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Discussed in this section is traditional, or standard, Treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. Chemotherapy is a treatment that uses drugs to stop the growth and division of tumor cells. While each patient responds differently to chemotherapy drugs, chemotherapy treatment can shrink lung cancer tumors, alleviate lung cancer symptoms, and extend life.1 Chemotherapy can be used at all The extent of cancer in the body of lung cancer and for both A group of lung cancers that are named for the kinds of cells found in the cancer and how the cells look under a microscope and An aggressive (fast-growing) cancer that forms in tissues of the lung and can spread to other parts of the body. The cells look small and oval-shaped when looked at under a microscope..
Chemotherapy has been used as a cancer treatment for many years and remains important despite the addition in recent years of newer types of drug treatment—A type of treatment that uses drugs to identify and attack specific types of cancer cells with less harm to normal cells, Drugs given during cancer treatment to prevent the growth of new blood vessels that tumors need to grow, and A type of therapy that uses substances to stimulate or suppress the immune system to help the body fight cancer, infection, and other diseases—that attack cancer in a different way. Chemotherapy may be used as a single drug or in combination with other chemotherapy drugs, in combination with some of the newer treatments, and with surgery and The use of high-energy radiation from X-rays, gamma rays, neutrons, protons, and other sources to kill cancer cells and shrink tumors to make them more effective.1 Your healthcare team will help to select the best treatment based on your medical history, your overall health and any other medical problems, the stage of your lung cancer, and your preferences.
How does chemotherapy work?
Our bodies are composed of trillions of individual cells, the "building blocks" of life. These cells—of which there are many types serving different functions in the body—have a natural life cycle. Cells that die or are old or damaged are replaced by new cells, through a process by which a living cell duplicates its contents and then divides to form two identical cells. Specifically, within each cell is the The central part of most cells that contains genetic material and is enclosed in a membrane, which is comparable to the "brain" of the cell. The nucleus contains Part of a cell that contains genetic information (DNA), which are made up of Coded instructions within a cell that control how the cell grows in a systematic and precsie way. Genes contain DNA.. Genes, in turn, are made up of The molecules inside cells that carry genetic information and pass it from one generation to the next. Also called deoxyribonucleic acid., the instructions within a cell that control how the cell grows in a systematic and precise way. Once a cell copies its gene, it divides, forming two new cells, each with its own complete set of genes.2
Healthy, normal cells grow and divide in an orderly manner, per the instructions encoded in the genes, to replace dead, old, or damaged cells.
When a gene has an alteration in its DNA code of instructions, it is said to be "mutated." Any change in the DNA or gene sequence of a cell. Certain mutations may lead to cancer. occur often, and normally the body can correct them. The correction method is similar to a "spell check" function on a computer or cell phone. However, sometimes the "spell check" function does not work as it should, and the DNA mutation may become part of the cell's blueprint. Over time, an accumulation of mutations can cause cells to lose the capacity to grow and divide in an orderly manner. Out-of-control growth may occur instead, which can lead to the formation of a tumor.3
Chemotherapy drugs work by damaging the DNA inside the nucelus of rapidly gowing cells or by keeping the cells from dividing and growing. This may happen either when a cancer cell is making copies of its gene or when the cancer cell is about to divide.2
How chemotherapy drugs differ from targeted therapy and immunotherapy drugs
Chemotherapy drugs are most often used systemically; that is, they travel throughout the whole body (the system) via the bloodsteam to reach and attack cancer cells wherever they may be. However, chemotherapy attacks not just fast-growing cancer cells but also fast-growing healthy cells. Targeted therapy drugs, each of which is intended to treat cancer that has a particular mutation, are aimed at specific A group of molecules in a cell that work together to control one or more cell functions that cancer cells use to thrive, blocking them in the same way that blocking a car's fuel line would keep it from running properly. Targeted therapies are more precise than chemotherapy drugs, which may make them more effective. However, not all cancers have a mutation that has a matching targeted therapy.
How is chemotherapy administered?
Chemotherapy can be administered systemically in many ways, including orally, Through a needle or tube inserted into a vein, Beneath the skin, and Within a muscle. To treat lung cancer, chemotherapy drugs are usually given intavenously—through a needle or tube inserted into a vein.6
Sometimes a A device used to deliver the chemotherapy drug. It is placed under the skin, usually in the chest, and attached to a catheter that is guided into a large vein, the superior vena cava, above the right side of the heart. may be placed under the skin. The chemoport may stay for a few weeks to months and helps in the administration of the chemotherapy drug while avoiding multiple needle pricks.7
The way the chemotherapy is given depends on the type and stage of the cancer being treated. Most often, chemotherapy is given systemically; this process is described here.
Chemotherapy may be given one drug at a time or as a combination of different drugs at the same time. Usually chemotherapy is given in cycles. A typical cycle consists of a period of treatment of 1 to 3 days, followed by a break before the next treatment is given so that a patient can rest and allow the body time to recover. A chemotherapy cycle generally lasts 3 to 4 weeks and continues over a period of months. Sometimes chemotherapies are planned for a specific number of cycles, typically 4-6 cycles. In other situations, chemotherapy is planned to be continual—on an ongoing basis as long as it is tolerated and controlling the cancer.8,9
The number of treatments within a cycle, the length of a cycle, and the number of cycles to be given may vary based on the type and stage of lung cancer and the drug(s) being given. It is always a good idea for you to check with your healthcare team to understand your treatment plans, including:
- What drugs are being used
- The drug schedule
- The length of a cycle
- How many cycles are planned
- What to expect between cycles
Preparing for chemotherapy treatment
- Having a surgcal procedure to insert a device, such as a chemoport, into a vein if your chemotherapy will be administered intravenously. The advantage of this is that a vein wil not need to be found at each chemotherapy session
- Going to your dentist to make certain that there is no existing infection that could complicate your treatment and having any necessary dental work done prior to starting treatment
- Planning ahead for possible side effects. Side effects and how to alleviate them will be discussed further along in this section
- Arranging for transportation and help around the house. You may or may not need the help, but it is not possible to predict before your treatment begins
- Getting a checklist from your healthcare team about what to expect before, during, and after chemotherapy
Goals of lung cancer chemotherapy
The goals of lung cancer chemotherapy depend on the type of lung cancer being treated, the stage of the lung cancer, and whether other types of treatment will be given. Some possible goals of chemotherapy are:
- To eliminate all of the cancer cells and to prevent recurrence after surgery or some other type of treatment
- To decrease the size of tumors for easier and safer removal by surgery
- To control the lung cancer by stopping it from growing and spreading
- To help make other cancer-killing treatments, such as radiation therapy, more effective
- To relieve symptoms caused by the cancer and to slow its growth when the lung cancer is at an advanced stage. This type of treatment is called Care given to improve the quality of life of patients who have a serious or life-threatening disease1,13
Commonly used chemotherapy drugs
|Generic (chemical) name||Brand Name (sold as)|
When combination chemotherapy is used (because the drugs work in different ways and may be more effective together), usually it is the drugs made with platinum—carboplatin (Paraplatin®) and cisplatin (Platinol-AQ®)—that are used with another drug.14
Commonly used chemotherapy drugs to treat SCLC include:17
|Generic (chemical) name||Brand Name (sold as)|
Combination chemotherapy is usually the main treatment for patients with SCLC as the first round of chemotherapy. As with NSCLC, the combinations are most oten a platinum-based drug (carboplatin [Paraplatin®] or cisplatin [Platinol-AQ®]) that is combined with another drug; cisplatin (Platinol-AQ®) and etoposide (Etopophos®) is most often the first combination chemotherapy used.17
When is chemotherapy given for lung cancer?
Chemotherapy is among the treatment options, but never the only option, at all stages of both NSCLC and SCLC. Note that treatment options develop over time; your healthcare team may suggest other options that are not outlined below.
When given along with other treatments, the chemotherapy is referred to as advjuvant, neoadjuvant, or concurrent.
- Adjuvant chemotherapy: After surgery or radiation therapy, there may still be some microscopic cancer cells left behind that cannot be seen on regular Procedure that uses a computer linked to an X-ray machine to make a series of detailed pictures of areas inside the body. When chemotherapy is given to kill those microscopic cancer cells, it is called adjuvant chemotherapy.
- Neoadjuvant chemotherapy: Chemotherapy may be given before surgery to shrink the cancer and make it easier to remove with surgery, in addition to killing cancer cells that cannot be seen on regular CT scans. This is called neoadjuvant chemotherapy. Sometimes neoadjuvant chemotherapy is given along with radiation therapy.
- Concurrent chemotherapy: When chemotherapy is given at the same time as radiation therapy, it is called concurrent chemotherapy, or sometimes concurrent chemoradiotherapy. Concurrent treatment may be given as the only planned therapy or it may be given in the neoadjuvant setting before a planned surgery.14,17
Treatment options for non-small cell lung cancer (NSCLC), by stage
In NSCLC, chemotherapy may be used as the main treatment, but it is also frequently given along with other treatments.
Stage 1 and stage II NSCLC: Your healthcare team may recommend adding chemotherapy to your surgical treatment plan. Chemotherapy may be given as neoadjuvant chemotherapy to reduce the size of the tumor or as adjuvant chemotherapy to reduce the risk of the cancer coming back.14,18,19
Stage III NSCLC: Chemotherapy is almost always used in stage III treatment, either alone or in combination with external beam radiation therapy (EBRT), a type of radiation therapy.14,19,20 The immunotherapy drug durvalumab (Imfinzi®) may also be administered to those stage III patients whose cancer cannot be removed by surgery and has not progressed following concurrent platinum-based chemotherapy and radiation therapy.20
Stage IV NSCLC: Treatment of stage IV NSCLC patients depends on the performance status of a patient and whether their cancer has a A change in the DNA of a gene that leads to the development or progression of a tumor (as determined by Analyzing DNA to look for a gene mutation that may indicate an increased risk for developing a specific disease or disorder). Your healthcare team will use one of several scales, such as the Eastern Cooperative Oncology Group (ECOG) Performance Scale, to measure your general health to help determine treatments that may be the best for you.21,22
Some patients' performance scores improve after treatment, making them eligible for additional treatments.
- For patients whose cancers do not have a biomarker for which a targeted therapy exists and who have the best performance scores, 0 or 1, platinum-based chemotherapy alone (e.g., cisplatin [Platinol-AQ®] or carboplatin [Paraplatin®]); chemotherapy in combination with bevacizumab (Avastin®), an anti-angiogenic treatment; pembrolizumab (Keytruda®), an immunotherapy drug, in combination with chemotherapy (specifically, pemetrexed [Alimta®] and carboplatin [Paraplatin®]); or atezolizumab (Tecentriq®), an immunotherapy drug, in combination with chemotherapy and bevacizumab (Avastin®), may be recommended.
- For patients with a performance score of 2, chemotherapy may be recommended.
- For patients with a performance score of 3 or 4, palliatve care may be recommended.
Depending on your health and response, your healthcare team will make recommendations for Treatment that is given to help keep cancer from coming back after it has disappeared following the initial therapy or Treatment that is given when initial treatment (first-line therapy) doesn't work or stops working or further therapy.
Maintenance treatments may include the same or other chemotherapies or simply a "watch and wait" approach. The goal of maintenance therapy is to help keep the cancer from growing again. Generally, a patient is kept on maintenance therapy as long as the cancer stays controlled.17
Second-line or further treatments may include immunotherapy drugs and other chemotherapies (including a combination of ramucirumab [Cyramza®], a [qtip:vascular endothelial growth factor receptor2 (VEGFR2)] inhibitor|A substance that blocks an enzyme needed to form blood vessels] with docetaxel [Taxotere®]) for patients with performance scores of 2 or lower, and palliative care for patients with performance scores of 3 or 4.14,15,16
Treatment options for patients with stage IV NSCLC whose tumors have high Programmed death ligand 1—part of the immune system mechanism that keeps T cells from functioning expression (The percentage of cancer cells that produce the PD-L1 proteins ≥ 50%) with no Epidermal growth factor receptor—the protein found on the surface of some cells and to which epidermal growth factor binds, causing the cells to divide. It is found at abnormally high levels on the surface of many types of cancer cells, so these cells may divide excessively. or Anaplastic lymphona kinase—A gene that the body normally produces but, when it fuses with another gene, produces an abnormal protein that leads to cancer cell growth mutations may include the immunotherapy drug pembrolizumab (Keytruda®) for The first therapy given for a disease. For patients who cannot receive pembrolizumab (Keytruda®), platinum-based chemotherapy may be an alternative.14,15,16
Treatment options for patients with stage IV A type of NSCLC that usually starts near a central bronchus in squamous cells, which are thin, flat cells that look like fish scales as determined by performance status include:14
- For patients whose performance score is 0 or 1, platinum-based chemotherapy alone or in combination with pembrolizumab (Keytruda®), an immunotherapy drug, is an option.
- For patients whose performance score is 2, chemotherapy is an option.
- For patients whose performance score is 3 or 4, palliative care is an option.
- For maintenance therapy, chemotherapy is an option, as is a "watch and wait" approach.
Treatment options for SCLC, by stage
In small cell lung cancer (SCLC), for which there are fewer treatment options than in NSCLC, chemotherapy is usally the main treatment for two reasons:
- SCLC responds initially very well to chemotherapy
- SCLC may spread quickly beyond the lungs. Chemotherapy is the best option to initially treat cancer that has spread, so it is given in almost all SCLC cases, even if there is no sign of spread on CT scans.17
If you have SCLC found in one lung, the tissues between the lungs, and nearby lymph nodes only, your healthcare team may recommend 4 to 6 cycles of a platinum compound (such as carboplatin [Paraplatin®] or cisplatin [Platinol-AQ®]) and etoposide (Etopophos®), along with Radiation therapy to the head to reduce the risk that cancer will spread to the brain and concurrent radiation.17
The current standard of care for first-line treatment of SCLC that has spead outside the lung in which it began or to other parts of the body includes a platinum compound (such as carboplatin [Paraplatin®] or cisplatin [Platinol-AQ®]) and etoposide (Etopophos®). A recent A type of research study that tests how well new medical approaches work in people has shown that the addition of an immunotherapy drug, atezolizumab (Tecentriq®), may be more effective than chemotherapy alone. Your healthcare team may decide to add an immunotherapy drug depending on your health status. SCLC patients tend to have a good initial response to chemotherapy, but the disease inevitably recurs (comes back) because resistance to the treatment develops.2,3
When the cancer recurs, a single chemotherapy, such as topotecan (Hycamtin®) or paclitaxel (Taxol®) or Onxol®), is often used. Another option is the immunotherapy drug nivolumab (Opdivo®), which is approved for patients with extensive-stage SCLC whose cancer has progressed after treatment with a platinum-based chemotherapy and at least one other line of therapy.17.24
Why there are side effects from chemotherapy drugs
Chemotherapy drugs kill rapidly dividing cells and cannot tell the difference between rapidly growing cancer cells and healthy, normal cells that also divide rapidly. Most healthy, normal cells do not divide rapidly. Those that do include hair cells, blood cells (A type of blood cell that carries oxygen from the lungs to all parts of the body, A type of blood cell responsible for blood clotting, and A type of blood cell that helps the body fight infection and other diseases), and the cells lining the mouth and intestines. When chemotherapy attacks these healthy, normal cells, it can cause side effects. However, normal cells can repair the damage or be replaced by other healthy cells, which is why side effects are usually temporary.8,14
Common side effects of lung cancer chemotherapy
The most common side effects of chemotherapy in both NSCLC and SCLC are:25
Note: Each chemotherapy drug has a different set of most common side effects. Likewise, each person differs in their response to chemotherapy. Just because a side effect is possible doesn’t mean that you will experience it.
- Easy bruising or bleeding: Due to a low number of blood platelets (thrombocytopenia)
- Hair loss
- Increased risk of infection: Due to a low number of white blood cells (neutropenia)
- Loss of appetite or change in taste buds
- Mouth and throat sores
- Nausea, vomiting
- Peripheral neuropathy: A nerve problem that causes pain, burning or tingling sensations, sensitivity to cold or heat, or weakness, mainly in the hands and feet
While most of the side effects of chemotherapy stop after treatment, some side effects may continue, recur, or develop later. Among the serious long-term effects may be heart disease, another type of cancer, low levels of thyroid hormones, fertility issues, and Relating to conscious intellectual activity, such as thinking, reasoning, or remembering problems. These can occur even years after treatment is completed. For that reason, it is essential if you receive chemotherapy that you are followed up throughout your life by a healthcare team that is aware of the potential side effects of treatment.14,25
Managing the side effects of lung cancer chemotherapy
When I was told I had cancer, one of the first images that popped into my head was of me being bald and frail from chemo. So one of the biggest lessons for me has been that the chemo with which I was treated doesn't cause the side effects I had come to associate with cancer treatment.
—C.K., survivor with NSCLC
It is important to discuss each chemotherapy drug with your healthcare team to be prepared for potential side effects and to understand what can be done to treat them. The healthcare team can often prescribe drugs or make recommendations about other ways to help relieve and/or prevent many of these side effects. Be sure to communicate with the healthcare team if and when new side effects begin, as treating them early on is often more effective than trying to treat them once they have already become severe. Sometimes the doses of the chemotherapy drugs may need to be lowered or treatment may need to be delayed to prevent the side effects from being worse.
Some specific ways in which the common side effects of chemotherapy drugs are sometimes managed are listed below; this list is by no means comprehensive. Again, discuss side effects with your healthcare team to determine the best approaches to managing them given your particular situation.
- Constipation: Stool softeners, laxatives26
- Diarrhea: Ani-diarrheal medications27
- Easy bruising or bleeding: Lower chemotherapy dose; longer time between chemotherapy cycle; drug that prevents lower platelet counts28
- Fatigue: If fatigue is related to derpession, antidepressant medications; lower chemotherapy dose; longer time beteween chemotherapy cycles29
- Hair loss: Wearing a cap or head covering with cold packs before, during, or after chemotherapy to help prevent hair loss. The cold narrows the blood vessels in the skin on the head, which means that less of the drug reaches the hair follicles, the small openings on the scalp through which hair grows; medications; emotional support; A wig custom-made after hair loss from a condition or a treatment, such as chemotherapy30
- Increased rate of infection: Preventive antibiotics; washing hands well; using lotion to keep skin from cracking; avoiding people with contagious illness; take filgrastim (Neupogen®), a medication that increases the number of infection-fighting cells in the body31
- Loss of appetite: Appetite stimulants and nutritional supplements can be given to improve appetite and reduce weight loss.32,33
- Mouth and throat sores: Rinsing/gargling with a solution of salt water and baking soda; avoidance of foods that are spicy, salty, or acidic34
- Nausea, vomtiing: Medications, including both preventive and therapeutic: IV fluids, behavioral therapy35
- Peripheral neuropathy: Physical therapy or complementary therapies (such as massage and acupuncture); medications (for neuropathic pain), including anticonvulsants and antidepressants; over-the-counter pain medications for mild pain; prescription A class of drugs that reduce pain, fever, and inflammation for severe pain; diet rich in B1 and B12, folic acid, and A substance that protects cells from the damage caused by free radicals, unstable molecules made by the process of oxidation during normal metabolism36
What clinical trial options are available?
If you are considering participating in a clinical trial, start by asking your healthcare team whether there is one that might be a good match for you in your geographic area. In addition, here are several resources to help you find one that may be a good match:
- LUNGevity Clinical Trial Finder: https://clinicaltrials.lungevity.org/
- EmergingMed: 877-769-4834, https://app.emergingmed.com/lcctal/home
- National Cancer Institute website: www.cancer.gov/clinicaltrials/search
- My Cancer Genome: www.mycancergenome.org/
- Lung Cancer Mutation Consortium (LCMC): www.golcmc.com/
Learn more about clinical trials here.
- Why do I need chemotherapy?
- What are the advantages and disadvantages of chemotherapy for me?
- How successful is chemotherapy for my type of cancer?
- Are there any other treatments I can have instead?
- How much does treatment cost?
- What drugs will I be receiving? How will they be given?
- How often will I receive this treatment? How long will I have treatment?
- Where will I have the chemotherapy? Can I have it close to where I live?
- What are the possible side effects of this treatment and what can I do to control them?
- Are there any complementary therapies that will help?
- How will I know if the treatment is working?
- Will chemotherapy affect my sex life and fertility?
- After treatment has finished, will I need checkups?
- Who should I contact for information or if I have a problem during treatment? Who is my after-hours contact?
Updated January 2, 2019
- Kris MG, Hellman MD, Chaft JE. Chemotherapy for Lung Cancers: Here to Stay. 2014 ASCO Educational Book website. http://meetinglibrary.asco.org/content/11400375-144. Accessed July 6, 2018.
- How chemotherapy works. Cancer Research UK website. https://www.cancerresearchuk.org/about-cancer/cancer-in-general/treatment/chemotherapy/how-chemotherapy-works. Reviewed November 15, 2017. Accessed July 6, 2018.
- The Genetics of Cancer. Cancer.Net website. https://www.cancer.net/navigating-cancer-care/cancer-basics/genetics/genetics-cancer. Approved March 2018. Accessed July 6, 2018.
- The Differences between Chemotherapy and Targeted Therapy. Sino Biological website. https://www.sinobiological.com/the-differences-between-chemotherapy-and-targeted-therapy.html. Accessed July 6, 2018.
- Malhotra J, Jammour S, Aisner J. Current state of immunotherapy for non-small cell lung cancer. Translational Lung Cancer Research. 2017:6(2):196-2011. https://www.nbci.nlm.nih.gov/pmc/articles/PMC5420529.
- How is Chemotherapy Given? Chemocare.com website. https://chemocare.com/chemotherapy/what-is-chemotherapy/how-chemotherapy-is-given.aspx. Accessed July 6, 2018.
- Catheters and Ports in Cancer Treatment. Cancer.Net website. https:///www.cancer.net/navigating-cancer-care/how-cancer-treated/chemotherapy/catheters-and-ports-cancer-treatment. Approved October 2017. Accessed November 19, 2018.
- Chemotherapy for Non-Small Cell Lung Cancer. American Cancer Society website. https://www.cancer.org/cancer/non-small-cell-lung-cancer/treating/chemotherapy.html. Revised May 16, 2018. Accessed July 6, 2018.
- Chemotherapy for Small Cell Lung Cancer. American Cancer Society website. https://www.cancer.org/cancer/small-cell-lung-cancer/treating/chemotherapy.html. Revised May 16, 2016. Accessed July 6, 2018.
- Chemotherapy. Mayo Clinic website. https://www.mayoclinic.org/tests-procedures/chemotherapy/about/pac-20385033. Accessed July 9, 2018.
- What to Expect When Having Chemotherapy. Cancer.Net website. https://www.cancer.net/navigating-cancer-care/how-cancer-treated/chemotherapy/what-expect-when-having-chemotherapy. Approved August 2017. Accessed July 9, 2018.
- Chemotherapy Before, During, and After. American Lung Association website. https://www.lung.org/assets/documents/lung-cancer/interactive-library/chemotherapy-worksheet-1.pdf. Accessed July 9, 2018.
- Understanding Chemotherapy. Cancer.Net website. https://www.cancer.net/navigating-cancer-care/how-cancer-treated/chemotherapy/understanding-chemotherapy. Approved May 2018. Accessed July 6, 2018.
- NCCN Guidelines for Patients® 2018: Lung Cancer-Non-Small Cell Lung Cancer. The National Comprehensive Cancer Network website. https://nccn.org/patients/guidelines/content/PDF/nsclc.pdf. Posted November 30, 2017. Accessed July 6, 2018.
- NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®): Non-Small Cell Lung Cancer. Version 1.2019. National Comprehensive Cancer Network, Inc. https://www.nccn.org/professionals/physician_gls/pdf/nsclc.pdf. November 21, 2018. Accessed December 3, 2018.
- NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®): Small Cell Lung Cancer. Version 1.2019. National Comprehensive Cancer Network, Inc. https://www.nccn.org/professionals/physician_gls/pdf/sclc.pdf. October 10, 2018. Accessed December 3, 2018
- Reck M, Heigener DF, Mok T. Management of non-small-cell lung cancer: recent developments. The Lancet. 2013; 382:709-713.
- How is Chemotherapy Used to Treat Cancer? American Cancer Society website. https://www.cancer.org/treatment/treatments-and-side-effects/treatment-types/chemotherapy/how-is-chemotherapy-used-to-treat-cancer.html. Revised February 16, 2016. Accessed July 29, 2018.
- Radiation Therapy for Non-Small Cell Lung Cancer. American Cancer Society website https://www.cancer.org/cancer/non-small-cell-lung-cancer/treating/radiation-therapy.html. Revised May 16, 2016. Accessed July 19, 2018.
- Imfinzi® (durvalumab) injection [package insert]. AstraZeneca Pharmaceuticals LP, Wilmington, DE. https://www.accessdata.fda-gov/drugsatfda_docs/label/2018/761069s002lbl.pdf. Revised February 2018. Accessed October 29, 2018.
- ECOG Performance Status. ECOG-ACRIN Cancer Research Group website. https://ecog-acrin.org/resources/ecog-performance-status. Accessed August 28, 2018.
- NCCN Guidlines for NSCLC Version 2.2018. 2017; https://www.nccn.og/professionals/physician_gls/PDF/nsclc.pdf. Accessed November 17, 2017.
- Tecentriq® (atezolizumab) injection [pacage insert]. Genentech, Inc. South San Francisco, CA. https://www.gene.com/download/pdf/tecentriq-prescribing.pdf. Revised December 2018. Accessed December 7, 2018.
- Opdivo® (nivolumab) injection [package insert]. Bristol-Myers Squibb Company. https://packageinserts.bms.com/pi/pi_opdivo.pdf. Revised August 2018. Accessed October 26, 2018.
- Side Effects of Chemotherapy. CancerNet website. https://www.cancer.net/navigating-cancer-care/how-cancer-treated/chemotherapy/side-effects-chemotherapy. Approved August 27, 2017. Accessed July 6, 2018.
- Constipation. Cancer.Net website. https://www.cancer.net/navigating-cancer-care/side-effects/constipation. Approved January 2016. Accessed July 2018.
- Diarrhea. Cancer.Net website. https://www.cancer.net/navigating-cancer-care/side-effects/diarrhea. Approved March 2017. Accessed July 6, 2018.
- Bleeding and Bruising (Thrombocytopenia) and Cancer Treatment. NIH: National Cancer Institute website. https://www.cancer.gov/about-cancer/treatment/side-effects/bleeding-bruising. Posted April 29, 2015. Accessed July 6, 2018.
- Fatigue. Cancer.Net website. https://www.cancer.net/navigating-cancer-care/side-effects/fatigue. Approved March 2017. Accessed July 6, 2018.
- Hair Loss or Alopecia. Cancer.Net website. https://www.cancer.net/navigating-cancer-care/side-effects/hair-loss-or-alopecia. Approved April 2018. Accessed July 6, 2018.
- Infection. Cancer.Net website. https://www.cancer.net/navigating-cancer-care/side-effects/infection. Approved October 2016. Accessed July 6, 2018.
- Appetie Loss. Cancer.Net website. https://www.cancer.net/navigating-cancer-care/side-effects/appetite-loss. Approved February 2018. Accessed July 6, 2018.
- Taste Changes. Cancer.Net website. https://www.cancer.net/navigating-cancer-care/side-effects/taste-changes. Approved October 2016. Accessed July 6, 2018.
- Mouth Sores or Mucositis. Cancer.Net website. https://www.cancer.net/navigating-cancer-care/side-effects/mouth-sores-or-mucositis. Approved October 2016. Accessed July 6, 2018.
- Nausea and Vomiting. Cancer.Net website. https://www.cancer.net/navigating-cancer-care/side-effects/nausea-and-vomiting. Approved July 2017; Accessed July 6, 2018.
- Peripheral Neuropathy. Cancer.Net website. https://www.cancer.net/navigating-cancer-care/side-effects/peripheral-neuropathy. Approved May 2017. Accessed July 6, 2018.