Lung cancer treatment in Germany: diagnosis, therapy and surgery

Diagnosis and treatment of lung cancer in Germany is very popular choice for foreign patients.

The latest technologies, high skill surgeons, innovative targeted drugs and affordable prices attract thousands of medical tourists from all over the world.

Lung cancer (carcinoma) means malignant neoplasm that grows in the lung tissue.

But tumors can be primary (originating from the lungs) and secondary (metastasis from distant organs).

This insidious disease can develop in any part of the lungs. But most tumors affect the upper parts, because they are intensively ventilated during breathing, being exposed to all kinds of toxic substances and dust particles.

Every year, more than 50,000 Germans are diagnosed with lung carcinoma. The most common type of disease is non-small cell carcinoma (NSCLC), accounting for 80% of all cases.

Lung cancer is one of the prognostically unfavorable neoplastic diseases.

Despite all the achievements of modern medicine, the 5-year survival rate (regardless of stage) is only about 19-22%. This is the #1 killer among all cancers in men and the second cause of death in women all over the world (after breast tumors).

Learn more about the causes, symptoms, diagnosis and treatment of lung cancer in Germany.

Why does lung cancer occur: causes and risk factors

The cause of neoplastic diseases is a specific DNA damage (mutation) that cannot be restored by the natural defense. Mutations in certain genes that are responsible for growth and differentiation ("maturation") trigger rapid uncontrollable cell division. A growing tumor gradually occupies healthy tissues and poisons the body with its toxic metabolites.

Natural mechanisms for "repairing" DNA must fight oncogenic mutations, but sometimes this defense fails. In this case, the immune system must destroy the neoplasm, but it fails too.

Cancer can be called a terrible coincidence in the cellular ecosystem.

The causes of oncogenic mutations are usually external. Every day a person inhales different toxic substances, radioactive gases and products of their decay. Leading role in the development of this deadly disease is assigned to active and passive smoking.

Known risk factors for lung tumors:

• Smoking
• E-cigarettes
• Air pollution
• Viral infections (HPV, EBV)
• Chronic obstructive pulmonary disease
• Asbestos, cement and coal dust
• Aggressive industrial chemicals
• Domestic radon exposure
• Uranium mining

Lung cancer signs and symptoms

In the early stages, the disease is usually asymptomatic.

Here are some symptoms and signs of stage III-IV lung cancer:

• chest pain
• unusual hoarseness
• wheezing, shortness of breath
• persistent cough that is not treated with antibiotics
• wet cough and hemoptysis
• unexplained weight loss
• weakness and fatigue
• night sweats
• fever

These symptoms do not always mean that you have lung carcinoma.

Many other diseases and conditions with similar symptoms, such as chronic bronchitis or pneumonia.

But you need to see a doctor as soon as possible!



The earlier lung cancer is detected, the better the chances of recovery. In the early stages, it can be completely cured, but in the advanced stages prognosis is usually poor.

The best lung cancer clinics in Germany

There are several dozen university hospitals, cancer centers and institutes ready to provide qualified and comprehensive oncology services to medical tourists.

Our list of the best lung cancer clinics in Germany:

1. University Medical Center Freiburg (Uniklinik Freiburg)
2. University Medical Center Erlangen (Uniklinik Erlangen)
3. Gesundheit Nord – Bremen Hospital Group (Klinikverbund Bremen)
4. HELIOS Medical Center in Berlin (HELIOS Klinikum Berlin-Buch)
5. Solingen City Hospital (Städtisches Klinikum Solingen)
6. Asklepios Hospital Barmbek in Hamburg (Asklepios Klinik Barmbek)
7. Charite University Hospital in Berlin (Charite Universitätsmedizin)
8. Northwest Hospital in Frankfurt (Nordwest Krankenhaus)

Sending an application for treatment or examination in Germany, we recommend that you contact the major university clinics (where advanced development and clinical trials are being implemented) or to well-known private centers.

Diagnosis of lung tumors in Germany

Local oncologists will require your medical history (translated into German) and the results of previous diagnostic studies (lab tests, CT, MRI, PET, chest X-ray, etc.) Some tests will have to be repeated. This is necessary for an accurate diagnosis.

Standard tests include:

Lab tests

The analysis of blood and urine provides an additional information about the patient's general health status, as well as the kidneys, liver function and bone marrow function. This information is necessary for treatment planning and prognosis.

Tumor marker tests are not widely accepted in lung carcinoma due to diagnostic uncertainty.

Chest X-ray

This is the first and simplest diagnostic procedure for detecting lung tumors. It is much easier to diagnose edge lesions, while central lung tumors they are less visible on the x-ray.

Bronchoscopic examination

Bronchoscopy is a standard procedure in German oncology. A flexible probe called bronchoscope is inserted through the nose or mouth into the patient's bronchi to examine suspicious areas and take samples for lab tests (transbronchial biopsy). This is the only way to confirm whether the tumor is cancerous. Bronchoscopy with transbronchial biopsy help to make the diagnosis and determine the sensitivity of cells.

Computed tomography and CT-guided biopsy

Small growths, which are less visible on X-rays, may be detected on CT. Thanks to modern tomographs, radiologists can detect tumors from 2-3 millimeters in size. Unfortunately, computed tomography does not distinguish between benign and malignant tumors.

Magnetic resonance imaging (MRI)

Magnetic resonance imaging helps to search for metastases in the bones, brain, spinal cord and other distant organs. Based on the use of electromagnetic waves and magnetic field, MRI is ideal for studying soft tissues. Are there metastases in the brain? Did the tumor spread through the lymphatic system? MRI will answer all these questions.

Positron Emission Tomography (PET)

A PET scan shows the metabolic activity in different tissues.

The patient is given radioactive tracer (FDG), which is distributed in body tissues with the fastest metabolic rate. This marker "highlights" the areas of inflammation and the malignancy. Combining PET with CT, oncologists provide much better results.

Video-assisted thoracoscopy (VAT)

Video-assisted thoracoscopy is designed for minimally invasive examining of the chest and sampling tissues without formal thoracotomy. The surgeon inserts a flexible probe with a camera through small incisions (keyholes). The data is transferred to the monitor in the operating room. VAT can be performed under local anesthesia.

Ultrasound scanning (sonography)

Ultrasound helps doctors to determine whether the tumor has spread to distant organs (metastases). Ultrasound scanning includes the liver, kidneys, adrenal glands, spleen and lymph nodes. Heart ultrasound is performed for evaluation of myocardium before making cancer treatment decisions (for example, aggressive chemotherapy).

Endobronchial ultrasound (EBUS) is a modern minimally invasive option that combines the diagnostic capabilities of sonography and bronchoscopy. During the procedure doctor inserts a probe with a sensor into the patient's airways, examining the tissues and lymph nodes.

Skeletal scintigraphy

Skeletal scintigraphy is performed to find out if lung cancer has spread to the bone. This procedure requires a small dose of a radioactive tracer, which is distributed throughout the body and accumulates in bone metastases. A special scanner determines the level of radiation in different parts of the skeleton and “highlights” the tumors. This diagnostic test is painless and completely safe because the dose of radiation used in German clinics is minimal.

Mediastinoscopy

This procedure is more risky, therefore it is performed only in specialized centers. Mediastinoscopy involves the examination of suspicious lymph nodes of the mediastinum with an optical probe. The lymph nodes removed during the procedure are studied in the histopathological laboratory for the presence of malignant cells.

Pulmonary function tests

Will the patient survive a lobectomy? What is the best treatment for this patient? Pulmonary function tests (PFT) are not looking for tumors. They show how well your respiratory system works. Based on this important data, doctors make complex clinical decisions.

Genetic tests

Advanced lung carcinoma cannot be completely cured. But the latest achievements of German scientists allowed to significantly prolong life even at the stage IV. This is the result of genetic research and highly selective targeted therapy.

“One drug fits all” is an outdated approach that does not treat, but kills.

New treatments are often called "personalized."

What does it mean?

Certain drugs are suitable for tumors with certain genetic mutations, but they are ineffective for others. Nowadays, before prescribing the drug, doctors use biopsy and high-tech lab tests.

What tumor mutations are tested?

EGFR Mutations

About 10% of non-small cell lung tumors contain mutations in the EGFR gene (epidermal growth factor receptor). It is a surface receptor containing tyrosine kinase – stimulator of growth and multiplication. Activating mutations of EGFR keep tyrosine kinases constantly active, causing cell to divide uncontrollably and invade normal tissues.

 ALK and ROS1 translocations

The term "translocation" means the rearrangement of genes. According to statistics, the translocation of the ALK gene (anaplastic lymphoma kinase) is found in 2-3% of non-small cell carcinomas. Another 1-2% of the samples contain translocations of the ROS1 gene. Each case requires unique treatment approach depending on its genetic profile.

Other mutations

Every year, scientists introduce new treatment options aimed at newly discovered genetic abnormalities: T790M, BRAF V600E, RET, HER2 mutations, MET amplification, etc. Let's take, for example, immune checkpoint inhibitors. These are modern drugs that affect patient's immune system functioning. They split the defense of malignant cells, making them vulnerable to our immunity. But not every tumor responds to this kind of treatment.

PD-L1 mutations are needed for success, otherwise the drug may not work.

Determining the stage of lung cancer

Right staging is the key for choosing the best treatment option and regimen.

In TNM classification system the stage depends on:

• the size and characteristics of the tumor (T)
• the involvement of nearby lymph nodes (N)
• the presence and characteristics of metastases (M)

The numbers behind the letters describe the tumor (T1-4), the number and localization of the affected lymph nodes (N0-3), and the presence of metastases (M0 and M1). For example, if your doctor noted "T1 N0 M0", this means the earliest stage: a small tumor that does not spread into the large bronchi, with no affected lymph nodes and metastases.

Stage-specific lung cancer treatment in Germany

German thoracic surgeons use the latest technological advances in the field of tumor resection and palliative surgery. For example, innovative argon laser tumor vaporization.

Its clearly understood that each cancer requires a unique approach. Cell type, stage of disease, genetic features. If your doctor finds a specific mutation of the tumor cell, the treatment process becomes much more effective, especially in advanced stages.

Non-small cell lung cancer (NSCLC) treatment regimens

In the early stage, locally effective options (surgical resection, radiotherapy) are used. After spreading outside the organ systemic treatment options are preferred (chemotherapy, targeted therapy, biological drugs). Often these methods combine to improve the results.

NSCLC stage IA and IB

For a single tumor up to 4 centimeters, German oncologists recommend immediate surgical resection, without subsequent chemotherapy. For tumors greater than 4 cm (IB), adjuvant chemotherapy may additionally be prescribed. If surgical treatment is impossible, the patient is offered stereotactic radiosurgery. Precision focused beams from different angles "cuts out" the tumor, so SRS is also called Gamma Knife.

General prognosis at this stage is very good.

NSCLC stage IIA and IIB

Forstages IIA and IIB, surgery should be followed by adjuvant (postoperative) combination chemotherapy regimen with cisplatin and other chemotherapeutics. Neoadjuvant chemo is also possible to reduce the size of the neoplasm before surgery. If surgery can not be performed because of to poor lung function or co-morbid conditions, stereotactic radiosurgery (SRS) is used. Adjuvant radiation therapy after resection helps to destroy residual tumor tissues and reduce the risk of cancer recurrence.

NSCLC stage IIIA and IIIB

Treatment of lung tumors penetrated adjacent tissues and affected nearby lymph nodes, is considered difficult and risky.

This is a complex process discussed by a team of oncologist, thoracic surgeon, pulmonologist and oncoradiologist. When tumor invades mediastinal lymph nodes (IIIA1 or IIIA2), surgical resection with adjuvant chemotherapy and radiotherapy are recommended to prevent the recurrence.

In the case of involvement of the lymph nodes on the opposite side (N3), as well as in case of invading certain organs (IIIA3, IIIA4 or IIIB), primary surgical treatment is ineffective.

A multistage therapy is recommended, starting with chemotherapy and neoadjuvant radiotherapy. If the tumor responds to treatment, surgery is scheduled.

NSCLC stage IV

Not only lymph nodes, but distant organs are also affected. Metastatic lung cancer is usually incurable, so treatment is aimed at alleviating the symptoms and prolonging life of the patient. But there is good news for some people. The exception is stage M1b, when the tumor initially formed one single metastasis in adrenal, brain, liver or bone. German doctors call this stage "oligometastatic disease" (OMD).

If PET-CT and MRI exclude other metastases, surgical removal or radiosurgery in combination with aggressive chemo (several drugs, including platinum compounds) may help those patients.

Complex treatment of OMD in German clinics provide good clinical results. If there are several metastases in distant organs (M1c) or the distant recurrence started after previous therapy, the surgery is usually ineffective. Prognosis is poor.

Targeted therapy for metastatic non-small cell lung cancer

1. EGFR mutation. Tyrosine kinase inhibitors such as afathinib (Gilotrif), erlotinib and gefitinib are usually prescribed. In the presence EGF receptor mutations, tyrosine kinase inhibitors are more effective than cytostatics, and they are better tolerated. The additional combination chemotherapy regimen depends on the specific genetic changes. The second line of treatment for resistant mutation EGFR T790M include osimertinib (Tagrisso).
2. ALK translocation. First-line therapy with tyrosine kinase inhibitor crisotinib. In recent studies, crisotinib improved response to chemotherapy, slowed the progression of the tumor, alleviated the symptoms, and improved quality of life significantly. Alectinib, ceritinib, brigatinib and other drugs are also prescribed.
3. ROS1 translocation. Activation of ROS1 transcription occurs in 1% of patients with NSCLC. Targeted therapy usually starts with crisotinib, in some cases combined with chemo based on pemetrexed.
4. BRAF mutation. BRAF and MEK inhibitors (like dabrafenib and trametinib) provide good results.
5. Wild-type tumors. In the absence of mutations (wild-type tumors), experimental regimens are being developed.

Small cell lung cancer treatment in Germany

Neoplasms consisting of small cells are much less common than NSCLC. But this cancer type is rapidly progressing and early forms metastases in distant organs.

SCLC Stage I and II

Unfortunately, only 5% of patients with this diagnosis begin treatment at an early stage. The surgical resection is followed by adjuvant combination chemotherapy with cisplatin and etoposide in several cycles. In some cases, radiotherapy is added. Preventive brain radiation may be required to prevent metastases.

SCLC Stage III

The first line is combined radiotherapy and chemotherapy. The most effective chemotherapy regimen for small cell lung cancer is a combination of cisplatin and etoposide, administered in 4-6 cycles. Preventive brain radiation increases the chances of recovery.

SCLC Stage IV

Most patients with SCLC are diagnosed at stage IV, when there is one or more metastases in the body. In these cases doctors focus on maintaining quality of life and controlling the symptoms. For otherwise healthy people, standard chemotherapy with cisplatin or carboplatin with etoposide is prescribed. With positive results, 4 to 6 cycles are performed. For weak patients with poor prognosis, treatment is usually limited to symptomatic therapy.

Whether preventive brain radiation is required at stage IV is a controversial issue.

Some clinics offer preventive radiation of a residual tumor in the lungs.

Treatment of recurrent SCLC

If the stage III tumor does not respond to chemoradiotherapy, surgery is considered.

Single metastases in the adrenal gland or brain are usually susceptible to stereotactic radiosurgery with further chemotherapy with other drugs. In these cases, topotecan, irinotecan, paclitaxel, bendamustine, ifosfamide and some anthracycline derivatives are widely used. If the disease recurs after six months or more after the initial course, the treatment is repeated.

Targeted agents (pembrolizumab, nivolumab and ipilimumab) have proved high efficacy in metastatic SCLC. Currently, German cancer clinics are testing perspective experimental drug Rovalpituzumab Tesirin (Rova-T) - selective antibodies against protein DLL-3. Deciding whether to continue therapy for patients with metastatic cancer, priority should be given to the quality of life. Sometimes the disease can be stabilized by “mild” chemo drugs, making the last months of life relatively comfortable.

More than just treatment

For most people, cancer is an emotional shock. Professionally organized care, qualified and passionate medical personnel helps patients and their relatives to go through this nightmare.

German clinics do not leave cancer patients alone with their problems.

In addition to the actual treatment that is the responsibility of oncologists and surgeons, you can receive psychological and psycho-oncological support, as well as professional rehabilitation.

Cost of lung cancer treatment in Germany

Cancer care in local clinics is considered high-tech and cost effective.

Approximate cost of diagnostic procedures:

• Blood test: 300 euros or more
• Tumor marker test: 350 euros or more
• Oncologist consultation: 400 euros or more
• Transbronchial biopsy: 2000 euros or more
• MRI of one area: 1000 euros or more
• PET-CT: 2300 euros or more

Approximate cost of treatment:

• Brachytherapy: 5,000 euros or more
• External beam radiation therapy: 8000 euros or more
• Chemotherapy: 2500 euros or more per one course
• Immunotherapy (pembrolizumab): 2000 euros or more
• Surgical resection (lobectomy): 20,000 euros or more
• Robotic surgery: 18,000 euros or more

A full range of diagnostic procedures for suspected lung cancer cost between 6,000-8,000 euros. Minimal treatment cost depends on the stage, ranging 35,000-40,000 euros or more. This is several times cheaper than similar procedures and drugs in the United States or Canada.

© Analytical reviews and oncology news by K. Mokanov: clinical pharmacist and professional medical translator