The lungs are paired cone-shaped organs situated in the thoracic cavity. They are covered with the double-layered pleural membranes (membrane directly covering the lung is called visceral pleura and the external one is called parietal pleura) that secrete and enclose a lubricating fluid within the space between them (the pleural cavity). The right lung has 3 lobes and is slightly bigger than the left lung, that has 2 lobes.
When air is inhaled, it travels from the nostrils into the lungs via trachea (windpipe) and its two branches called bronchi. Inside the lungs, bronchi further divide into small lobular bronchi and keep on dividing inside the lobes to form a network of microscopic branches called bronchioles. At the end of each bronchiole are small grape-like air-sacs called alveoli that act as a site of gases exchange during respiration. The main function of the lungs is to bring about this gases exchange, that is, intake of oxygen and removal of carbon dioxide.
Epidemiology of Lung Cancer in Delhi
Lung cancer is one of the leading causes of cancer across the world. But in Delhi, it is on the rise. With the increasing air pollution, incidence of lung cancer is rising even for non-smokers in Delhi. 30 years back, smokers accounted for almost 90% of cases of lung cancer.
But in the current scenario, it is almost equally divided between smokers and non-smokers. And in the younger age group, less than 50 years, around 70% of lung cancer cases are non-smokers. The average age of lung cancer is also falling in Delhi. 20 years back, it was 50-60 years, but currently it has come down to 30-40 years. Also, the incidence is on the rise in females, with 40% of cases being women.
What are the types of Lung Cancer?
Broadly, lung cancer is mainly divided into 2 types: Non-small cell lung cancer (NSCLC) that constitutes about 80% to 85% of all lung cancers and small cell lung cancer (SCLC). Histologically, lung cancer can be of several types such as squamous cell carcinoma, adenocarcinoma, large cell carcinoma, neuroendocrine tumors, large cell neuroendocrine carcinoma, small cell carcinoma, and lung carcinoid tumors among others. Adenocarcinoma, squamous cell carcinoma, and large cell carcinoma are grouped together as NSCLC. SCLC, also known as oat-cell carcinoma is a type of neuroendocrine tumors, which tend to grow and spread very rapidly.
What is the Staging of Lung Cancer?
Staging of Non-Small Cell Lung Cancer (NSCLC)
The staging system is called as TNM staging system.
Tis – Pre-cancerous changes or carcinoma in situ.
T1 – Cancer is </= 3 cm in greatest dimension, without invasion of pleural membrane or mainstem bronchus. It may be further sub-divided as below.
T1mi– Cancer is minimally invasive adenocarcinoma </=3 cm in greatest dimension and invasion </=5 mm.
T1a – A tumor </=1 cm in the greatest dimension.
T1b – A tumor >1 cm but </=2 cm in the greatest dimension.
T1c – A tumor >2 cm but </=3 cm in the greatest dimension.
T2 – Tumor is >3 cm but </= 5 cm in greatest dimension. It has invaded into the main bronchus but has not affected the carina or invades the visceral pleura, or is partially choking the airway
T2a – A tumor >3 cm but </=4 cm in the greatest dimension
T2b – A tumor >4 cm but </=5 cm in the greatest dimension
T3 – A tumor >5 cm but </=7 cm in the greatest dimension that has invaded into the parietal pleura, chest wall, phrenic nerve, or the membranes surrounding the heart (parietal pericardium); or
There are 2 separate primary tumor nodules within the same lobe.
T4 – A tumor >7 cm in the greatest dimension that has invaded into the diaphragm, mediastinum, heart, large blood vessels, trachea, recurrent laryngeal nerve, esophagus, backbone, or carina; or
there is another tumor nodule in the adjacent lobe of the same lung.
N0 – No spread of cancer to nearby lymph nodes
N1 – Cancer has spread to intraparenchymal, peribrochial or ipsilateral hilar lymph nodes.
N2 – Cancer has spread to subcarinal or ipsilateral mediastinal lymph nodes
N3 – Cancer has spread to contralateral mediastinal lymph nodes or supraclavicular nodes
M0 – Cancer has not spread to distant body parts
M1a – Cancer has spread to cause pleural nodules or pleural effusion, OR pericardial nodules or pericardial effusion.
M1b – Single tumor deposit in a single distant organ or to a non-regional lymph node.
M1c – Multiple tumor deposits in single or multiple distant organs.
Staging of Small Cell Lung Cancer (SCLC)
TNM staging discussed above also holds true for SCLC. But for practical treatment planning purposes, it may be broadly divided into LIMITED and EXTENSIVE disease.
Cancer is only on one side of the chest and might have spread to lymph nodes (including lymph nodes above the collarbone) on the same side.
Cancer has extensively spread throughout the lung, to other lung, lymph nodes on the other side of the chest, pleural membrane, distant lymph nodes, or distant organ.
Now, after discussing the staging, let’s discuss about the treatment of lung cancer.
What is the Treatment of Lung Cancer?
The treatment of lung cancer mainly depends on the histological subtype (small cell or non-small cell, and in NSCLC whether it is adenocarcinoma, squamous cell carcinoma, etc), presence of molecular abnormalities, lung function, performance status, etc.
Non-Small Cell Lung Cancer
Stage 0 (Tis N0 M0)
Surgery alone is the standard treatment for Stage 0 NSCLC. Other possible treatment option are brachytherapy, photodynamic therapy, etc.
Surgery is the mainstay of treatment for Stage I lung cancer. But assessment for operability is required by lung function tests and clinical assessment. In case of poor lung reserve or poor performance status, SBRT (Radiation Therapy) may be employed for treatment. Adjuvant chemotherapy may be added in some high-risk selected cases.
Surgery is uasually the preferred modality of treatment. But, as discussed above, in case of inoperability, chemotherapy with/without radiation therapy may be considered. Adjuvant chemotherapy is recommended in Stage II disease.
The treatment decision in Stage III NSCLC depends on many factors such as T stage, N stage, site and size of tumor, location and number of mediastinal nodes, operability of the patient, etc. After assessment of all such factors, a multimodality treatment with surgery, chemotherapy, and/or radiation therapy is planned.
Stage IV (Metastatic disease)
Most cases of metastatic disease are treated with a palliative intent. Treatment depends on the histological subtype (adenocarcinoma, squamous cell carcinoma, etc), presence of molecular abnormalities, site of metastasis, performance status, etc.
Chemotherapy, targeted therapy, and/or immunotherapy are the systemic treatment option in such cases. Also, other options like surgery, radiation therapy, etc may be considered in selected cases.
Small Cell Lung Cancer
Limited stage SCLC is preferably treated with chemotherapy and/or radiation therapy. Surgery may also be employed in selected cases.
Chemotherapy or Immunotherapy is the mainstay of treatment for extensive stage disease, and radiation therapy may be employed in selected cases.
Immunotherapy for Lung Cancer in Delhi
What are the different types of Immunotherapy for Lung Cancer treatment?
As described above, there are many different types of immunotherapeutic agents. These are used for advanced-stage NSCLC without epidermal growth factor receptor (EGFR) activating mutation, anaplastic lymphoma kinase (ALK) rearrangement, or ROS1 rearrangement. Following immunotherapeutic agents are approved for the treatment of advanced-stage non-small cell lung cancer (NSCLC):
First-line treatment of patients with and who express >/=50% PD-L1. For patients with PD-L1 expression <50% but >1%, it can be combined with chemotherapy for the first-line treatment. Subsequent treatment of patients with metastatic non-squamous or squamous NSCLC and PD-L1 expression levels of >/=1%.
Treatment of patients with advanced-stage metastatic squamous NSCLC and non-squamous NSCLC who have experienced disease progression on or after standard platinum-based chemotherapy (regardless of tumor PD-L1 protein expression).
Combined with chemotherapy with/without targeted therapy, atezolizumab can be given as first-line treatment of patients with metastatic non-squamous NSCLC. Subsequent treatment for patients with metastatic non-squamous or squamous NSCLC and PD-L1 expression levels of >/=1%.
It is recommended as consolidation treatment for patients who have not progressed after concurrent chemoradiation treatment for unresectable stage III NSCLC.
What are the advantages of Immunotherapy for Lung cancer Treatment?
Immunotherapy is the preferred treatment for the second-line treatment of advanced-stage NSCLC due to improved overall survival rate, longer duration of response, and fewer side-effects compared to standard chemotherapy. Immunotherapy can be combined with chemotherapy and targeted therapy for first-line treatment of advanced-stage disease with a better outcome. Based upon the durable response obtained from the immunotherapy, it is considered as the futuristic treatment for the advanced-stage lung cancer.
What are the disadvantages of Immunotherapy for Lung cancer Treatment?
Although the immunotherapy is considered safer compared to the standard chemotherapy, it can be associated with certain side-effects. Side effects of immunotherapy include fatigue, nausea, itching, skin rash, mouth sores, cough, high blood pressure, fluid build-up in legs, constipation, loss of appetite, joint pain, diarrhea, etc. Other less common severe side-effects include immunological reactions such as pneumonitis have also been reported.
What is the Cost of Immunotherapy for Lung Cancer in Delhi?
Immunotherapy is usually costlier than other modalities of treatment like surgery, chemotherapy and radiation therapy. The cost usually depends on the type of immunotherapy and for how long it is being given.
Targeted Therapy for Lung Cancer in Delhi
What is targeted therapy for lung cancer?
Lung cancer is a heterogeneous disease, that is, all individuals with the same cancer type do not contain the same mutations/alterations. Targeted anticancer therapy means treatment with specially designed drugs that produce their anticancer effect by selectively modifying a target (key to the growth of cancer cells). Examples of such targets include genetic or epigenetic alterations, chromosome/genetic rearrangements, cell-surface proteins/antigens, or certain molecular pathways in the cancer cells that promote growth and are responsible for disease progression. Targeted therapy helps in the selective destruction of cancer cells while sparing normal cells, which leads to a decrease in the overall side effects compared to standard chemotherapeutic drugs.
What Targeted therapies are available for the treatment of lung cancer?
Lung cancer is the leading causes of cancer-related deaths worldwide and is assessed to be the second most frequently diagnosed cancer in men and women. The following table list various targeted drug that has been approved for the treatment of NSCLC:
It is approved for the treatment of patients with unresectable, locally advanced, recurrent, or metastatic non-squamous NSCLC and without a recent history of hemoptysis. It can also be given along with chemotherapy for the treatment of patients with non-squamous NSCLC, and negative or unknown status of ALK/ROS1 rearrangements, sensitizing EGFR mutations, and PD-L1 expression <50%.
In combination with chemotherapy, it is approved for the treatment of patients with metastatic NSCLC whose disease has progressed on or after first-line platinum-based chemotherapy.
Gefitinib and Erlotinib
Both Gefitinib and erlotinib are approved as first-line therapy for patients with locally advanced, recurrent, or metastatic non-squamous NSCLC who have active sensitizing EGFR mutations.
It is an EGFR and HER2 inhibitor approved as the first-line therapy for patients with metastatic NSCLC who have active sensitizing EGFR mutations.
It is an EGFR and T790M inhibitor approved as the first-line therapy for patients with locally advanced or metastatic NSCLC who have sensitizing EGFR mutations. It is also approved as the subsequent therapy for patients with metastatic EGFR and T790M-positive NSCLC who have progressed on erlotinib, gefitinib, or afatinib.
It is an ALK and ROS1 inhibitor approved for the treatment of patients with locally advanced, metastatic, ALK and/or ROS1 rearrangement-positive NSCLC.
It is an ALK and ROS1 inhibitor approved for the treatment of patients with locally advanced, metastatic, ALK and/or ROS1 rearrangement-positive NSCLC who cannot tolerate crizotinib or have progressed on crizotinib treatment.
It is an ALK and MET inhibitor approved for the treatment of patients with locally advanced, metastatic, ALK rearrangement-positive NSCLC. It is also approved for the treatment of patients with metastatic, ALK-positive NSCLC who cannot tolerate crizotinib or have progressed on crizotinib treatment.
It is an ALK inhibitor approved for the treatment of patients with metastatic, ALK-positive NSCLC who cannot tolerate crizotinib or have progressed on crizotinib treatment.
Dabrafenib + trametinib combination is approved for the treatment of patients with metastatic, BRAF V600E positive NSCLC. Single-agent therapy with dabrafenib can also be given to patients with metastatic, BRAF V600E positive NSCLC who cannot tolerate the combination therapy.
Best Lung Cancer Specialist in Delhi
Dr Sunny Garg is a renowned Medical Oncologist in New Delhi with an experience of more than 6 years of treating lung cancer patients. He has practiced in leading cancer hospitals in Delhi, and currently practicing at Manipal Hospital, Dwarka.
He has a vest experience of treating lung cancer patients in all stages of disease. He is well versed with Immunotherapy, Targeted therapy, and Chemotherapy for Lung Cancer treatment and also general supportive care for such patients. He works in close collaboration with surgical and radiation oncologists, oncopathologists, nuclear medicine, and genetic counselors for comprehensive cancer care for the patients.
Call or watsapp +91 9686813020 for appointment.
Cost of Lung Cancer Treatment in Delhi
Treatment cost for lung cancer depends on many factors like stage of disease, type and number of treatment modalities that are being used for treatment, histopathology of the tumor, presence of molecular or genetic abnormalities, etc. For example, in localised and locally advanced lung cancer, cost of surgery, radiation therapy and/or chemotherapy is incurred depending upon the type and number of treatment modalities being used. In case of metastatic disease, cost of treatment depends on the treatment protocol being used, like number of chemotherapy drugs used, whether immunotherapy or targeted therapy is being used or not, other palliative modalities (like radiation,etc) being used, etc. So the cost of treatment will depend on the above and many other factors.
Best Hospital for Lung Cancer Treatment in Delhi
There are a multiple things to be considered while choosing a hospital for cancer treatment. Lung cancer is a morbid disease and treatment may continue for long, so adequate research must be done before selecting a hospital for cancer treatment.
You should enquire about the oncologist who will treat your case, about the tumor board facility, availability of radiation therapy (in case it is needed in your case), financial aspects of treatment, proximity of the hospital to your home, etc.