cities
than in rural areas, although factors other than outdoor air
pollution may be responsible for this pattern. It has also
been suggested that indoor air pollution from use of coal-
fuelled stoves may be a factor in some countries (Planchard
et al., 2018) . For example, in China there is an increased
rate of lung cancer in women, despite the fact that a lower
proportion of women are smokers in China compared with
some European countries.
Recent results from a study using computed tomography (CT) to screen for lung cancer reported a 26%
reduction in lung cancer deaths after 10 years of follow-up in men who had no symptoms of lung cancer but who
were considered to be at high risk of developing the disease (De Koning et al., 2018). However, at the present time,
large-scale screening for NSCLC is not a routine procedure in people who are at a higher risk of developing the
disease based on the above risk factors.
13
How is NSCLC diagnosed?

Most patients with NSCLC are diagnosed after seeing their doctor to report symptoms such as a persistent
cough, a chest infection that won’t go away, dyspnoea, wheezing, coughing blood, chest or shoulder pain that
won’t go away, hoarseness or lowering of the voice, unexplained weight loss, loss of appetite or extreme fatigue.
A diagnosis of lung cancer is based on the results of the following examinations and tests:
Clinical examination
Your doctor will carry out a clinical examination. He/she will
examine your chest and check the lymph nodes in your neck.
If there is a suspicion of lung cancer, he/she may arrange for a
chest x-ray, or possibly a CT scan, and refer you to a specialist for
further testing.
Imaging
Imaging is used to confirm a suspected diagnosis

of lung cancer, and to investigate how far the
cancer has progressed
Different imaging techniques include:

• Chest x-ray: A chest x-ray will enable the specialist to check
your lungs for anything that looks abnormal. This is usually the
first test that is carried out, based on your symptoms and the
clinical examination.
• CT scan of chest and upper abdomen: A series of images
are taken, which build up a three-dimensional picture of the
inside of your body. This allows the specialist to gather more
information about the cancer such as the exact location of
the tumour in your lungs, whether nearby lymph nodes
are affected, and whether the cancer has spread to other areas of the lungs and/or parts of your body. It is a
painless procedure and usually takes about 10–30 minutes.
• CT scan or magnetic resonance imaging (MRI) scan of the brain: This test allows doctors to rule out
or confirm whether the cancer has spread to your brain. An MRI scan uses powerful magnetism to build up
detailed images. You may be given an injection of dye into a vein in your arm to help the images show up
more clearly. The scan won’t hurt but may be slightly uncomfortable as you will need to lie still inside the
scanning tube for about 30 minutes. You will be able to hear and speak to the person doing the scan.
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ESMO Patients Guide
• Positron emission tomography (PET)/CT scan: A combination of a CT scan and a PET scan. PET uses
low-dose radiation to measure the activity of cells in different parts of the body, so a PET/CT scan gives more
detailed information about the part of the body being scanned. A mildly radioactive drug will be injected
into a vein in the back of your hand or arm and then you will need to rest for about an hour while it spreads
throughout your body. The scan itself will take 30–60 minutes and, although you will need to lie still, you
will be able to speak to the person operating the scanner. A PET/CT scan is often carried out to detect
whether the cancer has spread to the bones.
Histopathology
Examination of a biopsy is recommended for all

patients with NSCLC as it helps to determine the
best treatment approach
Histopathology is the study of diseased cells and tissues using a

microscope; a biopsy of the tumour allows a sample of cells to be
closely examined. Examination of a biopsy is recommended for all
patients as it is used to confirm a diagnosis of NSCLC, to identify
the histological subtype of NSCLC, and to identify any abnormal
proteins within the tumour cells that could help to determine the
best treatment for you (Planchard et al., 2018).
Techniques for obtaining a biopsy include:
• Bronchoscopy: A doctor or specially-trained nurse examines
the insides of the airways and lungs using a tube called a
bronchoscope. It is carried out under local anaesthetic.
During a bronchoscopy, the doctor or nurse will take samples
of cells (biopsies) from the airways or lungs.
• CT-guided needle lung biopsy: If a biopsy is difficult
to obtain with a bronchoscopy, your doctor may choose to
obtain a biopsy during a CT scan. In this procedure, you will
have a local anaesthetic to numb the area. A thin needle
is then inserted through your skin into your lung so that the
doctor can remove a sample of cells from the tumour. This
should only take a few minutes.
• Endobronchial ultrasound-guided sampling (EBUS): This
technique is used to confirm whether the cancer has spread to nearby lymph nodes, after radiological
examinations have suggested that this might be the case. A bronchoscope, containing a small
ultrasound probe, is passed through the trachea to see whether any nearby lymph nodes are larger than
15
normal. The doctor can pass a needle along the bronchoscope to take biopsies from the tumour or the
lymph nodes. This test can be uncomfortable but shouldn’t be painful. It takes less than an hour and you
should be able to go home the same day after it is finished.
• Oesophageal ultrasound-guided sampling (EUS): Similar to EBUS, this technique is used to confirm
whether the cancer has spread to nearby lymph nodes, after radiological examinations have suggested
that this might be the case. However, unlike EBUS, the ultrasound probe is inserted through the oesophagus.
• Mediastinoscopy: This procedure is more invasive than EBUS/EUS but is recommended as an extra test
if EBUS/EUS does not confirm that the cancer has spread to nearby lymph nodes or if the lymph nodes
requiring investigation cannot be reached by EBUS. A mediastinoscopy is carried out under general
anaesthetic and requires a short stay in hospital. A small cut is made in the skin at the front of the base of
your neck and a tube passed through the cut into your chest. A light and a camera attached to the tube allow
the doctor to closely look at the middle of your chest – the mediastinum – for any abnormal lymph nodes,
as these are the first areas that the cancer may spread to. Samples of tissue and lymph nodes can be taken
for further examination.
Ask your doctor for details if you have any

questions about these procedures
Cyto(patho)logy
Whereas histopathology is the laboratory examination of tissue or cells, cytology (or cytopathology) is the
examination of cancerous cells spontaneously detached from the tumour. Common methods for obtaining
samples for cytological examination include:
• Bronchoscopy: Bronchial washings (in which a mild salt solution is washed over the surface of the airways)
and the collection of secretions can be carried out during a bronchoscopy to look for the presence of
cancerous cells.
• Thoracentesis/pleural drainage: Pleural effusion is an abnormal collection of fluid between the thin
layers of tissue (pleura) that line the lung and the wall of the chest cavity. This fluid can be taken from the
pleural cavity by thoracentesis or pleural drainage and examined in the laboratory for the presence
of cancerous cells.
• Pericardiocentesis/pericardial drainage: Pericardial effusion is an abnormal collection of fluid between
the heart and the sac that surrounds the heart (pericardium). This fluid can be taken from the pericardial
cavity by pericardiocentesis or pericardial drainage and examined in the laboratory for the presence of
cancerous cells. These techniques are carried out in the hospital, usually with the aid of ultrasound to
help position the needle. You will be given a local anaesthetic and monitored closely for any
complications afterwards.
Because of the location of your lungs in your body, obtaining samples of cells/tissue can be difficult and it may
be necessary to repeat some of these tests if results are found to be inconclusive.
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ESMO Patients Guide
How will my treatment be determined?

After a diagnosis is confirmed, your cancer specialist will look at a number of factors to help plan your treatment.
This includes information about yourself and about the cancer.
Patient-related factors
• Your age.
• Your general health.
• Your medical history.
• Your smoking history.
• Results of blood tests and scans.
Cancer-related factors
Treatment also depends on the type of lung cancer that you have (histopathology or cytopathology results),
where it is in the lung (its location) and whether it has spread to other parts of the body (imaging results).
Staging
It is important for your doctor to know the

stage of the cancer so that he/she can
determine the best treatment approach
Staging of the cancer is used to describe its size and position and whether it has spread from where it started.
Cancer is staged using a number/letter system – described as Stages IA–IV. Generally, the lower the stage the
better the prognosis. Staging considers:
• How big the cancer is (tumour size; T).
• Whether it has spread into the lymph nodes (N).
• Whether it has metastasised (spread) to other areas within the lungs or to other parts of the body (M).
Staging is usually carried out twice: after clinical and radiological examinations; and after surgery, in the case
of surgically resected tumours.
17
The different stages of NSCLC are described in the table below. This may seem complicated but your doctor will
be able to explain which parts of this table correspond to your cancer, and how the stage of your cancer impacts
on treatment choice.
STAGE IA • The tumour is no larger than 3 cm, is still inside the lung and has not spread to
(T1-N0-M0) any of the nearby lymph nodes
STAGE IB • The tumour is 3–4 cm in size, is still inside the lung and has not spread to
(T2a-N0-M0) any of the nearby lymph nodes
STAGE IIA • The tumour is 4–5 cm in size, is still inside the lung and has not spread to any of
(T2b-N0-M0) the nearby lymph nodes Early-stage
NSCLC
STAGE IIB • The tumour is no larger than 5 cm, has spread to nearby lymph nodes but is
(T1/2-N1-M0 or not in any other part of the body; or
T3-N0-M0) • The tumour is 5–7 cm in size or there is more than one tumour in the same
lobe; it has not spread to nearby lymph nodes but may invade other parts
of the lung, the airway or the surrounding areas just outside the lung, e.g. the
diaphragm
STAGE IIIA • The tumour is no larger than 5 cm, has spread to further lymph nodes but is
(T1/2-N2-M0 not in any other part of the body; or
or T3-N1-M0 or • The tumour is 5–7 cm in size or there is more than one tumour in the same
T4-N0/1-M0) lobe; it has spread to nearby lymph nodes and may invade other parts of
the lung, the airway or the surrounding areas just outside the lung, e.g. the
diaphragm; or
• The tumour is larger than 7 cm and invades tissues and structures further away
from the lung, such as the heart, windpipe or oesophagus, but it has not spread
to other parts of the body; or there is more than one tumour in different lobes of
the same lung. The cancer may or may not have spread to nearby lymph nodes Locally advanced
STAGE IIIB • The tumour is no larger than 5 cm, has spread to more distant lymph nodes NSCLC
(T1/2-N3-M0 but is not in any other part of the body; or
or T3-N2-M0 or • The tumour is 5–7 cm in size or there is more than one tumour in the same
T4-N2-M0) lobe; it has spread to further lymph nodes and may invade other parts of
the lung, the airway or the surrounding areas just outside the lung, e.g. the
diaphragm; or
• The tumour is larger than 7 cm and invades tissues and structures further away
from the lung, such as the heart, windpipe or oesophagus, but it has not spread
to other parts of the body; or there is more than one tumour in different lobes of
the same lung. The cancer has spread to further lymph nodes
STAGE IV • The tumour is of any size and may or may not have spread to the lymph nodes.
(any T-any The cancer is in both lungs, has spread to another part of the body (e.g. the liver, Metastatic
N-M1) adrenal glands, brain or bones) or it has caused a collection of fluid around the NSCLC
lung or heart that contains cancer cells
AJCC/UICC system 8th edition – abridged version (Planchard et al., 2018)

AJCC, American Joint Committee on Cancer; NSCLC, non-small-cell lung cancer; UICC, Union for International Cancer Control
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ESMO Patients Guide
Type of NSCLC
Biopsy results
Your biopsy will be examined in the laboratory to
determine:
• The histological subtype (adenocarcinoma,
SCCor large cell carcinoma).
• Grade.
• Tumour biology.
Histological subtype
The histological subtype of the tumour can
influence the type of treatment you will receive. For
example,
non-squamous cancers may benefit from certain anti-
cancer therapies that have been shown to be effective
only in patients with this histological subtype.
Grade
Grade is based on how different tumour cells look from normal lung cells, and on how quickly they grow. The
grade will be a value between one and three and reflects the aggressiveness of the tumour cells; the higher the
grade, the more aggressive the tumour.
Biological testing of the tumour

Tissue specimens from metastatic NSCLC belonging to the non-squamous subtype should be tested for
the presence of specific mutations in the EGFR gene. Even though such mutations are rare (approximately
10–20% in Caucasians with adenocarcinoma), the detection of an EGFR gene mutation has important
prognostic and therapeutic implications in patients with metastatic NSCLC. EGFR testing is not recommended
in patients with a diagnosis of SCC, except in never-, long-time ex- or light smokers (<15 pack years). Tissue
should also be tested for the presence of a specific mutation (known as V600E) in the BRAF gene, as therapies
are available to treat tumours with this mutation (Planchard et al., 2018). Routine testing for rearrangement in the
ALK and ROS1 genes is now standard of care and should be carried out, if possible, in parallel with EGFR
mutation analysis. ALK rearrangement is more frequent in people who have never smoked, those with the
adenocarcinoma subtype (5%) and in younger patients (aged <50 years old). Detecting ALK rearrangements
has important therapeutic implications for patients with metastatic NSCLC due to the existence of drugs
targeting ALK (e.g. crizotinib, ceritinib and alectinib) (Planchard et al., 2018; Novello et al., 2016). Some ALK
inhibitors, including crizotinib, also inhibit ROS1, therefore the presence of ROS1 rearrangements also
guides treatment decisions in metastatic NSCLC (Planchard et al., 2018).
Programmed death-ligand 1 (PD-L1): This is a cellular protein thought to be involved in helping the tumour
to evade detection by the body’s immune system. The amount of PD-L1 present in a tumour may influence the
decision to treat the cancer with anti-PD-L1 immunotherapy.
19
Who is involved in planning my treatment?

In most hospitals, a team of specialists will plan the treatment they feel is best for your individual situation. This
multidisciplinary team of medical professionals may include:
• A surgeon.
• A medical oncologist (a doctor who specialises in the medical management of cancer).
• A radiation oncologist.
• A chest physician.
• A nurse specialist.
• A radiologist (or radiographer) who has been involved in the assessment of any x-rays and scans.
• A pathologist who has been involved in the analysis of your tumour biopsy.
• A molecular biologist who has been involved in the genetic analysis of your tumour biopsy.
• A psycho-oncologist to provide psychiatric assessment and counselling.
Other services that may be offered include: a dietician, a social worker, a community care nurse, a physiotherapist, a
clinical psychologist and a palliative care service (who can assist with pain management). After consultation with
the multidisciplinary team, your doctor, possibly with other members of the care team, will talk to you about the
best treatment plan for your situation (Planchard et al., 2018). They will explain the benefits and potential drawbacks of
different treatments.
It is important that patients are fully involved in the treatment decision-making – when there are several treatments
available, doctors should involve patients in making decisions about their care so that the patients can choose the
care that meets their needs and reflects what is important to them. This is called ‘shared decision-making’.
It is important that patients are fully involved in

discussions and decisions about their treatment
Your doctor will be happy to answer any questions you have about your treatment. Three simple questions that
may be helpful when talking with your doctor or any healthcare professional involved in your care are:
• What treatment options do I have?
• What are the possible benefits and side effects of these options?
• How likely am I to experience these benefits and side effects?
20
ESMO Patients Guide
What are the treatment options for NSCLC?

Aims of treatment
In early-stage NSCLC, when the cancer is confined to the lung and therefore considered to be curable, the
main treatment is surgical resection (Postmus et al., 2017). For locally advanced NSCLC, multimodal therapy
is usually adopted to help shrink or in some cases completely remove the cancer (Eberhardt et al., 2015). For
metastatic NSCLC, when the cancer has spread to other parts of the body, and cure is not an option, various
systemic anti-cancer treatments may be used in an attempt to slow down tumour growth and improve
symptoms and quality of life – this is called supportive or palliative care (Planchard et al., 2018).
Overview of treatment types
Treatments for NSCLC include surgery,

radiotherapy, chemotherapy and targeted therapies
The treatment you receive will depend on the stage and type of cancer, as well as your general health and
treatment preferences, which will be discussed together with your doctor. You may have a combination of
treatments. The main types of treatment are listed below:
• Surgery may be possible to remove NSCLC if it is diagnosed at an early stage. The type of operation that is
offered will depend on the size and location of the cancer (Postmus et al., 2017) :
-- A wedge or segment resection is the removal of a very small amount of the lung; this is sometimes
offered if the cancer is at a very early stage
-- A lobectomy is the removal of one of the lobes of the lung; it is the standard surgical treatment for NSCLC
-- A pneumonectomy is the total removal of one of the lungs; it is a more complex surgical resection than
lobectomy or wedge (segment) resection.
• Chemotherapy works by disrupting the way that cancer cells grow and divide. However, these drugs can
also affect normal cells. Chemotherapy can be given before or after surgery for NSCLC. Some people have
chemotherapy at the same time as radiotherapy – this is called chemoradiotherapy. Chemotherapy
may be given to try to cure the cancer or to prolong life and control symptoms (palliative care) (Postmus et
al., 2017; Planchard et al., 2018).
• Targeted therapies and antiangiogenic therapies are drugs that block specific signalling pathways in
cancer cells that encourage them to grow (Novello et al., 2016).
21
• Immunotherapies are treatments that block inhibitory pathways which restrict the body’s immune
response to cancer, thereby helping to reactivate the body’s immune system to detect and fight the cancer
(Novello et al., 2016).
• Radiotherapy is a type of treatment that uses ionising radiation, which damages the DNA of cancerous
cells, causing the cells to die. It may be used instead of surgery to try to cure early-stage NSCLC.
Radiotherapy can be given after chemotherapy or concurrently (chemoradiotherapy). Radiotherapy
is also used to control symptoms when the cancer is more advanced or has spread to other parts of the
body. There are various different techniques for delivering radiotherapy, including stereotactic ablative
radiotherapy (SABR) (when available), a type of external beam radiation therapy that delivers a high dose of
radiation specifically to the tumour (Postmus et al., 2017; Planchard et al., 2018).
Your doctor and nurse specialist can discuss all of the possible treatment options available to you to help you
to make an informed decision about the best way forward for you.
The response to any treatment you receive will be assessed regularly to see how effective the treatment is and
to check whether the benefits outweigh any side effects that you might experience. Evaluation of response
is recommended after 6–12 weeks of systemic anti-cancer treatment for Stage IV NSCLC. This relies on
repetition of the initial imaging tests that showed the cancer (Novello et al., 2016; Planchard et al., 2018).
22
ESMO Patients Guide
Treatment options for early (Stage I–II) NSCLC
Early-stage NSCLC that is confined to the lung

may be curable with surgery
Surgery is the main treatment approach for early-stage NSCLC (Postmus et al., 2017). This involves removing the
cancer and some of the nearby lymph nodes in the chest. The number of lymph nodes removed is dependent
on the type of surgery performed. Surgical resection of NSCLC is a major operation and you need to be in good
general health to be able to cope with it. The type of operation will either be a lobectomy (preferred) or a wedge
(segment) resection and may be carried out via open surgery or video-assisted thoracic surgery (VATS),
depending on the preference of your surgeon. VATS is generally the preferred choice for Stage I tumours
(Postmus et al., 2017).
The lymph nodes removed during surgery will be examined under a microscope to check for cancer cells.
Knowing if the cancer has spread to the lymph nodes also helps your doctors decide if you need further
treatment with adjuvant chemotherapy or radiotherapy (Postmus et al., 2017).
Adjuvant chemotherapy is typically given to patients with Stage II NSCLC and may be considered for some
patients with Stage IB disease. Your general health and your postoperative recovery will be taken into account
when deciding whether you should be offered adjuvant chemotherapy. A combination of two different drugs
is preferred (one of them being cisplatin), and it is likely that you will be offered 3 or 4 cycles of treatment
(Postmus et al., 2017).
Adjuvant radiotherapy may be given after surgery in patients with Stage II NSCLC (Postmus et al., 2017).
In patients with Stage I NSCLC who are unwilling or unable to undergo surgery, SABR may be offered.
This treatment will be given to you as an outpatient over 3–8 visits. If your tumour is larger than 5 cm and/
or is located at the centre of the lung, radical radiotherapy using more conventional daily or accelerated
schedules is preferred (Postmus et al., 2017).
23
Treatment of early (Stage I–II) NSCLC – summary (Postmus et al., 2017)
TREATMENT PATIENTS TREATMENT DETAILS CONSIDERATIONS

TYPE
Surgery Stage I or II NSCLC • Operation is either: • Risks associated with major surgery
-- Lobectomy: The removal of one • Recovery time (shorter with
of the lobes of the lung (preferred VATS)
option), or • Usually able to go home 3–7 days
-- Wedge or segment resection: after surgery
Only a small amount of the lung • Requires post-operative pain control
is removed (sometimes used for
very early NSCLC)
• Carried out either by open surgery
or by VATS
Adjuvant Stage II NSCLC, • A combination of two different drugs • Need to recover from surgery
chemotherapy following surgery usually given intravenously (one of before starting chemotherapy
which is cisplatin) • Pre-existing medical conditions
Stage IB NSCLC
following surgery, if • Typically, 3–4 cycles of treatment may affect whether you will be
primary tumour is suitable for chemotherapy
>4 cm in size
(Not recommended in
Stage IA NSCLC)
SABR Preferred for Stage I, • More precise than conventional • SABR is associated with low
if surgery not carried radiotherapy; very small areas can toxicity in patients with COPD and
out be targeted with a high dose in elderly patients
• Shorter treatment time vs • Surgery may be offered afterwards
conventional radiotherapy if SABR is not successful or if
(2-week course) there are complications
Radical Tumours >5 cm • Conventional (4–7-week course of

radiotherapy and/or centrally treatment of short, daily sessions
located Monday to Friday) or accelerated
schedule (an increased number of
Following incomplete
treatments delivered over a shorter
surgery
timeframe)
COPD, chronic obstructive pulmonary disease; NSCLC, non-small-cell lung cancer; SABR, stereotactic ablative
radiotherapy; VATS, video-assisted thoracic surgery
24
ESMO Patients Guide
Treatment options for locally advanced (Stage III) NSCLC
Treatment for locally advanced disease is likely to

involve different types of therapy
Locally advanced NSCLC represents a very diverse disease (see Stages IIIA and IIIB in the AJCC/UICC staging
system table) and so it is not possible to recommend a ‘one size fits all’ approach to treatment. Some patients
with Stage III NSCLC have a tumour that is considered resectable, i.e. your doctor/surgeon thinks that it can
be completely removed by surgery either straight away or after a course of chemotherapy (with or without
radiotherapy). On the other hand, some patients with Stage III NSCLC have a tumour that is considered
unresectable, i.e. surgery is not possible due to the size/location of the tumour and involvement of lymph
nodes in the middle of the chest. The best approach to treatment of Stage III NSCLC is therefore likely to be a
combination of various treatment types (surgery, chemotherapy and/or radiotherapy), called multimodal
therapy (Postmus et al., 2017; Eberhardt et al., 2015).
In patients staged with potentially resectable Stage III NSCLC, treatment options are generally either induction
therapy with chemotherapy or chemoradiotherapy, followed by surgery (preferred for those whose tumour
is likely to be completely removed by lobectomy) or chemoradiotherapy.
In patients with unresectable Stage III NSCLC, the preferred treatment is chemoradiotherapy. Alternatively,
sequential chemotherapy and then radiotherapy may be given to patients who are unable to tolerate
concurrent treatment (Postmus et al., 2017).
Chemotherapy is an integral part of the treatment of Stage III NSCLC. Generally, a cisplatin-based
combination regimen (two different drugs) is offered. You will usually be offered 2–4 cycles, whether
chemotherapy is given alone or as part of a course of chemoradiotherapy. In some patients who undergo
surgery upfront for NSCLC that is thought to be Stage I or II, but found to be Stage III during surgery, then
adjuvant chemotherapy will likely be administered after the surgery (Postmus et al., 2017).
When radiotherapy is given concurrently with chemotherapy for Stage III NSCLC, it is given as conventional
daily doses and treatment should not exceed 7 weeks. It may be given as an accelerated schedule as part of
a pre-operative chemoradiotherapy course, but any potential advantages to the likely outcome of surgery will
need to be weighed up against potential greater toxicity. When given sequentially, an accelerated schedule of
radiotherapy may be given, i.e. higher doses over a shorter timeframe (Postmus et al., 2017).
Following first-line treatment, the immunotherapy agent durvalumab may be offered to patients with
unresectable disease that has not progressed following platinum-based chemoradiotherapy, if their tumours
contain a certain level of PD-L1 (determined by molecular testing using a tumour biopsy) (Imfinzi SPC, 2018).
25
Treatment of locally advanced (Stage III) NSCLC – summary (Postmus et al., 2017)

TYPE
Surgery Resectable • Preferred when a complete resection by • Outcome depends on the extent
Stage III NSCLC lobectomy is expected, to spare as much of involvement of the lymph
lung tissue as possible nodes at the centre of the chest
• May require a pneumonectomy (removal – may not be known until after
of one lung) in some patients surgery
• May be offered after an initial course of • Lung function tests are important
chemotherapy (+/- radiotherapy) – before deciding on surgery
called induction therapy
Chemotherapy • Intravenous cisplatin-based regimen • A carboplatin-based

is preferred (cisplatin-etoposide or combination may be chosen
cisplatin-vinorelbine) if you have other medical
• Typically, 2–4 cycles of treatment are given conditions that could affect how
you tolerate chemotherapy
Resectable • If your tumour is considered resectable, • It is likely that you will
Stage III NSCLC chemotherapy may be given before experience more side
surgery as induction therapy effects if chemotherapy
(chemotherapy +/- radiotherapy) is given concurrently with
• If you have surgery upfront and it is found radiotherapy
that the cancer had spread to lymph
nodes in the chest, you may be offered
adjuvant chemotherapy
Unresectable • Delivered concurrently with

Stage III NSCLC radiotherapy (preferred) or
sequentially (before radiotherapy) if
concurrent treatment cannot be tolerated
Radiotherapy Resectable • May be given post-operatively in patients

Stage III NSCLC who have had incomplete resection
• When given pre-operatively concurrently
with chemotherapy, may be conventional
doses or as an accelerated schedule
Unresectable • May be given as conventional daily

Stage III NSCLC doses as part of a chemoradiotherapy
schedule (up to 7 weeks), or
sequentially (after chemotherapy) as
an accelerated schedule
Immunotherapy Unresectable • Durvalumab may be offered if disease has

Stage III NSCLC not progressed after chemoradiotherapy
(PD-L1 on ≥1% of tumour cells)
NSCLC, non-small-cell lung cancer; PD-L1, programmed death-ligand 1
26
ESMO Patients Guide
Treatment options for metastatic (Stage IV) NSCLC
Chemotherapy is the main treatment

for metastatic NSCLC
Metastatic NSCLC is usually considered inoperable. Complete removal of the tumour(s) is very unlikely and
therefore a chance of cure cannot be offered. However, surgical interventions can relieve symptoms caused by
the disease spreading to other parts of the body. Similarly, radiotherapy may help control symptoms that arise
due to the disease spreading to certain organs, including the brain and bones (Planchard et al., 2018).
Systemic anticancer treatment is the main treatment for Stage IV NSCLC, the aims of which are to improve
quality of life and to prolong survival. There are many different types of drugs available and the choice of which drugs
are offered will largely depend on your general health and the type of tumour that you have (Planchard et al., 2018).
Intravenous chemotherapy with a two-drug combination (doublet chemotherapy) is the main treatment for
patients with metastatic NSCLC whose cancer does not contain specific modifications to the EGFR or ALK
genes or high levels of the PD-L1 protein (determined by molecular testing using a tumour biopsy). Doublet
chemotherapy is likely to include a platinum-based compound plus either gemcitabine, vinorelbine
or a taxane. Addition of pemetrexed, the targeted therapy bevacizumab or the immunotherapy agent
pembrolizumab may also be considered for non-squamous NSCLC. In patients whose general health is
poor, single-agent chemotherapy with gemcitabine, vinorelbine or docetaxel is another treatment option
(Planchard et al., 2018).
Patients whose tumours have EGFR or BRAF mutations, or ALK or ROS1 rearrangements, are best
treated with oral targeted therapies. Gefitinib, erlotinib, afatinib, osimertinib or erlotinib in combination
with bevacizumab are options for EGFR-mutated tumours. Dabrafenib in combination with trametinib is
recommended for patients with tumours that have a BRAF V600E mutation. Crizotinib, ceritinib or alectinib
are offered to patients who have an ALK rearrangement, and crizotinib is recommended for patients with a
ROS1 rearrangement (Planchard et al., 2018).
Patients whose tumours express relatively high levels of PD-L1 protein (determined by molecular testing using
a tumour biopsy) may receive first-line immunotherapy with pembrolizumab (Planchard et al., 2018).
After 4–6 cycles of doublet chemotherapy, maintenance treatment with pemetrexed may be given to
patients in good general health with non-squamous tumours to prolong the effect of first-line chemotherapy
on tumour control. Erlotinib may be offered as maintenance treatment in patients whose tumours have
EGFR mutations (Planchard et al., 2018).
27
Further lines of treatment may be offered, depending on the first-line treatment received and on the
general health of the patient. Treatment options include: chemotherapy (pemetrexed or docetaxel),
immunotherapy (nivolumab, pembrolizumab or atezolizumab), antiangiogenic therapy (nintedanib
or ramucirumab) plus docetaxel, and targeted therapies (afatanib or erlotinib). Patients whose tumours
have EGFR mutations who have received first-line treatment with erlotinib, gefitinib or afatinib, and who
have a confirmed abnormality called a T790M mutation, may be treated with second-line osimertinib.
Patients with a confirmed BRAF V600E mutation who have received first-line treatment with dabrafenib and
trametinib may receive second-line platinum-based chemotherapy. Patients whose tumours have ALK
rearrangements who have received first-line treatment with crizotinib may be treated with second-line
ceritinib, alectinib, brigatinib or lorlatinib if available. Patients with confirmed ROS1 rearrangements
who have received first-line treatment with crizotinib might be offered second-line platinum-based
chemotherapy (Planchard et al., 2018).
continued overleaf
28
ESMO Patients Guide
Treatment of metastatic (Stage IV) NSCLC – summary (Planchard et al., 2018)

TYPE
Chemotherapy EGFR- and First line: • Response to platinum-based
ALK-negative • Intravenous platinum-based therapy, toxicity and patient’s
tumours regimen preferred (2-drug general health after initial treatment
• Good general combination including cisplatin needs to be considered when
condition, no other or carboplatin + gemcitabine, deciding upon maintenance
major medical vinorelbine or a taxane) treatment
conditions • Pemetrexed may be incorporated
into the treatment regimen in non- • Patients with a very poor general
squamous histology condition are not suitable for
• 4–6 cycles (may be offered chemotherapy; best supportive
maintenance treatment with single care is the only treatment
agent pemetrexed after 4 cycles)
Second line:
• Pemetrexed (non-squamous type)
or docetaxel
• Less fit patients/ First line:
elderly • Carboplatin-based regimen
preferred; may be offered single-
agent treatment with gemcitabine,
vinorelbine or docetaxel
Targeted EFGR mutation First line: • As most targeted therapies are
therapy • Gefitinib, erlotinib, afatinib or generally well tolerated, they may
osimertinib also be offered to patients with a
• Erlotinib + bevacizumab moderate/poor general condition
Second line:
• Osimertinib
BRAF mutation First line:
• Dabrafenib + trametinib
ALK First line:
rearrangement • Crizotinib, ceritinib or alectinib
Second line:
• Ceritinib, alectinib, brigatinib
or lorlatinib following first-line
crizotinib
ROS1 First line:
rearrangement • Crizotinib
Targeted therapy First line:
in tumours without • Intravenous bevacizumab may
specific mutations be added to a platinum-based
regimen (non-squamous type) in
patients in good general condition
Second line:
• Erlotinib, nintedanib + docetaxel
(adenocarcinoma), ramucirumab +
docetaxel, afatinib
continued overleaf
29

TYPE
Immunotherapy EGFR- and First line:
ALK-negative • Pembrolizumab (in patients with
tumours tumours strongly positive for
• Good general PD-L1)
condition, no • Pembrolizumab in combination
other major with pemetrexed and platinum-
medical based chemotherapy (non-
conditions squamous type)
Second line:
• Nivolumab, pembrolizumab or
atezolizumab (irrespective of PD-
L1 expression)
Surgery Can be used for relief Minimally-invasive procedures can

of symptoms caused be helpful, e.g. placement of a stent to
by cancer spreading alleviate obstruction of the airways
Radiotherapy Can be used for relief • Radiotherapy can achieve

of symptoms caused symptom control for bone and brain
by cancer spreading metastases
• It can also relieve symptoms caused
by airway obstruction
ALK, anaplastic lymphoma kinase; EGFR, epidermal growth factor receptor; NSCLC, non-small-cell lung cancer;
PD-L1, programmed death-ligand 1; SCC, squamous cell carcinoma
30
ESMO Patients Guide
Oligometastatic disease
When the cancer has spread beyond the site at which it started but is not yet widely metastatic, it is called
oligometastatic disease. If you have synchronous oligometastases at diagnosis, it may be possible to
achieve long-term disease-free survival following chemotherapy and radical local treatment, such as high-
dose radiotherapy or surgery; inclusion in a suitable clinical trial may be advised by your doctor (Planchard
et al., 2018). Similarly, if you have a limited number of metachronous oligometastases that appear following
treatment for your primary tumour, you may be offered treatment with high-dose radiotherapy or surgery
(Planchard et al., 2018).
31
Clinical trials
Your doctor may ask you whether you would like to take part in a clinical trial. This is a research study
conducted with patients in order to (ClinicalTrials.gov, 2017) :
• Test new treatments
• Look at new combinations of existing treatments, or change the way they are given to make them more
effective or reduce side effects
• Compare the effectiveness of drugs used to control symptoms
• Find out how cancer treatments work.
Clinical trials help to improve knowledge about cancer and develop new treatments, and there can be many
benefits to taking part. You would be carefully monitored during and after the study, and the new treatment may offer
benefits over existing therapies. It’s important to bear in mind, however, that some new treatments are found not to
be as good as existing treatments or to have side effects that outweigh the benefits (ClinicalTrials.gov, 2017).
Clinical trials help to improve knowledge about

diseases and develop new treatments – there can
be many benefits to taking part
Several new drugs for the treatment of NSCLC are being studied in clinical trials, including targeted
therapies and immunotherapy agents.
Lorlatinib is a targeted therapy that has recently been approved in Europe for the treatment of ALK-positive
metastatic NSCLC following treatment with one or more ALK inhibitors (EMA, 2019a). Another targeted therapy,
dacomitinib, is newly approved for the first-line treatment of locally advanced or metastatic NSCLC with
EGFR-activating mutations (EMA, 2019b).
Clinical trials have also investigated different combinations of existing drugs; for example, while atezolizumab
is currently used for the second-line treatment of NSCLC, it has recently shown promise as first-line
treatment of metastatic non-squamous NSCLC in combination with chemotherapy (Cappuzzo et al., 2018)
and bevacizumab plus chemotherapy (Socinski et al., 2018a) and in squamous NSCLC in combination with
chemotherapy (Socinski et al., 2018b). Erlotinib has also shown promise as neoadjuvant treatment in locally
advanced EGFR-mutated NSCLC (Zhong et al., 2018).
You have the right to accept or refuse participation in a clinical trial without any consequences for the quality
of your treatment. If your doctor does not ask you about taking part in a clinical trial and you want to find out
more about this option, you can ask your doctor if there is a trial for your type of cancer taking place nearby
(ClinicalTrials.gov, 2017).
32
ESMO Patients Guide
Supplementary interventions
Patients may find that supplementary care helps

them to cope with their diagnosis, treatment and
the long-term effects of NSCLC
Over the course of disease, anti-cancer treatments should be supplemented with interventions that aim to
prevent the complications of disease and treatment, and to maximise your quality of life. These interventions
may include supportive, palliative, survivorship and end-of-life care, which should all be coordinated by a
multidisciplinary team (Jordan et al., 2018). Ask your doctor or nurse about which supplementary interventions
are available; you and your family may receive support from several sources, such as a dietician, social worker,
priest or occupational therapist.
Supportive care
Supportive care involves the management of cancer symptoms and the side effects of therapy. There is a range
of therapies available that can help with the management of NSCLC. These include bone modifying agents (e.g.
zoledronic acid and denosumab, used to reduce the occurrence of fractures commonly associated with the
presence of bone metastases), stents (for relieving major airway obstructions that can cause dyspnoea), pain
management and nutritional support (Planchard et al., 2018). Generally, early supportive care is recommended in
parallel with treatments for the cancer itself: it may improve your quality of life and mood and lessen the need for
aggressive treatment (Planchard et al., 2018).
Palliative care
Palliative care is a term used to describe care interventions in advanced disease, including the management of
symptoms as well as support for coping with prognosis, making difficult decisions and preparation for end-of-life
care. Palliative care in advanced lung cancer may include treatment for pain, airway obstructions and bedsores.
Survivorship care
Support for patients surviving cancer includes social support,
education about the disease and rehabilitation. For example,
psychological support can help you to cope with any worries
or fears. Patients often find that social support is essential for
coping with the cancer diagnosis, treatment and the emotional
consequences. A survivor care plan can help you to recover
wellbeing in your personal, professional and social life. For further
information and advice on survivorship, see ESMO’s patient guide
on survivorship (http://www.esmo.org/Patients/Patient-Guides/
Patient-Guide-on-Survivorship).
33
End-of-life care
End-of-life care for patients with incurable cancer primarily focusses on making the patient comfortable and
providing adequate relief of physical and psychological symptoms, for example palliative sedation to induce
unconsciousness can relieve severe pain, dyspnoea, delirium or convulsions (Cherny, 2014). Discussions about end-
of-life care can be very distressing, but support should always be available to you and your family at this time.
34
ESMO Patients Guide
What are the possible side effects of treatment?

As with any medical treatment, you may experience side effects from
your anti-cancer treatment. The most common side effects for each
type of treatment are highlighted below, along with some information
on how they can be managed. You may experience side effects other
than those discussed here. It is important to talk to your doctor or
nurse specialist about any potential side effects that you are
concerned about.
Doctors classify side effects from any cancer therapy by assigning
each event a ‘grade’, on a scale of 1–4, by increasing severity. In general, ‘grade’ 1 side effects are considered
to be mild, ‘grade’ 2 moderate, ‘grade’ 3 severe and ‘grade’ 4 very severe. However, the precise criteria used
to assign a ‘grade’ to a specific side effect varies depending on which side effect is being considered. The aim
is always to identify and address any side effect before it becomes severe, so you should always report any
worrying symptoms to your doctor as soon as possible.
It is important to talk to your doctor about any

treatment-related side effects that you are
concerned about
Fatigue is very common in patients undergoing cancer treatment, and can result from either the cancer itself
or the treatments. Your doctor or nurse can provide you with strategies to limit the impact of fatigue, including
getting enough sleep, eating healthily and staying active (Cancer.Net, 2017). Loss of appetite and weight loss can
also arise due to the cancer itself or the treatments. Significant weight loss, involving loss of both fat and muscle
tissue, can lead to weakness, reduced mobility and loss of independence, as well as anxiety and depression
(Escamilla and Jarrett, 2016). Your doctor may refer you to a dietician, who can look at your nutritional needs and
advise you on your diet and any supplements that you might need.
continued overleaf
35
Surgery
Side effects following cancer surgery vary depending on the location and type of the surgery and your general
health (Cancer.Net, 2018). Common side effects following lung resection are summarised in the table.
POSSIBLE SIDE EFFECT HOW THE SIDE EFFECT MAY BE MANAGED

Pain Pain or discomfort following surgery is common and can usually be controlled using pain-
relief medication. Always let your doctor or nurse know if you are in pain, so they can treat it
as soon as possible (Cancer.Net, 2018)
Infection You will be taught how to lower the risk of infection occurring. Signs of infection include
redness, warmth, increased pain and weeping from around the wound. If you notice any of
these signs, contact your nurse or doctor (Cancer.Net, 2018)
Prolonged air leak Air leak is a natural occurrence after lung resection but its prolongation to over 7 days
increases the risks of other complications. Your surgeon will take precautions to minimise
the risk of prolonged air leak (Ziarnik et al., 2015)
Pneumonia The risk of pneumonia can be decreased by following advice provided by your doctor,
e.g. you should perform any recommended physiotherapy exercises (e.g. coughing), start
walking/moving about as soon as possible after surgery and refrain from smoking. If
pneumonia occurs, then it can usually be treated with an antibiotic (Ziarnik et al., 2015)
Common side effects of lung cancer surgery and how they can be managed
continued overleaf
36
ESMO Patients Guide
Radiotherapy
For some patients, radiotherapy causes few or no side effects; for others, the side effects can be severe. Side
effects occur because radiation therapy can damage healthy tissues near the treatment area. The side effects will
depend upon the location of the treatment area, the radiation dose and your general health. Usually, side effects
start to appear after 2 or 3 weeks of treatment, and resolve a few weeks following the final treatment (Cancer.Net, 2016).
POSSIBLE SIDE EFFECT HOW THE SIDE EFFECT MAY BE MANAGED

Skin damage (e.g. dryness, These side effects usually go away a few weeks after treatment has finished. If skin damage
itching, blistering or peeling) becomes a serious problem, then your doctor may change your treatment plan (Cancer.Net, 2016)
Oesophagitis After 2–3 weeks of radiotherapy to the chest, you may have difficulty swallowing, heartburn
or indigestion. This is because radiotherapy can cause inflammation in the oesophagus.
Your doctor or nurse will be able to advise you on how to cope with these symptoms and may
prescribe medicines to help (Macmillan, 2015a)
Radiation pneumonitis Patients receiving radiotherapy to the chest may develop a condition called radiation
(cough, fever and fullness pneumonitis. This generally appears between 2 weeks and 6 months following radiotherapy
of chest) but is usually temporary. Tell your doctor or nurse if you experience any of the signs of
radiation pneumonitis (Cancer.Net, 2016)
Common side effects of radiotherapy used to treat lung cancer and how they can be managed
continued overleaf
37
Chemotherapy
Side effects from chemotherapy vary depending upon the drugs and the doses used – you may get some of
those listed below but you are very unlikely to get all of them. Patients who receive a combination of different
chemotherapy drugs are likely to experience more side effects than those who receive a single chemotherapy
drug. The main areas of the body affected by chemotherapy are those where new cells are being quickly
made and replaced (bone marrow, hair follicles, the gastrointestinal system, the lining of your mouth).
Reductions in your levels of neutrophils (a type of white blood cell) can lead to neutropenia, which will make
you more susceptible to infections. Some chemotherapy drugs can affect fertility – if you are worried about
this, speak to your doctor before treatment starts. Most side effects of chemotherapy are temporary and can be
controlled with drugs or lifestyle changes – your doctor or nurse will help you to manage them (Macmillan, 2016).
CHEMOTHERAPY POSSIBLE SIDE EFFECT HOW THE SIDE EFFECTS MAY BE MANAGED
DRUG
Carboplatin • Anaemia • Your blood cell counts will be monitored frequently throughout
(Macmillan, 2015b) • Constipation your treatment in order to detect any neutropenia, anaemia
• Fatigue or thrombocytopenia – your doctor may adjust your treatment
• Hepatic (liver) toxicity according to test results, and will advise you on how to prevent
• Nausea infections.
• Neutropenia • Your doctor will be able to help you prevent or manage any nausea,
• Renal (kidney) toxicity vomiting or constipation.
• Thrombocytopenia
• You will have tests before and during treatment to check how well
• Vomiting
your kidneys and liver are functioning, and you will be asked to drink
plenty of fluids to prevent your kidneys from becoming damaged.
Cisplatin • Anaemia • Your blood cell counts will be monitored frequently throughout
(Macmillan, 2015c) • Anorexia your treatment in order to detect any neutropenia, anaemia
• Changes in kidney or thrombocytopenia – your doctor may adjust your treatment
function according to test results, and will advise you on how to prevent
• Decreased fertility infections.
• Diarrhoea • Effects on the gastrointestinal system (nausea, vomiting,
• Fatigue diarrhoea, taste changes) may result in loss of appetite
• Increased risk of (anorexia). Your doctor will be able to help you to prevent or
thrombosis manage these side effects.
• Nausea/vomiting
• Report any signs of peripheral neuropathy (tingling or
• Neutropenia
numbness in your hands or feet) to your doctor, who will help you
• Peripheral neuropathy
to manage this side effect.
• Taste changes
• Thrombocytopenia • You will have tests before and during treatment to check how well
• Tinnitus/changes in your kidneys are functioning. You will be asked to drink plenty of
hearing fluids to prevent your kidneys from becoming damaged.
• Tell your doctor if you notice any changes in your hearing or
experience tinnitus. Changes in hearing are usually temporary but
can occasionally be permanent.
continued overleaf
38
ESMO Patients Guide
DRUG
Docetaxel • Alopecia • Your blood cell counts will be monitored frequently throughout
(Taxotere SPC, • Anaemia your treatment in order to detect any neutropenia, anaemia or
2016) • Anorexia thrombocytopenia – your doctor may adjust your treatment
• Asthenia according to test results, and will advise you on how to prevent
• Diarrhoea infections. Report any fever to your doctor, as this may be a sign
• Nausea of infection.
• Neutropenia • Report any signs of peripheral neuropathy (tingling or numbness
• Oedema in your hands or feet) to your doctor, who will help you to manage
• Peripheral neuropathy this side effect.
• Skin reaction
• Effects on the gastrointestinal system (nausea, vomiting,
• Stomatitis
diarrhoea) and stomatitis may result in loss of appetite
(anorexia) or feelings of weakness (asthenia). Your doctor will
• Vomiting
be able to help you to prevent or manage these side effects.
• Let your doctor know if you experience any skin reactions or fluid
retention/swelling (oedema) – they will help you to manage these
side effects.
• Alopecia can be upsetting for many patients; your doctor will
provide you with information on how to cope with this side effect.
Some hospitals can provide cold caps to reduce hair loss.
Etoposide • Alopecia • Your blood cell counts will be monitored frequently throughout
(Vepesid SPC, • Anaemia your treatment in order to detect any neutropenia, anaemia,
2017) • Anorexia thrombocytopenia or leukopenia – your doctor may adjust your
• Asthenia treatment according to test results, and will advise you on how to
• Changes in liver function prevent infections.
• Constipation • Effects on the gastrointestinal system (constipation, nausea,
• Leukopenia vomiting) may result in loss of appetite (anorexia) or feelings of
• Nausea fatigue/asthenia. Your doctor will be able to help you to prevent
• Neutropenia or manage these side effects.
• Vomiting
your liver is functioning.
continued overleaf
39
DRUG
nab-Paclitaxel • Alopecia • Your blood cell counts will be monitored frequently throughout
(Abraxane SPC, • Anaemia your treatment in order to detect any neutropenia, anaemia,
2018) • Anorexia leukopenia, thrombocytopenia or lymphopenia – your doctor
• Arthralgia may adjust your treatment according to test results, and will
• Asthenia advise you on how to prevent infections. Report any fever to your
• Constipation doctor, as this may be a sign of infection.
• Diarrhoea • Effects on the gastrointestinal system (nausea, vomiting,
• Fatigue diarrhoea, constipation, stomatitis) may result in loss of
• Fever appetite (anorexia) or feelings of fatigue/asthenia. Your doctor
• Leukopenia will be able to help you to prevent or manage these side effects.
• Lymphopenia
• Let your doctor know if you experience arthralgia, myalgia or
• Myalgia
rash and they will help you to manage these side effects.
• Nausea
• Neutropenia • Report any signs of peripheral neuropathy (tingling or
• Peripheral neuropathy numbness in your hands or feet) to your doctor, who will help you
• Rash to manage this side effect.
• Stomatitis • Alopecia can be upsetting for many patients; your doctor will
• Thrombocytopenia provide you with information on how to cope with this side effect.
• Vomiting Some hospitals can provide cold caps to reduce hair loss.
Paclitaxel • Alopecia • Your blood cell counts will be monitored frequently throughout
(Paclitaxel SPC, • Anaemia your treatment in order to detect any neutropenia, leukopenia,
2017) • Arthralgia anaemia or thrombocytopenia – your doctor may adjust your
• Diarrhoea treatment according to test results and will advise you on how to
• Hypersensitivity prevent infections. Report any fever to your doctor, as this may be
reactions a sign of infection. Report any prolonged or unusual bleeding to
• Leukopenia your doctor as this can be a sign of thrombocytopenia.
• Low blood pressure • Report any effects on the gastrointestinal system (nausea,
• Mucositis vomiting, diarrhoea) to your doctor as they may be able to help
• Myalgia you to prevent or manage these side effects.
• Nail disorders
• To prevent and treat stomatitis/mucositis, you can maintain
• Nausea
good oral hygiene using a steroid mouthwash and mild toothpaste.
• Neutropenia
Steroid dental paste can be used to treat developing ulcerations.
• Peripheral neuropathy
For more severe (Grade 2 and above) stomatitis, your doctor
may suggest lowering the dose of treatment, or delaying therapy
• Vomiting
until the stomatitis resolves, but in most cases, symptoms will
be mild and will subside once you have finished treatment.
• Report any signs of peripheral neuropathy to your doctor, who
will help you to manage this side effect.
• Let your doctor know if you experience nail changes, arthralgia
or myalgia, so that they can decide how to manage these.
continued overleaf
40
ESMO Patients Guide
DRUG
Pemetrexed • Anaemia • Your blood cell counts will be monitored frequently throughout
(Alimta SPC, 2018) • Anorexia your treatment in order to detect any neutropenia, anaemia, or
• Fatigue leukopenia – your doctor may adjust your treatment according to
• Leukopenia test results, and will advise you on how to prevent infections.
• Nausea • Effects on the gastrointestinal system (stomatitis, pharyngitis,
• Neutropenia nausea) may result in loss of appetite (anorexia). Your doctor will
• Pharyngitis be able to help you to prevent or manage these side effects.
• Rash
• Let your doctor know if you develop a rash – they will help you to
• Stomatitis
manage this side effect.
Vinorelbine • Alopecia • Your blood cell counts will be monitored frequently throughout
(Vinorelbine SPC, • Anaemia your treatment in order to detect any neutropenia or anaemia
2018) • Constipation – your doctor may adjust your treatment according to test results,
• Nausea and will advise you on how to prevent infections.
• Neurological disorders • Report any signs of neurological disorders (e.g. loss of reflexes,
• Neutropenia weakness of the legs and feet) to your doctor, who will decide how
• Oesophagitis to manage these side effects.
• Skin reactions
• Your doctor will be able to help you to prevent or manage any
• Stomatitis
effects on the gastrointestinal system (stomatitis, nausea,
• Vomiting
vomiting, constipation, oesophagitis).
• Let your doctor know if you experience any burning or skin
changes at the injection site, so that they can decide how to
manage these.
Important side effects with chemotherapy (used as single drugs) in the treatment of NSCLC. The most recent
Summary of Product Characteristics (SPCs) for individual drugs can be located at: http://www.ema.europa.eu/ema/.
continued overleaf
41
Targeted therapies and antiangiogenic therapies

Common side effects in patients treated with targeted therapies or antiangiogenic therapies include effects
on the gastrointestinal system (e.g. diarrhoea, vomiting, nausea), skin problems (e.g. rash, dry skin, nail
changes, discolouration) and hypertension (high blood pressure). Many of the side effects from targeted
therapies can be effectively prevented or managed effectively. Always tell your doctor or nurse as soon as
possible if you notice any side effects from taking a targeted therapy or antiangiogenic therapy.
THERAPY POSSIBLE SIDE EFFECT HOW THE SIDE EFFECTS MAY BE MANAGED
Afatinib • Decreased appetite • Effects on the gastrointestinal system (diarrhoea, nausea,
(Giotrif SPC, 2018) • Diarrhoea vomiting, stomatitis) may result in loss of appetite (anorexia).
• Epistaxis Your doctor will be able to help you to prevent or manage these
• Nail disorders side effects.
• Nausea • Let your doctor know if you experience epistaxis (nose bleeds) –
• Skin reactions (rash, they will help you to manage this side effect.
acne, dry skin, itchiness)
• Stomatitis • Report any skin reactions or nail changes to your doctor – they will
• Vomiting help you to manage these side effects.
Alectinib • Constipation • Report any nausea or constipation to your doctor, who will be able
(Alecensa SPC, • Myalgia to help you to prevent or manage these side effects.
2018) • Nausea • Let your doctor know if you develop any oedema (fluid retention)
• Oedema or myalgia (muscle pain) – they will help you to manage these side
effects.
Bevacizumab • Anorexia • Your blood cell counts will be monitored frequently throughout
(Avastin SPC, • Arthralgia your treatment in order to detect any neutropenia, leukopenia
2018) • Bleeding disorders or thrombocytopenia – your doctor may adjust your treatment
• Constipation according to test results, and will advise you on how to prevent
• Diarrhoea infections.
• Dysarthria • Report any signs of peripheral neuropathy (tingling or
• Dysgeusia numbness in your hands or feet) to your doctor, who will help you
• Dyspnoea to manage this side effect.
• Fatigue
• Any treatment will be delayed until wounds have healed satisfactorily.
• Headache
• Hypertension • Your blood pressure will be monitored throughout treatment and
• Leukopenia any hypertension will be managed appropriately.
• Nausea • Effects on the gastrointestinal system (stomatitis,
• Neutropenia constipation, diarrhoea, nausea, vomiting) and dysgeusia (taste
• Peripheral neuropathy changes) may result in loss of appetite (anorexia). Your doctor
• Rhinitis will be able to help you to prevent or manage these side effects.
• Skin reactions
• Let your doctor know if you develop any skin reactions (e.g. rash, dry
• Stomatitis
skin, discolouration) – they will help you to manage these side effects.
• Vomiting • Report any other side effects, including changes in vision,
• Watery eyes dyspnoea (breathlessness), dysarthria (difficulty with speech),
• Wound healing arthralgia (painful joints) or headache to your doctor, who will
complications help you to manage these side effects.
continued overleaf
42
ESMO Patients Guide
Ceritinib • Anaemia • Your blood cell counts will be monitored frequently throughout your
(Zykadia SPC, • Changes in liver function treatment in order to detect any anaemia – your doctor may adjust
2018) • Constipation your treatment according to test results.
• Decreased appetite • You will have tests before and during treatment to check how well
• Diarrhoea your liver is functioning.
• Dyspepsia, acid reflux,
• If you experience diarrhoea, nausea, vomiting, constipation,
dysphagia
indigestion, heartburn or problems swallowing, your doctor will be
• Fatigue
able to help you to prevent or manage these side effects.
• Nausea
• Rash • Report any rashes to your doctor – they will help you to manage this
• Vomiting side effect.
Crizotinib • Anaemia • Your blood cell counts will be monitored frequently throughout
(Xalkori SPC, • Bradycardia your treatment in order to detect any neutropenia, anaemia or
2018) • Changes in liver function leukopenia – your doctor may adjust your treatment according to
• Constipation test results, and will advise you on how to prevent infections.
• Diarrhoea • Report any signs of peripheral neuropathy (tingling or
• Dizziness numbness in your hands or feet) to your doctor, who will help you
• Dysgeusia to manage this side effect.
• Fatigue
• Impaired vision
• Leukopenia
• Nausea • If you experience diarrhoea, nausea, vomiting, constipation, or
• Neutropenia changes in your sense of taste (dysgeusia), your doctor will be
• Oedema able to help you to prevent or manage these side effects.
• Peripheral neuropathy • Let your doctor know if you develop any problems with your eyes,
• Rash experience dizziness, oedema (fluid retention) or develop a rash
• Vomiting – they will help you to manage these side effects.
continued overleaf
43
Dabrafenib b • Abdominal pain • Effects on the gastrointestinal system (diarrhoea, constipation,
(Tafinlar SPC, • Arthralgia abdominal pain, nausea, vomiting) may result in loss of appetite
2018) • Asthenia (anorexia) and asthenia (weakness). Your doctor will be able to
• Bleeding help you to prevent or manage these side effects.
• Changes in liver function • You will have tests before and during treatment to check how well
• Chills your liver is functioning.
• Constipation
• Cough • Your blood pressure will be monitored throughout treatment and
• Decreased appetite any hypertension will be managed appropriately.
• Diarrhoea • You should tell your doctor immediately if you notice any signs
• Dizziness of increased bleeding (e.g. nose bleeds) as your medication may
• Dry skin need to be adjusted.
• Fatigue • Let your doctor know if you develop any skin reactions (e.g. rash,
• Fever dry skin, itchiness) – they will help you to manage these side
• Flu-like symptoms effects.
• Headache
• Hypertension
• Tell your doctor if you experience flu-like symptoms, including
fatigue, nasopharyngitis, chills or fever.
• Muscle spasms
• Myalgia • Report any other side effects, including cough, muscle spasms,
• Nasopharyngitis arthralgia (painful joints), myalgia (muscle pain), swelling,
• Nausea headache or dizziness to your doctor, who will help you to manage
• Oedema these side effects.
• Pain in extremities
• Pruritus
• Rash
• Vomiting
Erlotinib • Anorexia • Your doctor will advise you on how to prevent infections.
(Tarceva SPC, • Conjunctivitis • Effects on the gastrointestinal system (diarrhoea, nausea,
2018) • Cough vomiting, stomatitis) may result in loss of appetite (anorexia).
• Diarrhoea Your doctor will be able to help you to prevent or manage these
• Dry eyes side effects.
• Dyspnoea
• Let your doctor know if you develop any problems with your eyes
• Fatigue
(e.g. dry eyes, conjunctivitis), experience increased dyspnoea
• Increased risk of infection
(breathlessness) or cough, or develop a rash – they will help you
• Nausea
to manage these side effects.
• Rash
• Stomatitis
• Vomiting
continued overleaf
44
ESMO Patients Guide
Gefitinib • Anorexia • Diarrhoea may result in loss of appetite (anorexia) and asthenia
(Iressa SPC, 2018) • Asthenia (weakness). Your doctor will be able to help you to prevent or
• Changes in liver function manage these side effects.
• Diarrhoea • You will have tests before and during treatment to check how well
• Skin reactions your liver is functioning.
• Let your doctor know if you develop any skin reactions (e.g. rash,
acne, dry skin, itchiness) – they will help you to manage these side
effects.
Nintedaniba • Changes in liver function • Your blood cell counts will be monitored frequently throughout
(Vargatef SPC, • Diarrhoea your treatment in order to detect any neutropenia – your doctor
2018) • Mucositis may adjust your treatment according to test results, and will advise
• Nausea you on how to prevent infections.
• Neutropenia • Report any signs of peripheral neuropathy (tingling or
• Peripheral neuropathy numbness in your hands or feet) to your doctor, who will help you
• Rash to manage this side effect.
• Stomatitis
• Vomiting
• If you experience diarrhoea, nausea, vomiting, a sore mouth or
lips, your doctor will be able to help you to prevent or manage
these side effects.
• Let your doctor know if you develop any rash – they will help you
to manage this side effect.
Osimertinib • Diarrhoea • Your blood cell counts will be monitored frequently throughout
(Tagrisso SPC, • Leukopenia your treatment in order to detect any neutropenia, leukopenia
2018) • Nail disorders or thrombocytopenia – your doctor may adjust your treatment
• Neutropenia according to test results, and will advise you on how to prevent
• Skin reactions (rash, dry infections.
skin, itchiness) • If you experience diarrhoea or a sore mouth or lips, your doctor
• Stomatitis will be able to help you to prevent or manage these side effects.
• Report any skin reactions or nail changes to your doctor – they will
help you to manage these side effects.
Ramucirumaba • Epistaxis • Your blood cell counts will be monitored frequently throughout your
(Cyramza SPC, • Fatigue/asthenia treatment in order to detect any neutropenia or thrombocytopenia
2018) • Hypertension – your doctor may adjust your treatment according to test results, and
• Neutropenia will advise you on how to prevent infections.
• Oedema • Your blood pressure will be monitored throughout treatment and any
• Stomatitis hypertension will be managed appropriately.
• Let your doctor know if you experience a sore mouth or lips, or
oedema (fluid retention), your doctor will be able to help you to
prevent or manage these side effects.
continued overleaf
45
Trametinib c • Abdominal pain • Effects on the gastrointestinal system (diarrhoea, constipation,
(Mekinist SPC, • Arthralgia abdominal pain, nausea, vomiting) may result in loss of appetite
2018) • Asthenia (anorexia) and asthenia (weakness). Your doctor will be able to
• Bleeding help you to prevent or manage these side effects.
• Changes in liver function • You will have tests before and during treatment to check how well
• Chills your liver is functioning.
• Constipation
• Cough • Your blood pressure will be monitored throughout treatment and
• Decreased appetite any hypertension will be managed appropriately.
• Diarrhoea • You should tell your doctor immediately if you notice any signs
• Dizziness of increased bleeding (e.g. nose bleeds) as your medication may
• Dry skin need to be adjusted.
• Fatigue • Let your doctor know if you develop any skin reactions (e.g. rash,
• Fever dry skin, itchiness) – they will help you to manage these side
• Flu-like symptoms effects.
• Headache
• Hypertension
• Tell your doctor if you experience flu-like symptoms, including
fatigue, nasopharyngitis, chills or fever.
• Muscle spasms
• Myalgia • Report any other side effects, including cough, muscle spasms,
• Nasopharyngitis arthralgia (painful joints), myalgia (muscle pain), swelling,
• Nausea headache or dizziness to your doctor, who will help you to manage
• Oedema these side effects.
• Pain in extremities
• Pruritus
• Rash
• Vomiting
Important side effects with targeted therapy and antiangiogenic therapy in the treatment of NSCLC. The most
recent Summary of Product Characteristics (SPCs) for individual drugs can be located at: http://www.ema.europa.eu/ema/.
a
In combination with docetaxel chemotherapy; bIn combination with trametinib; cIn combination with
dabrafenib.
continued overleaf
46
ESMO Patients Guide
Immunotherapies
Common side effects in patients treated with immunotherapies include effects on the skin (e.g. rash, pruritus)
and gastrointestinal system (e.g. diarrhoea, nausea). Many of the side effects from immunotherapies can
be effectively prevented or managed. Always tell your doctor or nurse as soon as possible if you notice any side
effects from taking an immunotherapy.
Immuno-
therapy
For further information and advice on immunotherapy side effects, see ESMO’s
Side Effects
patient guide on immunotherapy-related side effects and their management
What are
Immunotherapy (https://www.esmo.org/Patients/Patient-Guides/Patient-Guide-on-Immunotherapy-
Side Effects?
Side-Effects).
Let us answer some of
your questions.
ESMO Patient Guide Series

based on the ESMO Clinical Practice Guidelines esmo.org
Atezolizumab • Arthralgia • Effects on the gastrointestinal system (nausea, vomiting,
(Tecentriq SPC, • Asthenia diarrhoea, taste changes) may result in loss of appetite and asthenia.
2018) • Back pain Your doctor will be able to help you to prevent or manage these side
• Cough effects.
• Decreased appetite • Let your doctor know if you experience increased dyspnoea or
• Diarrhoea cough, joint pain, itchiness or develop a rash – they will help you to
• Dyspnoea manage these side effects.
• Fatigue
• Fever
• Nausea
• Pruritus
• Rash
• Urinary tract infection
• Vomiting
Durvalumab • Abdominal pain • Let your doctor know if you experience respiratory symptoms.
(Imfinzi SPC, 2018) • Cough • Your thyroid function will be monitored before and during
• Diarrhoea treatment.
• Fever
• Hypothyroidism • Your doctor will be able to help you to prevent or manage any
diarrhoea or nausea.
• Pneumonia
• Pruritus • Let your doctor know if you experience any skin rash or itchiness
• Rash – they will be able to help you to prevent or manage these side
• Upper respiratory tract effects.
infection
continued overleaf
47
Nivolumab • Altered levels of • Your blood cell counts will be monitored frequently throughout your
(Opdivo SPC, minerals and salts treatment in order to detect any neutropenia, lymphopenia,
2018) (hypercalcaemia, leukopenia, anaemia or thrombocytopenia – your doctor may
hyperkalaemia, adjust your treatment according to test results, and will advise you on
hypokalaemia, how to prevent infections.
hypomagnesaemia, • You will have tests before and during treatment to check how well your
hyponatraemia) liver is functioning.
• Anaemia
• Changes in liver function
• Your doctor will be able to help you to prevent or manage any
diarrhoea or nausea.
• Diarrhoea
• Fatigue • Your body’s levels of minerals and salts will be measured during your
• Leukopenia treatment – your treatment may be adapted according to any changes.
• Lymphopenia • Let your doctor know if you experience any skin rash or itchiness –
• Nausea they will be able to help you to prevent or manage these side effects.
• Neutropenia
• Pruritus
• Rash
Pembrolizumab • Arthralgia • Your doctor will be able to help you to prevent or manage any
(Keytruda SPC, • Diarrhoea diarrhoea or nausea.
2018) • Fatigue • Let your doctor know if you experience any skin rash or itchiness
• Nausea or joint pain – they will be able to help you to prevent or manage
• Pruritus these side effects.
• Rash
Important side effects with immunotherapy in the treatment of NSCLC. The most recent Summary of Product
Characteristics (SPCs) for individual drugs can be located at: http://www.ema.europa.eu/ema/.
continued overleaf
48
ESMO Patients Guide
What happens after my treatment has finished?

Follow-up appointments
You will be able to discuss any concerns you have

at your follow-up appointments
After your treatment has finished, your doctor will arrange follow-up appointments. You will have regular chest
x-rays and/or CT scans to check that there are no further tumours. Your doctor will also evaluate any treatment
complications or side effects related to surgery, radiotherapy and/or systemic anti-cancer treatment. The
frequency of these appointments will be tailored to your situation, and will depend on the stage of the cancer
when you were initially diagnosed and the treatment that you have had (Postmus et al., 2017; Planchard et al., 2018).
Recommendations
• After surgery for Stage I-III NSCLC, you should be seen every 6 months for the first 2 years and then yearly
after that (Postmus et al., 2017).
• You may have a CT scan every 6 months, particularly if you are suitable for salvage treatment should there be
any complications (Postmus et al., 2017).
• After treatment for metastatic disease, depending on your suitability for further treatment, your doctor will
see you every 6–12 weeks so that second-line therapy can be started promptly, if needed (Planchard et al., 2018).
• If you have had multimodal therapy for Stage III disease you are likely to have brain scans to monitor for
the development of brain metastases, for which you may be offered treatment (Eberhardt et al., 2015).
What if I need more treatment?

Cancer that comes back is called a recurrence. The treatment that you will be offered depends on the extent
of the recurrence. When the tumour comes back as a recurrence at a single site, you may be offered
treatment such as surgical removal or radiotherapy. However, this approach is limited to a very small group
of patients. Recurrent tumours are normally regarded as metastatic cancers and you can usually have further
chemotherapy with different drugs, and some patients may be suitable for treatment with targeted therapies
or immunotherapy (see section ‘Treatment options for metastatic (Stage IV) NSCLC’ for more information).
In some cases, a repeated biopsy of the tumour may be carried out as it may result in a change to the treatment
decision. This may be particularly true if you have been cancer-free for some time after surgical resection.
Where available, patients who were previously treated for NSCLC with an EGFR-activating mutation may
undergo a liquid biopsy to detect any T790M mutation (also called plasma EGFR mutational analysis). This
will involve providing a small blood sample for analysis. Re-biopsy may be useful to differentiate between
disease recurrence and a new primary lung tumour (if the recurrence is detected in the lung) to ascertain the
type of tumour or to repeat the EGFR mutation test if a non-squamous cancer is detected (Planchard et al., 2018).
49
Looking after your health

After you have had treatment for NSCLC, you may feel very tired and emotional. It is important to take good care
of yourself and get the support that you need.
• Stop smoking: If you are a smoker, it is important to stop smoking as soon as you can as it may reduce
the risk of disease recurrence (Postmus et al., 2017; Planchard et al., 2018). Your doctor and nurse can offer help
with stopping smoking.
• Take plenty of rest when you need it: Give your body time to recover and make sure you rest as much
as you can. Complementary therapies, such as aromatherapy, may help you relax and cope better with side
effects. Your hospital may offer complementary therapy; ask your doctor for details.
• Eat well and keep active: Eating a healthy diet and keeping active can help improve your fitness. It is
important to start slowly, with gentle walking, and build up as you start to feel better.
The following eight recommendations form a good foundation for a healthy lifestyle after cancer (Wolin et al., 2013):
• Don’t smoke.
• Avoid second-hand smoke.
• Exercise regularly.
• Avoid weight gain.
• Eat a healthy diet.
• Drink alcohol in moderation (if at all).
• Stay connected with friends, family and other cancer survivors.
• Attend regular check-ups and screening tests.
A healthy, active lifestyle will help you to recover

physically and mentally
Regular exercise is an important part of a healthy

lifestyle, helping you to keep physically fit and avoid
weight gain. Studies have shown that an exercise
training programme can improve fatigue and well-
being in patients with unresectable lung cancer
(Wiskemann et al., 2018). It is very important that you listen
carefully to the recommendations of your doctor or
nurse, and talk to them about any difficulties you have
with exercise.
50
ESMO Patients Guide
Emotional support
It is common to be overwhelmed by your feelings when
you have been diagnosed with cancer and when you
have been through treatment. If you feel anxious or
depressed, talk to your doctor or nurse – they can refer
you to a specialist counsellor or psychologist who
has experience of dealing with emotional problems of
people dealing with cancer. It may also help to join a
support group so that you can talk to other people who
understand exactly what you are going through.
For further information and advice regarding how to
regain your life as far as possible after treatment for
cancer, see ESMO’s patient guide on survivorship Survivorship
(http://www.esmo.org/Patients/Patient-Guides/Patient-Guide-on-Survivorship).
What does
survivorship mean?
Let us explain
it to you.
ESMO Patient Guide Series In collaboration with
based on the ESMO Clinical Practice Guidelines

esmo.org
51
Support groups
In Europe, there are some lung cancer patient advocacy groups, which help patients and their families to navigate
the lung cancer landscape. They can be local, national or international, and they work to ensure patients receive
appropriate and timely care and education. These groups can provide you with the tools you may need to help you
better understand your disease, and to learn how to cope with it, living the best quality of life that you can.
You can access information from the following organisations:
• Global Lung Cancer Coalition (GLCC): www.lungcancercoalition.org
• Lung Cancer Europe (LuCE): www.lungcancereurope.eu
• Women Against Lung Cancer in Europe (WALCE) educational booklets:
www.womenagainstlungcancer.eu/?lang=en
52
ESMO Patients Guide
References
Bailey-Wilson JE, Amos CI, Pinney SM, et al. A major lung cancer susceptibility locus maps to chromosome
6q23-25. Am J Hum Genet 2004;75(3):460–474.
Cancer.Net. 2016. Side effects of radiation therapy. Available from: http://www.cancer.net/navigating-cancer-
care/how-cancer-treated/radiation-therapy/side-effects-radiation-therapy. Accessed 20th November 2018.
Cancer.Net. 2017. Fatigue. Available from: http://www.cancer.net/navigating-cancer-care/side-effects/fatigue.
Accessed 20th November 2018.
Cancer.Net. 2018. Side effects of surgery. Available from: http://www.cancer.net/navigating-cancer-care/how-
cancer-treated/surgery/side-effects-surgery. Accessed 20th November 2018.
Cappuzzo F, McCleod M, Hussein M, et al. IMpower130: Progression-free survival (PFS) and safety analysis
from a randomised phase III study of carboplatin + nab-paclitaxel (CnP) with or without atezolizumab (atezo) as
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ESMO Patients Guide
GLOSSARY
ACCELERATED SCHEDULE ANOREXIA
A higher dose of radiation is given at each treatment A lack or loss of appetite
and there are fewer total treatments than in a
conventional radiotherapy schedule. The total amount ANTIANGIOGENIC THERAPY
of radiation given is about the same in each schedule A type of therapy that interferes in the growth and
survival of new blood vessels (angiogenesis), which
ADENOCARCINOMA plays a critical role in the growth and spread of cancer
The most common type of lung cancer; it develops from
mucus-producing cells that line the airways ANTIBIOTIC
A type of drug used to treat and prevent bacterial infections
ADRENAL GLANDS
Glands in the body that produce hormones, such ARSENIC
as adrenaline and steroids. They are located above A naturally occurring substance that has been widely
the kidneys used in some industries (copper or lead smelting;
agriculture/pesticides), but has been linked to cancer,
ADJUVANT (TREATMENT) including lung cancer
Additional treatment given after the primary treatment
to reduce the chance of the cancer coming back; usually ARTHRALGIA
refers to radiotherapy and/or chemotherapy after surgery Pain in a joint(s)
AFATINIB ASBESTOS
A type of targeted therapy called a tyrosine kinase A natural, fibrous material that was previously widely
inhibitor, which works by blocking signals within used as a building material. Its use is now banned
cancer cells and stopping the action of epidermal throughout Europe as it is linked to lung diseases,
growth factor receptor, causing cancer cells to die. It is including cancer
administered as a once daily tablet ASTHENIA
AIR LEAK Abnormal feeling of weakness or lack of energy
When air escapes from the airways (bronchioles, ATEZOLIZUMAB
alveoli) into the parts of the lung where air is not A type of immunotherapy that blocks a protein called
usually present PD-L1 on the surface of certain immune cells called
ALECTINIB T-cells; this activates the T-cells to find and kill cancer
A type of targeted therapy called a tyrosine kinase cells. It is administered through a drip into a vein in
inhibitor, which works by blocking a protein called your arm or chest
anaplastic lymphoma kinase. It only works in cancer BEVACIZUMAB
cells with an abnormal version of this protein. It is A type of targeted therapy used to treat some cancers,
administered twice-daily as oral capsules including advanced NSCLC. It is a monoclonal antibody
ANAPLASTIC LYMPHOMA KINASE that targets vascular endothelial growth factor and
REARRANGEMENTS (ALK) prevents the cancer cells from developing their own
Anaplastic lymphoma kinase is a cell surface protein. blood supply, thus helping to slow down tumour growth
Rearrangement of the ALK gene is an abnormality found BIOPSY
in some cancer cells, including NSCLC A medical procedure in which a small sample of cells or
ALOPECIA tissue is taken for examination under a microscope
Hair loss BLOOD VESSELS
ALVEOLI The structures (tubes) carrying blood through the
Tiny air sacs within the lungs that allow oxygen and carbon tissues and organs of the body – they include veins,
dioxide to move between the lungs and bloodstream arteries and capillaries
ANAEMIA
A condition characterised by the shortage of
haemoglobin (a protein in red blood cells that carries
oxygen throughout the body)
55
GLOSSARY
BONE MARROW CHRONIC OBSTRUCTIVE PULMONARY DISEASE
A spongy tissue found inside some bones (e.g. hip and (COPD)
thigh bones). It contains stem cells, which are cells that A type of lung disease characterised by long-term poor
can develop into the red blood cells, white blood cells airflow. The main symptoms include shortness of
or platelets breath and cough
BRADYCARDIA CISPLATIN
Abnormally slow heart rate A type of chemotherapy that is administered through a
drip into a vein in your arm or chest
BRAF
A gene that makes a protein involved in cell signalling CLINICAL TRIAL
and growth. BRAF may be mutated in cancer cells A study that evaulates the effects of treatment
BRIGATINIB COLD CAP
A type of targeted therapy that works by inhibiting A cap that cools the scalp before, during and after
a protein called anaplastic lymphoma kinase. It is treatment to reduce the effects of the treatment on
administered as a once-daily tablet to patients who hair follicles
have previously received crizotinib
COMORBIDITIES
BRONCHI Additional diseases or disorders experienced by the
The right bronchus and the left bronchus (the bronchi) patient at the same time
are the two main airways that take air into the lungs
COMPUTED TOMOGRAPHY (CT)
BRONCHIOLES A scan using x-rays and a computer to create detailed
The bronchi divide into smaller bronchioles, which then images of the inside of your body
lead to the alveoli
CONCURRENT
BRONCHOSCOPE Different types of treatment (e.g. chemotherapy and
A thin, fibre-optic cable that is inserted into the airways radiotherapy) given at the same time
(usually through the nose or mouth)
CONJUNCTIVITIS
BRONCHOSCOPY Inflammation of the membrane that covers the eyeball
A clinical investigation where your doctor examines and lines the eyelid
your airways using a bronchoscope
CONVENTIONAL RADIOTHERAPY
CARBOPLATIN Refers to radiotherapy that is given to the tumour as
A type of chemotherapy that is administered through a a fraction of the complete dose over several sessions
drip into a vein in your arm or chest – treatment usually consists of a small daily dose over
several weeks
CERITINIB
A type of targeted therapy that works by inhibiting CRIZOTINIB
a protein called anaplastic lymphoma kinase. It is A type of targeted therapy called a tyrosine kinase
administered as a once-daily capsule to patients who inhibitor, which works by blocking a protein called
have previously received crizotinib anaplastic lymphoma kinase. It only works in cancer
cells with an abnormal version of this protein. It is
CHEMORADIOTHERAPY administered as a twice-daily capsule
Chemotherapy and radiotherapy given together
DABRAFENIB
CHEMOTHERAPY A type of targeted therapy, which works by blocking
A type of cancer treatment using medicine that kills signals within cancer cells and stopping the action
the cancer cells by damaging them, so that they cannot of proteins made by the mutated BRAF gene. It is
reproduce and spread administered as a twice daily tablet
56
ESMO Patients Guide
GLOSSARY
DACOMITINIB EPIDERMAL GROWTH FACTOR RECEPTOR (EGFR)
A type of targeted therapy called a tyrosine kinase A protein involved in cell growth and division. It is
inhibitor, which works by blocking signals within found in abnormally high amounts on the surface of
cancer cells and stopping the action of epidermal many types of cancer cells
growth factor receptor, causing cancer cells to die. It is
administered as a once-daily tablet EPISTAXIS
The medical term for a nose bleed
DENOSUMAB
A drug used to treat osteoporosis and prevent broken ERLOTINIB
bones and other bone problems caused by bone A type of targeted therapy called a tyrosine kinase
metastases inhibitor, which works by blocking signals within cancer
cells and stopping the action of epidermal growth factor
DIAPHRAGM receptor, causing cancer cells to die. It is administered
The muscle that separates the chest cavity from the as a once-daily tablet
abdomen; the diaphragm contracts and relaxes as we
breathe in and out ETOPOSIDE
A type of chemotherapy that is administered through a
DNA drip into a vein in your arm or chest, or as an oral tablet
Deoxyribose nucleic acid, the chemical that carries or capsule
genetic information in the cells of your body
FATIGUE
DOCETAXEL Overwhelming tiredness
drip into a vein in your arm or chest FIRST-LINE TREATMENT
The initial treatment given to a patient
DOUBLET CHEMOTHERAPY
A combination of two different types of chemotherapy GASTROINTESTINAL SYSTEM
administered at the same time The system of organs responsible for getting food into
and out of the body and for making use of food to keep
DURVALUMAB the body healthy – includes the oesophagus, stomach
A type of immunotherapy that blocks a protein called and intestines
PD-L1 on the surface of certain immune cells called
T-cells; this activates the T-cells to find and kill cancer GEFITINIB
cells. It is administered through a drip into a vein in A type of targeted therapy called a tyrosine kinase
your arm or chest inhibitor, which works by blocking signals within
cancer cells and stopping the action of epidermal
DYSARTHRIA growth factor receptor, causing cancer cells to die. It is
Difficult or unclear articulation of speech (e.g. slurred, administered as a once-daily tablet
nasal-sounding, hoarse or excessively loud or quiet)
GEMCITABINE
DYSGEUSIA A type of chemotherapy that is administered through a
A change in the sense of taste drip into a vein in your arm or chest
DYSPEPSIA GENES
The medical term for indigestion Pieces of DNA responsible for making substances that
the body needs to function
DYSPHAGIA
The medical term for difficulties with swallowing GENERAL ANAESTHETIC
A medication that causes a reversible loss of
DYSPNOEA consciousness
Shortness of breath
EARLY-STAGE (CANCER)
Cancer that has not spread to the lymph nodes or other
parts of the body
57
GLOSSARY
GRADE LARGE CELL (UNDIFFERENTIATED) CARCINOMA
Cancer grade is based on how different tumour cells A type of NSCLC that does not look like adenocarcinoma
look from normal cells under a microscope, and on how or squamous cell carcinoma under the microscope
quickly they grow. The grade will be a value between
one and three and reflects the aggressiveness of LEUKOPENIA
tumour cells; the higher the grade, the more aggressive A decrease in the number of leukocytes (a type of white
the tumour blood cell) in the blood, which places individuals at
increased risk of infection
HAIR FOLLICLE
A small sac in the skin from which hair grows from LIQUID BIOPSY
Tests performed in blood samples or other body
HEPATIC fluids to detect the presence of substances that have
Relating to the liver originated in a tumour, and therefore, indicate the
presence of a cancer
HISTOLOGICAL SUBTYPE
Cancer type based on the type of tissue in which the LOBE
cancer started A (usually rounded) part of an organ that appears to be
separate in some way from the rest of that organ
HYPERCALCAEMIA
An abnormally high level of calcium in the blood LOBECTOMY
A type of lung cancer surgery in which one lobe of a
HYPERKALAEMIA lung is removed (the right lung has three lobes, and the
An abnormally high level of potassium in the blood left lung has two lobes)
HYPERTENSION LOCAL ANAESTHETIC
Abnormally high blood pressure A medication that causes reversible absence of pain
HYPOKALAEMIA sensation around the site of administration
An abnormally low level of potassium in the blood LOCALLY ADVANCED
HYPOMAGNESAEMIA Cancer that has spread from where it started to nearby
An abnormally low level of magnesium in the blood tissue or lymph nodes
HYPONATRAEMIA LORLATINIB
An abnormally low level of sodium in the blood A type of targeted therapy, which works by inhibiting
a protein called anaplastic lymphoma kinase. It is
HYPOTHYROIDISM administered as a once-daily tablet
Abnormally low levels of thyroid hormones
LYMPH
IMMUNOTHERAPY The fluid that circulates throughout the lymphatic
A type of cancer treatment that stimulates the body’s system; it contains infection-fighting white blood cells
immune system to fight the cancer
LYMPH NODES
INDUCTION THERAPY Small structures throughout the lymphatic system that
Initial treatment with chemotherapy and/or work as filters for harmful substances, such as cancer
radiotherapy to shrink the tumour before a second cells or bacteria
planned treatment (for example, surgery)
LYMPHATIC SYSTEM
INTRAVENOUS A network of tissues and organs that help rid the
Administered into a vein body of toxins, waste and other unwanted materials.
The primary function of the lymphatic system is to
IONISING RADIATION transport lymph, a fluid containing infection-fighting
Any type of particle or electromagnetic wave that white blood cells, throughout the body
carries enough energy to ionise or remove electrons
from an atom (e.g. x-rays)
58
ESMO Patients Guide
GLOSSARY
LYMPHOPENIA MYALGIA
An abnormally low level of lymphocytes (a type of white Pain in a muscle(s)
blood cell) in the blood, which places individuals at
increased risk of infection NAB-PACLITAXEL
MAGNETIC RESONANCE IMAGING (MRI) drip into a vein in your arm or chest. Nab-Paclitaxel is
A type of scan that uses strong magnetic fields and a protein-bound form of paclitaxel
radio waves to produce detailed images of the inside
of the body NASOPHARYNGITIS
Swelling and inflammation of the nasal passages and
MAINTENANCE TREATMENT the back of the throat
Treatment given after the initial cycles of chemotherapy
with the aim of keeping the cancer under control NEOADJUVANT (TREATMENT)
Treatment given as a first step to shrink a tumour
METACHRONOUS OLIGOMETASTASES before the main treatment is given
Oligometastases that appear following treatment for a
primary tumour NEUROLOGICAL
Relating to the nerves and the nervous system
METASTATIC
A cancer that has spread from its (primary) site of NEUTROPENIA
origin to different parts of the body An abnormally low level of neutrophils in the blood,
which increases risk of infection
METASTASIS (METASTASES)
A cancerous tumour or growth that has originated from NEUTROPHIL
a primary tumour/growth in another part of the body A type of white blood cell that plays an important role in
(plural = metastases) fighting off infection
MONOCLONAL ANTIBODY NINTEDANIB

A type of targeted therapy. Monoclonal antibodies A type of targeted therapy that blocks proteins called
recognise and attach to specific proteins produced protein kinases, which are present in cancer cells and
by cells. Each monoclonal antibody recognises involved in cancer cell growth. It is administered as a
one particular protein. They work in different ways twice-daily capsule
depending on the protein they are targeting NIVOLUMAB
MUCOSITIS A type of immunotherapy that blocks a protein called
Inflammation and ulceration of the membranes lining PD-1 on the surface of certain immune cells called
the gastrointestinal system T-cells; this activates the T-cells to find and kill cancer
cells. It is administered through a drip into a vein in
MULTIDISCIPLINARY TEAM your arm or chest
A group of health care workers who are members of
different disciplines (e.g. oncologist, nurse specialist, NURSE SPECIALIST
physiotherapist, radiologist) and provide specific A nurse specialised in the care of patients with a certain
services to the patient. The activities of the team are condition (e.g. cancer)
brought together using a care plan OEDEMA
MULTIMODAL THERAPY A build-up of fluid in the body which causes the affected
A treatment approach that includes two or more tissue to become swollen
treatment types – usually some combination of surgery, OESOPHAGITIS
chemotherapy and radiotherapy Inflammation of the oesophagus
MUTATION OESOPHAGUS
A permanent alteration in the DNA sequence that makes The food pipe; the tube that connects your throat with
up a gene, such that the sequence differs from what is your stomach
found in most people
59
GLOSSARY
OLIGOMETASTATIC DISEASE (OLIGOMETASTASES) PHARYNGITIS
Cancer that has spread from its original site to a limited Inflammation of the pharynx, which is in the back of
number of other sites/organs; disease progression may the throat
occur at these sites but without spread to additional
organs (oligometastases can be described as either PLATELETS
synchronous or metachronous) Tiny blood cells that help your body form clots to stop
bleeding
ONCOLOGIST
A doctor who specialises in the medical management PLATINUM-BASED
of cancer A class of chemotherapy that includes cisplatin and
carboplatin
OSIMERTINIB
A type of targeted therapy called a tyrosine kinase PLEURA
inhibitor, which works by blocking signals within cancer One of the two membranes around the lungs. These two
cells and stopping the action of epidermal growth factor membranes are called the visceral and parietal pleurae
receptor, causing cancer cells to die. It is administered PNEUMONECTOMY
as a once-daily tablet to patients who have previously The surgical removal of a lung or part of a lung
been treated with another tyrosine kinase inhibitor
PNEUMONIA
PACLITAXEL Inflammation of the lung, usually caused by an infection
drip into a vein in your arm or chest POSITRON EMISSION TOMOGRAPHY (PET)
An imaging test that uses a dye with radioactive
PALLIATIVE CARE tracers, which is injected into a vein in your arm
The care of patients with advanced, progressive illness.
It focuses on providing relief from pain, symptoms and PRIMARY LUNG CANCER
physical and emotional stress, without dealing with the A cancer that first started in the lungs
cause of the condition
PRIMARY TUMOUR
PASSIVE SMOKING The tumour where the cancer first started to grow
The inhalation of smoke by a person who is not actively
smoking themselves PROGNOSIS
The likely outcome of a medical condition
PATHOLOGIST
Doctor who diagnoses disease by examining cell and PROGRAMMED DEATH LIGAND-1 (PD-L1)
tissue samples A cellular protein thought to be involved in helping
the tumour to evade detection by the body’s immune
PEMBROLIZUMAB system
A type of immunotherapy that blocks a protein called
PD-1 on the surface of certain immune cells called PRURITUS
T-cells; this activates the T-cells to find and kill cancer Severe itching of the skin
cells. It is administered through a drip into a vein in
RADIATION PNEUMONITIS
your arm or chest
Symptoms of cough, fever and fullness of the chest
PEMETREXED that usually appear between 2 weeks and 6 months
A type of chemotherapy drug used to treat NSCLC, following radiotherapy but are usually temporary
which is given intravenously (directly into your
RADIOACTIVE
bloodstream through a vein in your arm or chest)
A material that is unstable and spontaneously emits
PERICARDIUM energy (radiation)
The membrane that encloses the heart
RADIOLOGICAL EXAMINATION
PERIPHERAL NEUROPATHY A test that uses x-rays or other medical imaging
Damage to the nerves in the extremities of the body. techniques to visualise the body and organs for the
Symptoms may include pain, sensitivity, numbness or detection of signs of cancer or other abnormalities
weakness in the hands, feet or lower legs
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ESMO Patients Guide
GLOSSARY
RADIOLOGIST SECOND-LINE TREATMENT
A doctor specialised in diagnosing and treating The second treatment given to a patient once the
disease and injury through the use of medical imaging initial (first-line) therapy has not worked or has been
techniques such as x-rays, computed tomography, stopped because of the occurrence of side effects or
magnetic resonance imaging, positron emission other concerns
tomography and ultrasound
SEGMENT (OR WEDGE) RESECTION
RADIOTHERAPY Surgical removal of the segment of the lung where the
Treatment involving the use of high-energy radiation, tumour is located
which is commonly used to treat cancer
SEQUENTIALLY
RAMUCIRUMAB Treatment given one after the other
A type of targeted therapy that blocks the action of
vascular endothelial growth factor, and prevents SQUAMOUS CELL CARCINOMA (SCC)
the cancer cells from developing their own blood A type of NSCLC; usually occurs in the central part of
supply, thus helping to slow down tumour growth. the lung or in one of the bronchi
It is administered through a drip into a vein in your STENT
arm or chest in combination with another type of A small tube that is used to keep an airway or artery open
chemotherapy
STEREOTACTIC ABLATIVE RADIOTHERAPY (SABR)
RECURRENCE A specialised type of radiotherapy that is given to the
Return of a cancer tumour from many different directions using detailed
REGIMEN scans to ensure precise targeting so that higher doses
Treatment plan can be given over a shorter time
REGIONAL LYMPH NODES STOMATITIS

Lymph nodes close to the tumour Inflammation of the inside of the mouth
RELAPSE SUPPORTIVE CARE

Return of a cancer or deterioration in a person’s state Care that provides relief from pain, symptoms and
of health physical and emotional stress, without treating the
cancer itself
RENAL
Relating to the kidneys SYNCHRONOUS OLIGOMETASTASES
Oligometastases diagnosed within a few months of a
RESECTABLE primary tumour
Able to be removed (resected) by surgery
SYSTEMIC ANTICANCER TREATMENT
RESECTION Drugs that spread throughout the body to treat
Surgery to remove tissue cancer cells wherever they may be. They include
chemotherapy, hormonal therapy, targeted therapy
RHINITIS and immunotherapy
Inflammation of the lining inside the nose
T790M MUTATION
RISK FACTOR A mutation of the epidermal growth factor receptor
Something that increases the chance of developing a (also known as Threonine 790 Methionine [Thr790Met]
disease mutation)
ROS1 REARRANGEMENT TARGETED THERAPY
ROS1 is a cell surface protein. Rearrangement of the A newer type of cancer treatment that uses drugs or
ROS1 gene is an abnormality found in some cancer other substances to precisely identify and attack cancer
cells, including NSCLC cells, usually while doing little damage to normal cells
TAXANE
A class of chemotherapy that includes paclitaxel
and docetaxel
61
GLOSSARY
THIRD-LINE TREATMENT VINORELBINE
A third line of treatment given to a patient once the A type of chemotherapy that is administered through a
previous two lines (first-line and second-line) of drip into a vein in your arm or chest
therapy have not worked or have been stopped because
of the occurrence of side effects or other concerns WEDGE (OR SEGMENT) RESECTION
Surgical removal of the segment of the lung where the
THROMBOCYTOPENIA tumour is located
A deficiency of platelets in the blood. This causes
bleeding into the tissues, bruising, and slow blood X-RAY
clotting after injury An imaging test, using a type of radiation that can pass
through the body, that allows your doctor to see inside
THROMBOSIS your body
The formation of a blood clot inside a blood vessel,
obstructing the flow of blood through the blood system ZOLEDRONIC ACID
A type of bisphosphonate used to treat cancers that
TINNITUS have spread to the bone
The hearing of a sound (such as ringing, whining or
buzzing) when no external sound is present
TRACHEA
The windpipe – the wide, hollow tube that connects the
larynx (or voice box) to the bronchi of the lungs
TRAMETINIB
A type of targeted therapy, which works by blocking
signals within cancer cells and stopping the action of
proteins called MEK1 and MEK2. It is administered as a
once daily tablet
TUMOUR
A lump or growth of abnormal cells. Tumours may be
benign (not cancerous) or malignant (cancerous). In
this guide, the term ‘tumour’ refers to a cancerous
growth, unless otherwise stated
TYROSINE KINASE INHIBITOR (TKI)
A type of targeted therapy that inhibits tyrosine
kinases, which are substances that send growth
signals to cells
ULTRASOUND
A type of medical scan where sound waves are
converted into images by a computer
UNRESECTABLE
Unable to be removed (resected) by surgery
URANIUM
A naturally radioactive element
VASCULAR ENDOTHELIAL GROWTH FACTOR (VEGF)
A protein produced by cells that stimulates the growth
of new blood vessels
VIDEO-ASSISTED THORACIC SURGERY (VATS)
A surgical procedure that allows doctors to see inside
the chest and lungs. It is a form of ‘keyhole’ surgery
62
ESMO Patients Guide
This guide has been prepared to help you, your friends and your family better understand the nature of non-
small-cell lung cancer (NSCLC) and the treatments that are available. The medical information described in this
document is based on the clinical practice guidelines of the European Society for Medical Oncology (ESMO) for the
management of early-stage, locally advanced or metastatic NSCLC. We recommend that you ask your doctor about
the tests and types of treatments available in your country for your type and stage of NSCLC.
This guide has been written by Kstorfin Medical Communications Ltd on behalf of ESMO.
© Copyright 2019 European Society for Medical Oncology. All rights reserved worldwide.
European Society for Medical Oncology (ESMO)
Via Ginevra 4
6900 Lugano
Switzerland
Tel: +41 (0)91 973 19 99
Fax: +41 (0)91 973 19 02
E-mail: [email protected]
63
We can help you understand non-small-cell lung
cancer and the available treatment options.
The ESMO Guides for Patients are designed to assist patients, their
relatives and caregivers to understand the nature of different types of cancer
and evaluate the best available treatment choices. The medical information
described in the Guides for Patients is based on the ESMO Clinical
Practice Guidelines, which are designed to guide medical oncologists
in the diagnosis, follow-up and treatment in different cancer types.
For more information, please visit www.esmo.org

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ESMO Patient Guide Series

Non-small-cell lung cancer (NSCLC)

2 An ESMO guide for patients

Lung cancer: A summary of key information

Introduction to lung cancer

Treatment options for NSCLC

Follow-up after treatment

Anatomy of the lungs

What is lung cancer?

What subtypes of NSCLC are there?

What are the symptoms of lung cancer?

How common is NSCLC?

Lung cancer represents the third most

• 312,000 new cases in men.

NSCLC is the most common type of lung cancer,

43.1 / 15.7 34.0 / 26.9 26.3 / 9.6

SOUTH AMERICA WESTERN AFRICA 28.4 / 24.0

SOUTHERN AFRICA 3.4 / 2.2 POLYNESIA

26.0 / 8.9 52.0 / 24.6

What causes NSCLC?

Household and environmental pollutants

How is NSCLC diagnosed?

Imaging is used to confirm a suspected diagnosis

Different imaging techniques include:

Examination of a biopsy is recommended for all

Histopathology is the study of diseased cells and tissues using a

Ask your doctor for details if you have any

How will my treatment be determined?

It is important for your doctor to know the

AJCC/UICC system 8th edition – abridged version (Planchard et al., 2018)

Biological testing of the tumour

Who is involved in planning my treatment?

It is important that patients are fully involved in

What are the treatment options for NSCLC?

Overview of treatment types

Treatments for NSCLC include surgery,

Treatment options for early (Stage I–II) NSCLC

Early-stage NSCLC that is confined to the lung

Treatment of early (Stage I–II) NSCLC – summary (Postmus et al., 2017)

TREATMENT PATIENTS TREATMENT DETAILS CONSIDERATIONS

Radical Tumours >5 cm • Conventional (4–7-week course of

Treatment options for locally advanced (Stage III) NSCLC

Treatment for locally advanced disease is likely to

TREATMENT PATIENTS TREATMENT DETAILS CONSIDERATIONS

Chemotherapy • Intravenous cisplatin-based regimen • A carboplatin-based

Unresectable • Delivered concurrently with

Radiotherapy Resectable • May be given post-operatively in patients

Unresectable • May be given as conventional daily

Immunotherapy Unresectable • Durvalumab may be offered if disease has

NSCLC, non-small-cell lung cancer; PD-L1, programmed death-ligand 1

Treatment options for metastatic (Stage IV) NSCLC

Chemotherapy is the main treatment

Treatment of metastatic (Stage IV) NSCLC – summary (Planchard et al., 2018)

TREATMENT PATIENTS TREATMENT DETAILS CONSIDERATIONS

TREATMENT PATIENTS TREATMENT DETAILS CONSIDERATIONS

Surgery Can be used for relief Minimally-invasive procedures can