Lung Adenocarcinoma

Lung adenocarcinoma brochureTo help you understand and share this information, you can download and print a booklet that summarizes the detailed information in the following sections. (This booklet was produced in February 2016, before the 2016 and 2017 FDA approvals and expanded indications for several targeted therapies and immunotherapy drugs. Information about these drugs can be found in this section as well as in the Targeted Therapy and Immunotherapy sections of this website.)

Lung adenocarcinoma accounts for about 40% of all lung cancers. It tends to grow more slowly than other kinds of lung cancer.

There are numerous treatment options available to people affected by lung adenocarcinoma, and doctors are working hard to develop and improve these treatments.

This website can help you:

  • Learn about lung adenocarcinoma
  • Understand the treatment options available for lung adenocarcinoma
  • Consider whether participating in a clinical trial might be right for you
  • Understand how to manage the side effects associated with lung cancer treatment

What is lung adenocarcinoma?

Adenocarcinoma is a subtype of of non-small cell lung cancer (NSCLC)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. It tends to develop in smaller airways, such as bronchioles, and is usually located more along the outer edges of the lungs.1

Adenocarcinoma of the lung

Adenocarcinoma is a cancer that begins in cells in the glands. Glandular cells are found in the lungs and some other internal organs. Most cancers of the breast, pancreas, prostate, and colon are also adenocarcinomas. Only adenocarcinoma that begins in the lungs is considered lung cancer.2

Adenocarcinoma accounts for 40% of all lung cancers, is found more often in women, and tends to grow more slowly than other lung cancers. Most lung cancers in people who have never smoked are adenocarcinomas.1

Diagnosing lung adenocarcinoma

This type of lung cancer may be diagnosed in many different ways. In addition, doctors have come up with very specific modes of categorizing lung cancer to help treat them better. Understanding the ways that doctors categorize lung cancers may help you understand your diagnosis.

How is Lung Adenocarcinoma Diagnosed?

Many different tests are used to diagnose lung cancer and determine whether it has spread to other parts of the body. Some can also help to decide which treatments might work best. The steps and tests used in diagnosing lung adenocarcinoma include:

  • Imaging tests
  • Laboratory tests
  • Biopsies

Not all of these will be used for every person. The approaches used for an individual will depend on your medical history and condition, symptoms, location of the nodule(s), and other test results.

Read the Diagnosing Lung Cancer section to learn about the different steps and tests for making a lung cancer diagnosis.

Stages of Lung Cancer

Staging is a way of describing where the cancer is located, if or where it has spread, and whether it is affecting other parts of the body. Doctors use diagnostics to determine the cancer’s stage, so staging may not be complete until all of the tests are finished. Knowing the stage helps the doctor to recommend a treatment plan. Although lung cancer is treatable at any stage, only certain stages of lung cancer can be cured.

The Lung Cancer Staging section provides more information about this way of understanding lung adenocarcinoma.

Biomarker Profile

Lung cancer describes many different types of cancer that start in the lung or related structures. There are two different ways of describing what kind of lung cancer a person has:

  • Histology—what the cells look like under a microscope. Adenocarcinoma is a histological subtype of non-small cell lung cancer. Other subtypes of non-small cell lung cancer include squamous cell lung cancerA type of non-small cell lung cancer that usually starts near a central bronchus, large cell lung cancerLung cancer in which the cells are large and look abnormal when viewed under a microscope, and some rarer types. Small cell lung cancer (SCLC)A fast-growing cancer that forms in tissues of the lung and can spread to other parts of the body is the other major type of lung cancer.
  • Biomarker profile (also called molecular profile, genomic profile, or signature profile)—the mutations, or characteristics, as well as any other unique biomarkers, found in a person’s cancer that allowed the cancer to grow.

A person’s lung cancer may or may not have one of the many known driver mutations that cause cancer. Researchers are making progress in understanding mutations in adenocarcinoma. Several therapies targeting these mutations are approved for use as first-line treatmentThe first treatment given for a disease and subsequent treatments in adenocarcinoma, and others are being studied in clinical trials.3

The decision to test for mutations (via biomarker testing) should be made together by you and your doctor.

Below are the driver mutations that have been identified for lung adenocarcinoma at this time:4

Driver mutations in lung adenocarcinoma

More information about driver mutations, and how and when testing for them is performed, can be found here (see “What is a driver mutation?,” “How is biomarker testing performed?,” and “Who should have their tumor tested, and when?”).

Treatment options for lung adenocarcinoma

There are a number of treatment options for lung adenocarcinoma. Which ones are used to treat a specific patient’s lung cancer will depend on the stage of the cancer and the patient’s overall health and preferences.

Treatment options fall into two categories:

  • Those that are approved by the FDA 
  • Those that are being studied in clinical trials

What are Currently Approved Treatment Options?

Approved treatment options for lung adenocarcinoma include:

  • Surgery
  • Radiation therapy
  • Chemotherapy
  • Targeted therapy
  • Angiogenesis inhibitors
  • Immunotherapy

Note that a patient’s age alone does not predict whether that patient will benefit from treatment, and should not be the only factor when deciding what treatment is best. Other factors, such as how fit a patient is othrwise and what other medical problems exist, also need to be considered.5

Surgery

Lung cancer that is only in one lung and that has not spread to other organs is often treated with surgery, if the patient can tolerate it. Read more about different surgical options and what to expect after surgery in the Treatment Options: Surgery section.

Radiation Therapy

Radiation therapy is a type of cancer treatment that uses high-powered energy beams to kill cancer cells. Depending on the individual patient’s situation, radiation therapy may be used when trying to cure cancer, control cancer growth, or relieve symptoms caused by the tumor, such as pain.

Radiation therapy can be given as the main treatment in early-stage lung adenocarcinoma if surgery is not possible. In that case, it may be given either with or without chemotherapy.

Read more about radiation treatment, including how it works, how and when it is given, the different kinds, and common side effects, in the Treatment Options: Radiation Therapy section.

Chemotherapy

Patients whose lung cancer has spread beyond the lung to local lymph nodes are often given chemotherapy and radiation therapy. As with other types of non-small cell lung cancer, patients with lung adenocarcinoma are often given two chemotherapy agents as first-line therapy. Which drugs are chosen will depend in part on the patient’s overall health and ability to tolerate different possible side effects.

For patients with lung adenocarcinoma, most often one of the platinum drugs cisplatin or carboplatin is combined with another chemotherapy drug, such as pemetrexed or doctataxel.6,7

There are other drug therapy options, like targeted therapies, angiogenesis inhibitors, and immunotherapy. These are discussed in more detail below. Your doctor will help to select the best treatment based on your medical history and other factors. Read more about chemotherapy, including how it works, how and when it is given, and possible side effects and how to manage them, in the Treatment Options: Chemotherapy section.

Targeted Therapy

Targeted therapies are a type of therapy that aims to target cancer cells directly. They focus on specific parts of cells and the signals that cause cancer cells to grow uncontrollably and thrive. All of the targeted therapies that have been studied and FDA-approved belong to a class of drugs called tyrosine kinase inhibitors (TKIs).

As discussed earlier in this section, there are a number of known driver mutations in lung adenocarcinoma. TKIs are currently approved by the US Food and Drug Administration (FDA) for four of them: the anaplastic lymphoma kinase (ALK)A gene that the body normally produces but, when it fuses with another gene produces an abnormal protein that leads to cancer cell growth gene rearrangement, the epidermal growth factor receptor (EGFR)The protein found on the surface of some cells and to which epidermal growth factor binds, causing the cells to divide mutation, the ROS1 gene rearrangement, and the BRAF V600E mutation. Lung cancers with these mutations are called ALK-positive, EGFR-positive, ROS1-positive, and BRAF-positive.

ALK gene rearrangements happen in a small proportion (about 7%) of patients with lung adenocarcinoma. The following ALK inhibitors are currently FDA-approved for patients with ALK-positive metastatic non-small cell lung cancer, including adenocarcinoma:

Crizotinib (Xalkori®): as first-line and greater treatment8
Ceritinib (Zykadia®): as first-line and greater treatment9
Alectinib (Alecensa®): as first-line and greater treatment10
Brigatinib (AlunbrigTM): for patients whose cancer has grown while they were on crizotinib or are intolerant to crizotinib11

EGFR mutations occur in about 10% of lung adenocarcinoma tumors. There are currently four FDA-approved EGFR inhibitors approved for patients with metastatic EGFR-positive non-small cell lung cancer:

  • Afatinib (Gilotrif®): as first-line treatment12
  • Erlotinib (Tarceva®): as first-line treatment, maintenance therapyTreatment that is given to help keep cancer from growing after it has shrunk or stabilized following initial therapy , and second-line or greater treatment after progression following at least one chemotherapy regimen.13
  • Gefitinib (Iressa®): as first-line treatment 14
  • Osimertinib (Tagrisso®): as second-line treatment for patients whose tumors are (EGFR) T790M-positive and whose disease has proressed on or after EGFR TKI therapy15

About 1% to 2% of patients with lung adenocarcinoma have tumors with a ROS1 mutation. There is currently one tyrosine kinase inhibitor that has been approved for patients with metastatic NSCLC whose tumors are ROS1-positive. This is crizotinib (Xalkori®), a TKI that is also used for patients with ALK-positive tumors.8 Other ROS1 inhibitors are currently being studied in clinical trials.

The BRAF V600E mutation is found in 1%-3% of lung adenocarcinoma patients. There is currently one FDA-approved combination inhibitor treatment for patients with metastatic NSCLC with the BRAF V600E mutation: dabrafenib (Tafinlar®) and trametinib (Mekinist®).16

The biggest challenge of TKIs is that all patients with lung cancer who initially benefit from them eventually develop resistance, known as acquired resistanceDisease progression after initial benefit with a targeted therapy. Doctors and researchers are working to overcome resistance in tumors and to keep TKIs effective against cancer for longer periods of time. 

Read more about targeted herapy, including how it works, how and when it is given, possible side effects and how to manage them, and acquired resistance in the Treatment Options: Targeted Therapy section.

Angiogenesis Inhibitors

As the body develops and grows, it makes new blood vessels to supply all of the cells with blood. This process is called angiogenesis. When the new blood vessels provide oxygen and nutrients to cancer cells, they help the cancer cells grow and spread.

Angiogenesis inhibitors help stop or slow the growth or spread of tumors by stopping them from making new blood vessels. The tumors then die or stop growing because they cannot get the oxygen and nutrients they need. The way they do this is by blocking the cancer cells’ vascular endothelial growth factor (VEGF)A protein made by cells that stimulates new blood vessel formation receptors.18

Currently, two angiogenesis inhibitors are FDA-approved for patients with non-small cell lung cancer, including adenocarcinoma:

  • Bevacizumab (Avastin®)In combination with carboplatin and paclitaxel for the first-line treatment  of patients with unresectable, locally advanced, recurrent, or metastatic non-squamous  adenocarcinoma19
  • Ramucirumab (Cyramza®)In combination with docetaxel for the second-line treatment of patients with metastatic NSCLC whose disease has progessed on or after platinum-based chemotherapy20

Read more about how angiogenesis inhibitors work and common side effects, as well as questions to ask your healthcare team, in the Treatment Options: Angiogenesis Inhibitors section.

Immunotherapy

Immunotherapy aims to strengthen the natural ability of the patient’s immune system to fight cancer. Instead of targeting the person’s cancer cells directly, immunotherapy trains a person’s natural immune system to recognize cancer cells and selectively target and kill them.21

Currently, there are three FDA-approved immunotherapy drugs for people with non-small cell lung cancer. These drugs belong to the type of immunotherapy called immune checkpoint inhibitorsAgents that target the pathways tumor cells use to evade recognition and destruction by the immune system, which work by targeting and blocking the fail-safe mechanisms of the immune system. The goal is to block the immune system from limiting itself, so the immune system can target the cancer cells.

The three FDA-approved immunotherapy drugs are:

  • Nivolumab (Opdivo®): For patients with metastatic NSCLC whose cancer has progressed after platinum-based chemotherapy. Patients with EGFR or ALK mutations should have disease progression on FDA-approved therapy for those mutations before they are treated with nivolumab.22
  • Pembrolizumab (Keytruda®):
    • For first-line treatment of patients with metastatic NSCLC whose tumors have high PD-L1 expression as determined by an FDA-approved test, with no EGFR or ALK mutations
    • For patients with metastatic NSCLC whose tumors express PD-L1 as determined by an FDA-approved test, with disease progression on or after platinum-containing chemotherapy. (Note: Platinum-based chemotherapies include carboplatin and cisplatin.) Patients with EGFR or ALK mutations should have disease progression on FDA-approved therapy for those mutations before they are treated with pembrolizumab
    • ​For first-line treatment of patients with metastatic non-squamous NSCLC, irrespective of PD-L1 expression, in combination with pemetrexed and carboplatin23
  • Atezolizumab (Tecentriq®): For patients with metastatic NSCLC who have disease progression during or following platinum-containing chemotherapy. Patients with EGFR or ALK mutations  should have disease progression on FDA-approved therapy for those mutations before they are treated with atezolizumab24

For more about immunotherapy, including how the immune system works, possible side effects, other kinds of immunotherapy being studied, and questions to ask your healthcare team, see the Treatment Options: Immunotherapy section.

What clinical trial treatment options are available?

In addition to the approved treatments described above, there is a great deal of promising research going on now in clinical trials focused on people with lung adenocarcinoma.25 The following describe some, but by no means all, of the clinical trials available for people with lung adenocarcinoma.

Targeted Cancer Therapy

As shown earlier, a number of mutations have been found in lung adenocarcinoma in addition to EGFR, ALK, ROS1, and BRAF. Among these are HER2, KRAS, MAP2K1, MET, NRAS, NTRK1, PIK3CA, and RET. Currently, researchers are working to develop drugs that target a number of these mutations.

Immunotherapy

Three main types of immunotherapy are currently being studied in clinical trials for people with all stages of non-small cell lung cancer:

  • Immune checkpoint inhibitors by themselves or combined with other drugs
  • Therapeutic cancer vaccinesA type of treatment, using a vaccine that is usually made from a patient’s own tumor cells or from substances taken from tumor cells
  • Adoptive T cell transferTherapy that involves removing some of a patient's own immune-system cells—often altering and increasing their ability to recognize and kill cancer cells—growing billions of them in the laboratory and infusing the cultured cells into the patient

Immune checkpoint inhibitors, such as nivolumab (Opdivo®), pembrolizumab (Keytruda®), and atezolizumab (Tagrisso®) continue to be studied for treatment of earlier stages of lung cancer and in combination with other treatments.25

New Approaches to Existing Treatments

In addition to new treatments, doctors are also trying new approaches to existing treatments. Some examples include:

  • Chemotherapy agents given in combination with radiation therapy, surgery, immunotherapy, and targeted cancer therapy
  • Radiation therapy given in combination with chemotherapy and surgery
  • Looking at whether using imaging procedures, such as PET and CT scans, can help doctors guide radiation therapy so that higher doses can be delivered directly to the tumor, causing less damage to healthy tissue

Finding a Clinical Trial That Might Be Right for You

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, there are several online and phone-based resources to help you find one that may be a good match. Read more about clinical trials and resources for finding one for you.

Managing symptoms and side effects

As already noted, lung cancer treatments can cause side effects. Some cancer therapy side effects are temporary, while others can be more long-term. When you start a new treatment, you should discuss with your doctor which potential side effects to expect, what can be done to manage them, and which side effects are serious and need to be reported immediately. Often, drugs can be prescribed to help reduce many of these side effects.  

In addition to the side effects of lung cancer treatment, lung cancer itself can result in a number of symptoms. Read more about the symptoms of lung cancer.

Note: It’s important to let your doctor or nurse know if you are experiencing any problems while on treatment, so they can sort out whether the problems are related to treatment or not.

Tips for managing specific symptoms and side effects related to treatment can be found in the For Supporters & Advocates section of the website, along with other practical and supportive resources for patients/survivors and caregivers.

To help reduce the severity and duration of most side effects and alleviate the cancer’s symptoms, you may want to request palliative care, also called “supportive care” or “symptom management.” There is sometimes confusion about the difference between palliative care and hospice care. Hospice care is a form of palliative care given only to patients whose life expectancy is six months or less. On the other hand, palliative care in general is an extra layer of support than can be initiated alongside other standard medical care. In fact, scientific evidence is starting to emerge that shows that palliative care may actually help patients live longer.

Read more about how palliative care can improve quality of life from the time of diagnosis.

Your healthcare team

There are a number of doctors and other medical professionals who diagnose and treat people with lung cancer. Together, they make up the comprehensive medical or healthcare team that a patient sees over the course of his or her care. Your healthcare team can describe your treatment options, the expected results of each option, and the possible side effects. You and your healthcare team can work together to develop a treatment plan.

Read more about what each member of your healthcare team does.

Updated January 10, 2018

References

  1. What is Non-Small Cell Lung Cancer? American Cancer Society website. https://www.cancer.org/cancer/non-small-cell-lung-cancer/about/what-is-non-small-cell-lung-cancer.html. Revised May 16, 2016. Accessed November 30, 2017.
  2. NCI Dictionary of Cancer Terms. National Cancer Institute website. http://www.cancer.gov/dictionary. Accessed November 30, 2017.
  3. Ramalingham S, Pillai RN, Reinmuth N, Reck M. Chapter 44: First-line Systematic Therapy Options for Non-small Cell Lung Cancer. In: Pass HI, Ball D, Scagliotti GV, eds. IASLC Thoracic Oncology, Second Edition. Philadelphia, PA: Elsevier; 2018: 418-43. Accessed November 30, 2017.
  4. Hirsch FR, Suda K, Wiens J, Bunn PA, Jr. New and emerging targeted treatments in advanced non-small-cell-lung-cancer. Lancet. Sep 3 2016. 388(10048): 1012-1024.  
  5. Lung Cancer – Non-Small Cell: Stages. Cancer.Net website. http://www.cancer.net/cancer-types/lung-cancer-non-small-cell/stages. Approved August 20, 2017. Accessed November 30, 2017.
  6. Lung Adenocarcinoma: The Evolving Role of Chemotherapy. OncLive website. http://www.onclive.com/insights/nondriver-lung-adenocarcinoma/lung-adenocarcinoma-the-evolving-role-of-chemotherapy. Posted July 5, 2017. Accessed December 13, 2017.
  7. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®): Non-Small Cell Lung Cancer. Version 1.2018-November 17, 2017. National Comprehensive Cancer Network, Inc. Accessed December 20, 2017.
  8. Xalkori® (crizotinib) capsules [package insert]. Pfizer, Inc. New York, NY. http://labeling.pfizer.com/showlabeling.aspx?id=676. Revised July 2017. Accessed November 30, 2017.
  9. Zykadia® (ceritinib) capsules [package insert]. Novartis. Basel, Switzerland. http://www.pharma.us.novartis.com/sites/www.pharma.us.novartis.com/files/zykadia.pdf. Revised November 2017. Accessed November November 30, 2017.
  10. Alecensa® (alectinib) capsules [package insert]. Genentech, Inc. South San Francisco, CA. http://www.gene.com/download/pdf/alecensa_prescribing.pdf. Revised November 2017. Accessed November 30, 2017.
  11. AlunbrigTM (brigatinib) tablets [package insert]. ARIAD Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceuticals Company. Cambridge, MA. http:www.accessdata.fda.gov/drugsatfda_docs/label/2017/208772lbl.pdf. REvised April 2017. Accessed November 30, 2017.
  12. Gilotrif® (afatinib) tablets [package insert]. Boehringer Ingelheim Pharmaceuticals, Inc. Ridgefield, CT. . Revised December 2015. November 30, 2017. https://www.docs.boehringer-ingelheim.com/Prescribing%20Information/PIs/Gilotrif/Gilotrif.pdf?DMW_Format=pdf. Revised April 2016. Accessed November 30, 2017.
  13. Tarceva® (erlotinib) tablets [package insert]. OSI Pharmaceuticals, LLC. Northbrook, IL. https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/021743s025lb1.pdf. Revised October 2016. Accessed November 30, 2017.
  14. Iressa® (gefitinib) tablets [package insert]. AstraZeneca Pharmaceuticals LP. Wilmington, DE. http://www.accessdata.fda.gov/drugsatfda_docs/label/2015/206995s000lbl.pdf?et_cid=36354018&et_rid=933008744&linkid=http%3a%2f%2fwww.accessdata.fda.gov.... Revised July 2015. Accessed November 30, 2017.
  15. Tagrisso® (osimertinib) tablets [package insert]. AstraZeneca Pharmaceuticals LP. Wilmington, DE. https:www.accessdata.fda.gov/drugsatfda_docs/label/2017/208065s006lbl.pdf. Revised March 2017. Accessed November 30, 2017.
  16.  Tafinlar® (dabrafenib) capsules [package insert]. Novartis Pharmaceuticals Corporation. East Hanover, NJ. https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/202806s006lbl.pdf. Revised June 2017. Accessed November 30, 2017.
  17. Ricciuti B, Baglivo S, et al. Osimertinib in patients with advanced epidermal growth factor receptor T790M mutation-positive non-small cell lung cancer: rationale, evidence and place in therapy. Ther Adv Med Oncol. 2017 June; 9(6): 387-404. doi: 10.1177/1758834017702820. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5455880/. Posted 2017 Apr 16. Accessed December 13, 2017.
  18. Angiogenesis Inhibitors. National Cancer Institute website. http://www.cancer.gov/about-cancer/treatment/types/immunotherapy/angiogenesis-inhibitors-fact-sheet. Reviewed October 7, 2011. Accessed November 30, 2017.
  19. Avastin® (bevacizumab) solution [package insert]. Genentech, Inc., South San Francisco, CA; November 2014. http://www.gene.com/download/pdf/avastin_prescribing.pdf. Revised December 2016. Accessed November 30, 2017.
  20. Cyramza® (ramucirumab) injection [package insert]. Eli Lilly and Company, Indianapolis, IN; December 2014. http://pi.lilly.com/us/cyramza-pi.pdf. Revised March 2017. Accessed November 30, 2017.
  21. Gandhi L, Vansteenkiste JF, Shepherd FA. Chapter 50: Immunotherapy and Lung Cancer. In: Pass HI, Ball D, Scagliotti GV, eds. IASLC Thoracic Oncology, Second Edition. Philadelphia, PA: Elsevier; 2018:501-511. Accessed November 30, 2017.
  22. Opdivo® (nivolumab) injection [package insert]. Bristol-Myers Squibb Company. Princeton, NJ. http://packageinserts.bms.com/pi/pi_opdivo.pdf. Revised October 2017. Accessed November 30, 2017.
  23. Keytruda® (pembrolizumab) injection [package insert]. Merck & Co., Inc. Whitehouse Station NJ. https://www.merck.com/product/usa/pi_circulars/k/keytruda/keytruda_pi.pdf. Revised November 2017. Accessed November 30, 2017.
  24. Tecentriq® (atezolizumab) injection [package insert]. Genentech, Inc., South San Francisco, CA; 2016. https://www.gene.com/download/pdf/tecentriq_prescribing.pdf. Revised April 2017. Accessed November 30, 2017.
  25. Clinicaltrials.gov. US National Institutes of Health website. http://clinicaltrials.gov. Accessed November 30, 2017.

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