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What To Know About Stage 4 Non-Small Cell Lung Cancer
Stage 4 non-small cell lung cancer (NSCLC) is the most advanced form of the condition and can be challenging to treat. Treatments include chemotherapy, surgery, immunotherapy, and radiotherapy.
At stage 4, NSCLC is no longer isolated in one lung. It has spread to either your other lung or other organs and tissues elsewhere in your body.
Living with stage 4 NSCLC can feel scary. However, encouraging treatment developments are helping people live longer and enjoy a better quality of life.
A 2020 research review even states that new treatments are "turning lung cancer from an incurable disease into a chronic disease."
This article takes a closer look at stage 4 NSCLC, including symptoms, treatment, and outlook.
The symptoms of stage 4 NSCLC go beyond the coughing and congestion that come with earlier stages of NSCLC. It's often the severity of these symptoms that leads people to get a lung cancer screening.
The symptoms of stage 4 NSCLC include:
Metastatic cancer symptoms
If the cancer has metastasized, meaning it has spread to other parts of your body, you may have other symptoms. Some of them may include:
Moffitt Cancer Center specialists note that some symptoms may be more likely to develop based on where the cancer has spread. For example, headaches are more strongly associated with brain metastasis, while jaundice suggests liver metastasis.
The National Cancer Institute reports that 40% of new NSCLC diagnoses are already at stage 4.
If you have lung cancer symptoms or a history of smoking or exposure to airborne toxins, your doctor may recommend that you have some imaging tests to diagnose or rule out lung cancer.
The first test may be a simple chest X-ray, which could reveal a suspicious nodule or mass. For more precision and to find lesions that may be missed on an X-ray, a CT scan might be ordered instead of or in addition to a lung X-ray.
Lung function tests may also be performed after a diagnosis to determine whether your lungs can withstand the removal of cancerous tissue.
Bronchoscopy
If you are coughing up mucus, a lab test may reveal the presence of cancer cells. Your doctor may also perform a bronchoscopy. In this procedure, they insert a thin, flexible tube with a camera attached down your throat and into a lung.
This provides a close-up view of lung tissue and any abnormal masses or nodules. A bronchoscopy may also include a biopsy.
Lymph node testing
If your doctor suspects the cancer has traveled to your nearby lymph nodes or other parts of your body, further tests may be appropriate. These may include:
The treatment timeline for NSCLC can vary significantly based on the type of treatment you're receiving and how your body and the cancer respond to various treatments.
Chemotherapy
In stage 4 NSCLC, treatment is usually indefinite. Chemotherapy and immunotherapy can last longer than months.
Chemotherapy generally starts killing cancer cells and reducing tumor size within a few weeks, whereas immunotherapy takes longer, at least a couple of months.
Surgery
When NSCLC has reached stage 4, surgery to remove cancerous tissue may not be an option. This is because the cancer may have spread to multiple sites, including organs and bones, and it may be inoperable.
In some cases of stage 4A, when the cancer has spread to one other site, surgery may be an option. It may be combined with radiation therapy and chemotherapy.
Immunotherapy
Another treatment producing encouraging results in recent years is immunotherapy. This treatment involves the use of medications that help your immune system destroy cancer cells.
A 2020 review states that immunotherapy medications prove to be effective in treating people living with advanced NSCLC. Some medications include:
Radiotherapy
A 2018 review found that radiotherapy, when combined with immunotherapy and chemotherapy, may be especially helpful in repressing the tumor's growth and providing systemic control over the condition.
The outlook for people living with stage 4 NSCLC can be a hopeful one, particularly if your body and the cancer respond well to treatment. In fact, the National Cancer Institute reported in 2020 that NSCLC mortality rates are falling in the United States due to remarkable advances in treatment.
A cancer outlook is often presented as a 5-year relative survival rate. People with the same type of cancer at the same stage are compared with people in the larger population. For stage 4 NSCLC, the 5-year relative survival rate is about 9%.
While coping with stage 4 NSCLC is certainly a challenge, know that there are plenty of people living and maintaining a strong quality of life with the condition.
Living with NSCLC means more than treating symptoms and side effects — it also means handling the emotional weight of the condition. Managing the emotional aspect of a serious condition like NSCLC is important and shouldn't be ignored as you focus on the cancer treatment itself.
Some of the important steps you can take include:
The following organizations provide support and resources for people with stage 4 NSCLC as well as their families and caregivers:
Stage 4 NSCLC is the most advanced form of the condition and can be the most challenging to treat. That said, new treatments are available that can slow the progression of the disease and improve your quality of life.
Stage 4 NSCLC is the most advanced form of the condition and can be the most challenging to treat. That said, new treatments are available that can slow the progression of the disease and improve your quality of life.
What is the survival rate for stage 4 non-small cell lung cancer?According to the American Cancer Society, the 5-year relative survival rate for stage 4 NSCLC is 9%. This survival rate is based on people who received a diagnosis of NSCLC between 2012 and 2018.
It's worth noting that treatments for NSCLC have improved since then. In addition, survival rates are only estimates, and everyone responds to the disease and its treatments differently.
According to the American Cancer Society, the 5-year relative survival rate for stage 4 NSCLC is 9%. This survival rate is based on people who received a diagnosis of NSCLC between 2012 and 2018.
It's worth noting that treatments for NSCLC have improved since then. In addition, survival rates are only estimates, and everyone responds to the disease and its treatments differently.
How fast does non-small cell lung cancer grow?NSCLC may spread at different rates. The average time for a tumor to double in size is 7 months. However, this is different for everyone.
Factors that may influence the progression of NSCLC include the type of NSCLC, its stage at diagnosis, and how a person and the cancer respond to treatment.
NSCLC may spread at different rates. The average time for a tumor to double in size is 7 months. However, this is different for everyone.
Factors that may influence the progression of NSCLC include the type of NSCLC, its stage at diagnosis, and how a person and the cancer respond to treatment.
Do people ever beat stage 4 non-small cell lung cancer?While there is no cure for stage 4 NSCLC, some people may live for many years after receiving a diagnosis. Advances in treatments are helping people live longer and improving their quality of life.
While there is no cure for stage 4 NSCLC, some people may live for many years after receiving a diagnosis. Advances in treatments are helping people live longer and improving their quality of life.
Advancements in the treatment of stage 4 NSCLC are making it possible for people to live longer and enjoy more comfortable lives.
If you or someone you know has stage 4 NSCLC, the best thing you can do is become educated about the condition and treatment options. The more you know, the better you can discuss these topics with your doctors and make decisions about your care.
Stages Of Non-Small Cell Lung Cancer
Doctors stage non-small cell lung cancer (NSCLC) according to how far it has progressed. Stages range from occult (or hidden) cancer to stage 4 cancer, in which multiple organs may be affected.
Several different staging systems for non-small cell lung cancer (NSCLC) are used worldwide, but the most widely used approach is the TNM system.
A staging system helps doctors determine the best treatment plan and helps individuals with cancer and their families understand the severity of the disease and the outlook.
This article will examine the TNM stages of NSCLC and the cancer traits and grouping for each stage.
The TNM system for NSCLC staging considers the size and location of the tumor, as well as what other parts of the body are involved:
In addition to the TNM classifications, doctors use six stages to further describe the cancer. Stages 1 through 4 are divided into substages, as shown in this table:
At the occult stage, the main cancerous tumor can't be found (TX). Cancer cells might be found in phlegm or other lung fluid but not in other tests. The cancer isn't thought to have traveled to the lymph nodes (NO) or other parts of the body (MO).
In stage 0, the tumor is contained to the top layer of the airways and not deep into other lung tissue (Tis). The cancer also hasn't spread to the lymph nodes (NO) or other parts of the body (MO).
Doctors divide stage 1 NSCLC into four further classifications:
Stage 1A1
The characteristics of stage 1A1 are as follows:
Stage 1A2
In stage 1A2, the tumor is between 1 cm and 2 cm across and hasn't affected the bronchi or penetrated the visceral pleura (T1b), which covers the surface of each lung. It also hasn't reached the lymph nodes (NO) or distant body parts (MO).
Stage 1A3
In stage 1A3, the tumor is between 2 cm and 3 cm across and hasn't migrated to the visceral pleura or the main branches of the bronchi (T1c). The cancer still hasn't reached the lymph nodes (NO) or other parts of the body (MO).
Stage 1B
In stage 1B, the tumor hasn't reached the lymph nodes (NO) or other body parts (MO) but has at least one of the following traits (T2a):
Stage 2 is broken down into two classifications:
Stage 2A
At this stage, the cancer is still contained in the lungs and hasn't spread to nearby lymph nodes (NO) or distant body parts (MO). However, the tumor has at least one of the following characteristics (T2b):
Stage 2B
In this stage, the tumor is no bigger than 3 cm across but hasn't migrated to the visceral pleura or the branches of the bronchi (T1). It has, however, spread to the lymph nodes in or around the lungs on the same side as the tumor (N1) but not distant parts of the body (MO).
Or, the tumor has at least one of the following traits (T2):
In stage 2B, the cancer may also have reached the lymph nodes in or near the lungs on the same side as the tumor (N1) but hasn't spread to distant body parts (MO).
Or, the tumor hasn't reached the nearby lymph nodes (NO) or the distant body parts (MO) but has at least one of these following characteristics (T3):
Stage three has three classifications:
Stage 3A
Stage 3 NSCLC is considered an advanced stage of the disease. However, it's treatable in many cases, with positive outcomes still possible. This stage covers a wide range of paths the cancer may be taking.
Path 1
In this case, the tumor is no more than 3 cm across, doesn't touch the main branches of the bronchi (T1), and hasn't reached the visceral pleura. It has spread to the lymph nodes on the same side as a main tumor (N2) but hasn't extended to distant body parts (MO).
Or, the tumor has at least one of the following traits (T2):
Path 2
In this case, the cancer has reached the lymph nodes near the main tumor (N2) but hasn't spread to distant body parts (MO).
Or, the tumor has at least one of the following features (T3):
Path 3
In this path of NSCLC, the cancer has spread to the nearby lymph nodes on the same side as the main tumor (N1) but hasn't reached other body parts (MO).
Or, the tumor has at least one of the following traits (T4):
The cancer may have spread to the lymph nodes in or near the lungs. If that has occurred, the lymph nodes are on the same side as the main tumor (NO or N1). The cancer hasn't spread to distant body parts (MO).
Stage 3A groupingStage 3B
This stage can also mean many different paths for the NSCLC.
Path 1
One possibility is that the cancer is no more than 3 cm across, hasn't entered the visceral pleura, and doesn't affect the main branches of the bronchi (T1).
However, the cancer has reached the lymph nodes close to the collarbone on either side of the body and may have also spread to the lymph nodes near the lungs on the side opposite the main tumor (N3). The cancer hasn't spread to distant parts of the body (MO).
Or, the tumor has at least one of the following traits (T2):
Path 2
In this scenario, the cancer has reached the lymph nodes close to the collarbone on either side of the body or has spread to the lymph nodes in or near the lungs on the opposite side from the main tumor (N3). This cancer hasn't reached distant parts of the body (MO).
Or, the tumor has at least one of the following traits (T3):
Path 3
In this case, the cancer has reached the lymph nodes near the carina or in the mediastinum on the side of the main tumor (N2) but hasn't traveled to distant parts of the body (MO).
Or, the tumor has at least one of the following characteristics (T4):
Path 4
In the path 4 scenario, the cancer has made its way to the lymph nodes surrounding the carina or in the mediastinum on the same side as the main tumor (N2). However, the cancer has not spread to distant body parts (MO).
Stage 3B groupingStage 3C
At this stage, the tumor has at least one of the following features:
The cancer has also spread to the lymph nodes close to the collarbone on either side of the body and may have reached lymph nodes on either side of the body from the main tumor (N3). The cancer hasn't reached distant body parts (MO).
Other characteristics of this stage
In this stage, the tumor may also have at least one of the following characteristics (T4):
The cancer may also have spread to the lymph nodes close to the collarbone on either side of the body and may have reached lymph nodes on either side of the body from the main tumor (N3). The cancer hasn't reached distant body parts (MO).
Stage 4A
At stage 4, the tumor may be any size, and the cancer may have extended into nearby tissue (any T). Likewise, it may not have reached nearby lymph nodes (any N).
For M1a grouping, at least one of the following traits must be present:
Or, the tumor may be any size, and the cancer may have extended into nearby tissue (any T). It may also involve any of the nearby lymph nodes (any N).
In addition, it has spread as one tumor outside of the chest cavity to a distant lymph node or an organ, such as the brain or liver (M1b).
Stage 4B
At stage 4, the tumor may be any size, and the cancer may have extended into nearby tissue (any T). Likewise, it may have reached nearby lymph nodes (any N).
The cancer has also spread as at least two tumors outside the chest cavity to distant lymph nodes and other organs (M1c).
As precise as these stages and groupings may seem, health experts acknowledge that classifying the state of a particular NSCLC is imperfect.
One 2017 study found that, as NSCLC progresses, staging accuracy declines. The authors recommend that an individual's healthcare team reassess the status of the cancer after every surgery or test to build a consensus about the next phase of treatment.
How One Young Adult With Stage 4 Lung Cancer Is Beating The Odds
It was a hot, humid night in 2010 when Giancarlo Oviedo-Mori and his parents sat in a Bronx hospital and received the shock of their lives. They learned that he had advanced non-small cell lung cancer. He was only 18 years old and had big dreams. "Every South American kid wants to be a professional soccer player. I wanted to be the next Messi," remembers Giancarlo, who immigrated to the United States with his family from Peru when he was 8 years old.
"I had never seen my parents cry like that before. It really broke me," says Giancarlo, who has no family history of cancer and never smoked. "There was no logical reason why I got lung cancer, but I didn't question it. I just trusted God and had this peace that everything was going to be OK."
Fifteen years later, Giancarlo is now married and has a 2-year-old son as he continues to live with stage 4 metastatic lung cancer. Over the years, the cancer has remained persistent, but each time one treatment stopped working, there has been a new drug to try, thanks to clinical trials at Memorial Sloan Kettering Cancer Center (MSK) where he is now being treated.
The Difficulty of Diagnosing Lung Cancer in Young Non-SmokersLung cancer is rare in people under age 45. The average age of diagnosis is 70. It took six months of tests and treatments for a nagging cough that wouldn't go away for doctors to rule out asthma, cystic fibrosis, and other conditions that would be more likely to affect a young adult like Giancarlo.
"He's in the category of our younger patients who don't fit the historical profile of lung cancer diagnoses, which tend to be heavy smokers in their 70s," says thoracic medical oncologist Alexander Drilon, MD, Chief of the Early Drug Development Service at MSK.
Giancarlo with his family and care team at MSK. From left: Dr. Drilon, Amanda, Josiah, Giancarlo, and nurse practitioner Virginia Ferreira.
Experts have seen a rise in lung cancer rates among non-smokers. "It's something we should be paying attention to," says Dr. Drilon. "No one would have thought to screen a non-smoking teenager for lung cancer, but we need to be better at knowing what to do for screening in patients without traditional risk factors."
Maintaining Quality of Life During Lung Cancer TreatmentNo stranger to overcoming difficult circumstances, Giancarlo was a survivor and seemed poised to tackle this new challenge head on. He had already conquered the hurdles of moving to a new country, adapting to a new culture, learning a new language, and making new friends.
He had several cycles of chemotherapy at a local hospital, in 2010 and 2011, to reduce the lung cancer in his left lung. In 2012, he was referred to MSK, where he had his entire left lung removed.
"I didn't think you could live a good quality of life after getting a whole lung removed, but I was grateful that you can," says Giancarlo. "Just nine days after surgery, I was able to ride my bike to the park and play soccer. I finished college. By God's grace, I had good lung capacity, and I started thinking I could do a lot of great things."
Tackling Recurrent Lung CancerFour months after Giancarlo's surgery, his doctors discovered that a spot on his right lung — previously thought to be inflammation — had grown. A needle biopsy confirmed that it was a slow-growing cancer, which they monitored closely on active surveillance until 2013. That's when Giancarlo was introduced to new treatment options being studied in clinical trials.
Thoracic medical oncologist Alexander Drilon, MD, Chief of the Early Drug Development Service at MSK
He joined an immunotherapy trial at MSK in late 2014 and another trial studying a targeted therapy in 2015. Those treatments helped keep the cancer under control until doctors were able to analyze the genetics of his tumor using MSK-Impact®, a sophisticated blood test that searches for genetic mutations or changes in a person's cancer. The results are used to guide treatment choices and identify people who are candidates for clinical trials testing therapies that target the specific mutations driving the cancer.
"There's a higher likelihood of finding something actionable and targetable in lung cancers from younger patients like Giancarlo," says Dr. Drilon. In fact, when Giancarlo was tested in late 2015, the results showed that his cancer had a ROS1 fusion mutation, and there was a treatment available that could target it.
In 2016, Giancarlo began taking Crizotinib, the first ROS1 targeted therapy approved by the U.S. Food and Drug Administration (FDA). His willingness to try new treatments along the way allowed him to reap the benefits of these novel therapies.
Living a Full Life With Advanced Lung CancerNow 32 years old, Giancarlo has been surviving — and thriving — with advanced lung cancer since he was first diagnosed as a freshman in college. Despite the difficulties of having a chronic condition that demands ongoing monitoring and care, he has continued to lean on his deep-rooted Christian faith and a positive attitude, and has managed to accomplish just about everything he's set out to do, from graduating from college to getting married and starting a family.
Giancarlo's experience shows us the power of research and why it's so important to study new therapies," says Dr. Drilon. "He was able to access four options that he would never have had access to if clinical trials didn't exist."
"Life is short, regardless of cancer, so I don't let this chronic invisible disease define me," says Giancarlo.
His wife, Amanda, was inspired by Giancarlo's resolve to live life to the fullest from the time she met him through mutual friends in 2019. "He doesn't let cancer stop him from dreaming about what his future could look like," she says.
They married during the height of the pandemic and discussed the possibility of having children while he was on Crizotinib. Doctors said there was no data available to show if they could conceive — and if they did, whether the medication would impact the development of the baby. Nonetheless, they decided to try and had a healthy baby boy in 2023.
"We named our son Josiah because his name means 'God heals,'" notes Giancarlo. "Every time we say his name, it's a reminder to us of God's truth. That He heals, not just physically but emotionally."
Giancarlo, who works for a Christian organization that hosts events for international students, has also been able to travel while on treatment. He has gone on several business trips, and he and Amanda have visited her family in North Carolina. In 2024, he and his mother vacationed in their native Peru after being cleared by his doctors to take the trip.
"I make plans and set goals, but I'm realistic too," says Giancarlo, who lives with Amanda and Josiah in Union City, New Jersey, about an hour's drive to his appointments at MSK. "There have been moments of uncertainty, and it hasn't always been easy, but our faith has given us rest for our minds and our souls."
Clinical Trials Offer New OptionsGiancarlo was on Crizotinib for four years, until 2020, when imaging showed that the lung cancer had begun to grow once again. Radiation was added to his care plan and that kept it at bay until 2023, when tests confirmed that the cancer had developed a new mutation making it resistant to Crizotinib.
Amanda and Giancarlo were introduced by mutual friends in 2019 and married at the height of the pandemic.
But because MSK has one of the largest clinical trial programs in the country, there was a new targeted treatment option that Dr. Drilon and his team had been working on.
"We looked at our portfolio and saw that we had something that might hit the ROS1 target really well but also hit this resistance mutation that developed with prior ROS1 inhibitors," says Dr. Drilon. "We had a clinical trial open that allowed us to give him what is likely the best-in-class ROS1-inhibitor for his specific cancer."
The drug is called Zidesamtinib (NVL-520), and Giancarlo continues to do well on the treatment without experiencing serious side effects.
"Giancarlo's experience shows us the power of research and why it's so important to study new therapies," explains Dr. Drilon, noting that this is the fourth clinical trial that Giancarlo has participated in. "He was able to access four options that he would never have had access to if clinical trials didn't exist."
He encourages other providers to help patients consider both standard of care and investigational options throughout the course of their disease. "As Giancarlo's case demonstrates, it has bought him a lot more quality time with his wife and child," says Dr. Drilon. "And as research continues, new treatments are being developed all the time."
Beating the OddsGiancarlo credits Dr. Drilon and his care team at MSK for helping him to stay well, remain hopeful, and continue to have a good quality of life. He and Amanda treasure a photo of themselves with Dr. Drilon and MSK nurse practitioner Virginia Ferreira celebrating the first time they got a good report back from the Zidesamtinib trial.
"It's a picture we keep near and dear to our hearts because they are our partners," says Amanda. "I can't imagine all the work that's gone into these clinical trials, but it's made it possible for Giancarlo to become a husband and a dad, to work, and live a normal life. We're so grateful for the whole team there."
"Giancarlo has already well exceeded what we might expect from any patient with a metastatic lung cancer diagnosis," says Dr. Drilon. "There is hope that with access to new treatments being developed that he will continue to beat the odds."
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