Metastatic Lung Cancer: Symptoms, Diagnosis and Treatments - HealthCentral.com
If you or someone you love has been diagnosed with metastatic lung cancer, there's no doubt you're worried and have a ton of questions. We're ready to help by providing you with clear, concise information (that doesn't require a medical dictionary to decipher) on this challenging condition. Rest assured, we've poured over the latest research, share the most up-to-date stats, and rely upon some of the nation's leading lung cancer doctors to offer their wisdom here—so you can find answers to all your pressing concerns in one easy-to-navigate place. We've got your covered during this health journey, every step of the way.
Metastatic Lung Cancer
Frequently Asked Questions
What is the difference between metastatic lung cancer and advanced lung cancer?
There is no difference. After a diagnosis of MLC, you may hear your cancer called either term by your team of doctors.
Can metastatic lung cancer be cured?
In many cases, MLC cannot be cured, per se. But there are many effective treatments that can prolong your life while also improving your quality of life. And breakthroughs in science are happening at a rapid rate that are making these treatments even more powerfully effective.
Will I have to do chemo if I have metastatic lung cancer?
For both main types of metastatic lung cancer, chemotherapy may be on the table. It's a common treatment, and if your doctor does prescribe it, you'll likely receive four to six cycles of chemo, sometimes paired with other drugs.
What is immunotherapy for metastatic lung cancer?
Exciting breakthroughs have been made in immunotherapy for advanced lung cancers in recent years, which taps into the power of your own immune system to fight cancerous growths. Sometimes, immunotherapy is used in combination with chemo as a first-line treatment.
What Is Metastatic Lung Cancer?
Before we tackle what metastatic lung cancer (MLC) is, it's helpful to rewind a bit and cover what comes before it: regular lung cancer. Lung cancer, diagnosed in more than 235,000 Americans last year, develops when the DNA in a cell or cells in the lungs changes or mutates and starts to multiply and cluster together. That cluster of wonky cells then forms a tumor that grows. The chance of a man developing lung cancer is his lifetime is one in 15; for women, it's one in 17, according to the American Cancer Society.
What's the Difference Between Lung Cancer and Metastatic Lung Cancer?
What differentiates lung cancer from metastatic lung cancer is one simple thing: Metastatic lung cancer is lung cancer that has started to spread in very specific ways. In other words, cancer cells have broken off from the original lung cancer tumor and have begun to do any or all of the following:
Invade and destroy otherwise healthy lung tissue nearby (a.k.a, "locally advanced" MLC)
Travel through the bloodstream to other areas in the body
Move through the lymphatic system (which consists of bone marrow, lymph nodes, lymphatic vessels, spleen, and thymus) to distant parts of the body
Metastatic lung cancer is also known as advanced lung cancer. Roughly 51% of all lung cancers are metastatic upon diagnosis, and about two out of three people with small cell lung cancer (SCLC, more detail on this type in a moment) have extensive disease when their cancer is first detected. Your original diagnosis could be metastatic lung cancer, or your lung cancer may progress to metastatic lung cancer, even after lung cancer treatment.
Where in the Body Does Lung Cancer Ususally Metastasize?
While it's true that metastatic lung cancer can spread to virtually any part of the body, the most common hot spots where lung cancer gravitates to include the:
Once lung cancer cells arrive at their new destination, they keep on growing and multiplying. Eventually, they can cobble together to create yet another tumor. This is called a secondary tumor. The original tumor in the lungs? That's now called the primary tumor. No matter where the second tumor develops, the diagnosis remains as metastatic lung cancer. For instance, if the secondary tumor grows in the liver, the diagnosis does not morph from lung cancer to liver cancer. Instead, it's classified as lung cancer that's metastatic to the liver.
Spread, or metastasis, is typically a pretty stealth process, raising few if any red flags until tumors grow big enough to disturb nearby organs and cause recognizable symptoms. (More on what those symptoms are, below.) In fact, the majority of lung cancers are only detected after the original tumor has metastasized, notes research from the journal Cancer Metastasis Reviews.
Get the Basics (and So Much More) About Lung Cancer
What Are the Different Types of Lung Cancer That Can Become Metastatic?
Not only are there different types of lung cancer, there are different types of spread. But in order to understand when spread is actually diagnosed as metastatic, it's important to know how lung cancer tumors are categorized in the first place. They usually fall into one of two buckets:
Let's go over the basics of both:
Non-Small Cell Lung Cancer (NSCLC)
Up to 85% of all lung cancers are classified as NSCLC. These include cancers that are diagnosed as adenocarcinoma, squamous cell carcinoma, large cell carcinoma, and a few others that are considered super-rare.
Generally speaking, NSCLC grows and spreads more slowly than SCLC, which we'll detail next.
Now, here's the confusing (and somewhat complicated) part when it comes to what is, and what is not, considered to be metastasis: Your NSCLC tumor is given what's known as a "stage" based on its size, location, and the amount of spread. But, here's the thing: There are stages of NSCLC that technically DO have spread beyond the initial tumor yet are NOT categorized as metastatic lung cancer.
Some examples: Say you've been diagnosed with Stage IIB lung cancer. That means your cancer has migrated to your lymph nodes on the same side of your chest as the initial tumor and maybe to the airway into your lungs (called the main bronchus), or to the lung lining (called the pleura). It may seem counterintuitive (since the cancer has advanced beyond the original tumor), but this is NOT, in fact, classified as metastatic lung cancer. And, if you have Stage III lung cancer (meaning your cancer has spread to lymph nodes within the center of the chest), that's often referred to as locally advanced lung cancer, but again, is NOT metastatic lung cancer.
This is because in order to be diagnosed with metastatic NSCLC, there must be spread from the original tumor to more than one area in your other lung, or to the fluid surrounding the lung or the heart, OR to distant parts of the body through your bloodstream or lymphatic system (since cancer cells can travel to any part of the body in this way). Simply put: Metastatic non-small cell lung cancer is the same thing as Stage IV lung cancer (which is then further broken down into different types) and, again, is sometimes referred to as advanced lung cancer.
Small Cell Lung Cancer (SCLC)
This type of cancer is also sometimes called small cell carcinoma or oat cell cancer, and there's just one subtype here, dubbed combined small cell carcinoma. While SCLC can be staged with Roman numerals I through IV (just like NSCLC), that kind of classification is usually reserved for doc-to-doc discussions. When your doctor talks to you about it, whether it's regarding your treatment or simply to define your diagnosis, SCLC boils down to two types:
Limited stage. While limited stage SCLC may be detected in nearby lymph nodes, again, it's NOT metastatic lung cancer.
Extensive stage. However, ALL extensive stage SCLC cases ARE classified as metastatic lung cancer. Here, your lung cancer has spread to other areas of your lungs and chest and, perhaps, to the fluid surrounding your lungs (the pleura) or to other organs.
Symptoms of Metastatic Lung Cancer
The unsettling truth is this: The majority of lung cancers don't cause any telltale signs until they have spread. (There are very few nerve endings inside of the lungs, making early symptoms detection incredibly difficult.) Even then, not everyone experiences obvious or typical symptoms. Instead, some show signs of reduced appetite, unexplained weight loss, or fatigue—all associated with many other conditions, and not all of them serious—which can make it tough to connect the dots that lead back to your lungs.
That said, detectable symptoms can sometimes occur. When they do, they often cluster in the upper chest and include:
chest pain
chronic cough
shortness of breath
When clearer signs of metastatic lung cancer emerge, it's often because the lung cancer tumor has grown into a nearby structure, like, say, a rib, and starts hurting. Either that, or the lung cancer has spread to other organs. Those symptoms vary, depending on which organ is involved. For example:
If lung cancer has spread to the liver, you might experience:
constant feeling of fullness
jaundice, or the yellowing of the skin
swollen abdomen
If lung cancer has spread to the adrenal glands, you might experience:
abdominal pain
low blood pressure / low blood sugar, which are signs of Addison's disease, which occurs when both adrenal glands are impacted
pain in the mid-back area
If lung cancer has spread to the bones, you might experience:
fractures
pain in pelvic bone, upper arm bones, and the spine, where spread is most common
radiating pain in legs or arms if spinal metastases compress a nerve
If lung cancer has spread to the brain, you might experience:
balance problems
blurred vision
headaches
memory issues
seizures
How Do Doctors Diagnose Metastatic Lung Cancer?
It's important to understand that there is no single, simple test to check for metastatic lung cancer. But there are many diagnostic tools to help doctors discern whether or not your lung cancer has spread.
Chest X-Ray
The American Cancer Society reports that a chest X-ray is often the first test physicians use when looking for lung cancer. While that may seem like a logical move, a 2019 report in The British Journal of General Practice, noted that chest X-rays only pick up 77% to 80% of symptomatic lung cancers. Meaning, about one in five are missed, and that a negative chest X-ray doesn't necessarily mean you're free and clear.
So, this begs the question: What is the best way to diagnose metastatic lung cancer? Here are some other exams your doctor may order:
Low-Dose Computed Tomography (LDCT) Scan
If you're between 50 and 80 years old and have an elevated risk for lung cancer (note: a history of heavy smoking heavily factors into your risk assessment), the very best way to detect disease is before it spreads with an annual low-dose computed tomography (LDCT) scan. This type of scan is sort of like a an X-ray, but instead of one picture, an LDCT takes many highly detailed, cross-sectional images of the body. A large 2021 study in JAMA showed that this type of screening reduced lung cancer mortality in high-risk folks by up to 20%. If you're not getting screened annually, docs can (and should) still use LDCT or CT scans (or another imaging scan) to help detect any signs of lung cancer or spread.
Position Emission Tomography (PET) Scan
Another imaging test is a PET scan, where radioactive material is injected into the bloodstream, clumping around any growths, making them visible on a scan.
Magnetic Resonance Imaging (MRI)
And MRI scan uses radio waves and strong magnets to create detailed images of soft tissues, in this case, in and around your lungs.
Bone Scan
Your doctor may order a bone scan (even if you don't report experiencing any bone pain), since the skeletal system is a common target of metastatic lung cancer. This nuclear imaging test relies on radioactive tracers to produce a series of images that highlight any areas in the body where cancer cells might be clustering in your bones. That said, this test isn't utilized that often since PET scans can often show if lung cancer has spread to the bones.
Ultrasound
This imaging tool uses sound waves to create images, in this case in and around your lungs, depending on where you may be experiencing symptoms.
Fine-Needle Aspiration (FNA) Biopsy
While imaging tests can absolutely detect tumors, an official diagnosis of MLC can only be made after your doctor examines tissues or fluid taken from your lungs (or sometimes from MLC tumors that have traveled to other parts of your body, like, for example, the liver). There are several different ways to gain a lung cancer sample, including via a fine-needle aspiration biopsy. This simple, safe, outpatient procedure takes about 30 minutes and typically uses a thin needle to extract tissue from the lung (or from a MLC tumor that has grown elsewhere).
Sputum Test
For this test, your doctor gains a sample of lung fluid by asking you to cough up mucus (sputum, a.k.a., phlegm) that'll be examined under a microscope for cancer cells. If cancer cells are detected, you'll undergo even more testing to help determine what type of lung cancer you have and which treatment options are right for you.
Additional Testing for Metastatic Lung Cancer
If your doctor suspects that the lung cancer has spread to the liver, blood chemistry tests will be ordered, too. Here, the doc is looking for elevated liver enzymes such as alanine transaminase (ALT) and aspartate transaminase (AST).
If you've been diagnosed with metastatic NSCLC, that means that you'll also need to undergo further genetic and protein testing to find out if you may benefit from targeted therapy and/or immunotherapy. (More on these treatments in just a bit.) Important note: Even though current guidelines clearly state that this type of testing should be conducted at your initial diagnosis, in real life, that's just not happening at rates it should—often resulting in delayed or inappropriate treatment, notes a 2019 report in the journal Translational Lung Cancer Research. While this is unwelcome news for all with advanced lung cancer, know this: Research shows that Black individuals are the least likely group to be treated with immunotherapy when compared to other lung cancer patients—regardless of insurance status. So please: If your care team does not bring up immunotherapy as an option, please request genetic (or mutation) and protein testing: The results can help determine proper treatment—and it's your absolute right to have it.
Metastatic Lung Cancer Treatment
The overall treatment goal for any metastatic lung cancer is the same: Good tumor control and good quality of life. While there are bright pockets of hope emerging with treatment outcomes in recent years, a cure is not always a realistic goal for some cases of metastatic lung cancer. That does not mean treatment advances aren't real, or that specific treatment regimens are not worth perusing. Not at all! If you're otherwise in good health, proper treatment may help relieve symptoms and help you live longer.
Here is the latest on treatments for advanced lung cancer:
Treatments for Metastatic Non-Small Cell Lung Cancer
Before you and your care team settle on treatment options, your overall health and lung function has to be factored in. Are you a smoker? If yes, before embarking on treatment do everything in your power to quit smoking or vaping. Smoking is the #1 cause of lung cancer, according to the Centers for Disease Control and Prevention (CDC). So, pursue treatments, absolutely—and do everything in your power not to work against them by continuing to inhale all those carcinogens into your lungs. Research shows that most folks who stub out the habit after a lung cancer diagnosis have better outcomes than those who don't.
Once your health assessment is completed, your doctor may prescribe:
Targeted therapy. This range of medications attacks cancer cells that have specific gene mutations. As noted earlier, your tumors definitely need to be checked for genetic mutations (including errors or changes in your DNA), which will guide which medications are used. If a mutation in any of these genes are detected—EGFR, ALK, ROS1, BRAF, RET, MET, or NTRK—your first treatment will most likely be a targeted therapy drug. (And they're all very different, depending on the specific mutation.) Targeted drugs work differently from standard chemotherapy drugs, according to cancer.org. They can sometimes be effective when chemo drugs aren't, and they can have different side effects, too. Targeted drugs are sometimes used along with chemotherapy.
Chemotherapy. If you don't have one of those mutations, your physician will most likely offer a platinum-containing chemotherapy and another chemotherapy at the start of treatment. After four to six rounds, you'll usually begin what's dubbed maintenance therapy, which aims to continue disease control, but with less toxicity than the combo chemo. This phase of treatment usually consists of just one chemotherapy med (or immunotherapy—see the very next listing) given every three weeks.
Immunotherapy. This is a treatment that uses certain parts of your own immune system to fight lung cancer. If your lung cancer tumors have higher levels of something called the PD-L1 protein, you may be treated with immunotherapy drugs by themselves or in combo with chemotherapy. These meds include:
Keytruda (pembrolizumab)
Libtayo (cemiplimab)
Opdivo (nivolumab)
Tecentriq (atezolizumab)
Yervoy (ipilimumab)
Radiation. If your NSCLC is limited to your lungs and has only spread to one other site, like the brain, radiation therapy may be used to target the area of spread. Radiation would then be followed by treatment of the cancer in the lung.
Surgery. If your lung cancer has spread to the brain, but there's no other spread, surgery may be in the cards. While there are some studies examining whether surgical treatment for other single-site metastatic NSCLC is worth it, right now, the standard of care currently does not include surgery for stage IV disease, other than for those patients with brain metastasis.
Palliative care. This is also called supportive care, which aims to improve quality-of-life. Radiation can be used for this purpose, lessening symptoms like shortness of breath or pain, depending on where cancer has spread. There are also procedures to drain fluid from outside the lungs and from around the heart, as well as laser therapy or stents to open up airways.
Treatments for Metastatic (or Extensive Stage) Small Cell Lung Cancer
Here, your cancer has spread too far for surgery to be considered effective as a first-line treatment. Instead, if you're otherwise in pretty good health, these are your options:
Chemotherapy. You'll likely receive four to six cycles (or rounds) of platinum-based chemotherapy with another agent, usually with the drug Toposar or Vepesid (etoposide).
Immunotherapy. Immunotherapy drugs, including Imfinzi (durvalumab) or Tecentriq (atezolizumab), are used along with chemotherapy as a first-line treatment or solo as a maintenance therapy.
Radiation. If your lung cancer responds well to your first treatment, radiation (which uses high-energy beams to destroy cancer calls directed to the chest or brain) may be an option, as well. For some, this approach has been shown to help prolong life.
Palliative care. Radiation may be used to ease shortness of breath or pain. Something a stent, laser therapy, or something called photodynamic therapy can also help open up blocked airways. Other procedures can remove fluid that has built up outside the lungs or the heart.
All people with metastatic lung cancer should also consider enrolling in a clinical trial. You may think, No way! I'm not going to risk getting a placebo! But let's set the record straight: When it comes to MLC, there are no placebos in clinical trials. You'll either be given the proven standard treatment or a newer, promising, perhaps breakthrough treatment for your disease. Of course, not all people with metastatic lung cancer will qualify for a study. For instance, if you have other medical issues on top of lung cancer, you likely won't be a top candidate. And not all people with metastatic lung cancer are interested, and that's OK, too.
Metastatic Lung Cancer Prognosis
Metastatic lung cancer is very serious. Treatments can help relieve symptoms and improve quality of life, but right now, the five-year survival rate for lung cancer that has spread to other organs sits at just 6%. Still, these impersonal stats don't account for things like your age and overall health, subtypes of NSCLC, gene changes, and how well your cancer has responded to treatment. And, remember this: You are not a number! So, yes, these stats aren't great, but treatments have improved exponentially over the last 10 years—and they just keep improving. Which is good news.
How Do I Live and Cope With Metastatic Lung Cancer?
Receiving a diagnosis of metastatic lung cancer can change all aspects of your life, which means you really need to take care of your whole self. We're talking about the physical and the emotional. But you don't have to do it all on your own. Friends, family, physicians, nurses, therapists, fellow lung cancer warriors—all of these folks can be a source of solace, support, and knowledge. Allow them to help. Ask for what you need. And if you don't know what that is just yet, that's okay.
Organizations like CancerCare can help you with things like finding a counselor, support group, even financial assistance. The American Lung Association can help you prep for each doctor visit with their downloadable worksheets and videos. And over here at HealthCentral you can find a slew of cancer communities that, hopefully, really strike a chord with you. There are podcasters, Instagrammers, bloggers, and networks of people going through what you're going through and they're ready to share. And no matter what, always remember: You are not alone.
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Holly Pevzner
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