Lung Cancer Treatment Options for Veterans: Surgery, Chemotherapy, Immunotherapy, and Targeted Therapy

Asbestos-related lung cancer is a treatable disease, and treatment options for US veterans are increasingly multimodal — combining surgery, chemotherapy, radiation, immunotherapy, and targeted therapy depending on the cancer’s histology, stage, and tumor genomic profile. The 2020s have seen meaningful improvements in outcomes for several lung cancer subtypes thanks to immunotherapy and targeted therapies. This page explains the major treatment categories, where US veterans typically receive treatment, and what questions to ask when starting the conversation with the oncology team.

This page is an educational overview of public oncology information. It is not medical advice for any individual. Treatment decisions are made between the patient, family, and the diagnosing oncology team, who have access to the specific pathology, imaging, comorbidities, and genomic test results that determine which treatments apply.

The first 30 days after diagnosis

The first month after a lung cancer diagnosis is typically about confirming the diagnosis, staging the disease, and choosing a treatment center. The oncology team will usually order:

• Confirmatory pathology review — the biopsy specimen is reviewed for histology (adenocarcinoma, squamous cell, large cell, or small cell) and immunohistochemistry markers.
• Staging imaging — typically a chest CT, a PET-CT for whole-body metastatic survey, and a brain MRI to rule out brain metastases.
• Pulmonary function testing — establishes baseline lung function. Important for surgery candidacy and for tracking treatment-related lung changes.
• Tumor genomic testing (next-generation sequencing) — identifies actionable mutations (EGFR, ALK, ROS1, BRAF, KRAS-G12C, MET, RET, NTRK) and PD-L1 expression. This is the test that determines which targeted therapies and which immunotherapies apply.

All four are standard. If your veteran’s diagnosing center is not running tumor genomic testing, ask explicitly — it is now standard of care for non-small cell lung cancer and changes the treatment menu materially.

Treatment categories

Surgery

For early-stage non-small cell lung cancer (Stage I and selected Stage II) where the tumor is operable and the patient has adequate lung function, surgical resection remains the standard of care. Procedures include:

• Lobectomy — removal of one lobe of the lung. The most common operation for early-stage NSCLC.
• Wedge resection / segmentectomy — partial removal of a lobe. Used for smaller tumors or patients with limited lung function.
• Pneumonectomy — removal of an entire lung. Reserved for centrally located tumors that cannot be addressed with lesser resection.

Most lung cancer surgery is now done minimally invasively (VATS, video-assisted thoracoscopic surgery, or robotic-assisted) at high-volume centers. Recovery is faster than the open thoracotomy approach of an earlier era. Major VA medical centers with thoracic surgery programs include Houston, Dallas, Long Beach, Boston, Madison, Pittsburgh, and several others.

Chemotherapy

Platinum-based chemotherapy (cisplatin or carboplatin) combined with a second agent (pemetrexed for non-squamous NSCLC, paclitaxel or gemcitabine for squamous NSCLC, etoposide for small cell lung cancer) remains the chemotherapy backbone for most lung cancer treatment. Chemotherapy is used:

• As neoadjuvant therapy (before surgery) for some Stage II-III cases.
• As adjuvant therapy (after surgery) to reduce recurrence risk.
• As primary systemic therapy for unresectable or metastatic disease.
• In combination with immunotherapy (chemo + checkpoint inhibitor) which is now standard first-line for many advanced NSCLC cases.

Radiation therapy

Radiation has multiple roles in lung cancer treatment:

• Stereotactic body radiation therapy (SBRT) for inoperable early-stage NSCLC. SBRT delivers high-dose precise radiation in a few sessions; outcomes for selected patients approach those of surgery.
• Chemoradiation (concurrent chemotherapy and radiation) for unresectable Stage III NSCLC. Often followed by consolidation immunotherapy.
• Palliative radiation for symptomatic metastases (bone pain, brain metastases, spinal cord compression, airway obstruction).
• Prophylactic cranial irradiation for limited-stage small cell lung cancer responders.

Immunotherapy (checkpoint inhibitors)

Immunotherapy using checkpoint inhibitors (pembrolizumab, atezolizumab, nivolumab, durvalumab, cemiplimab) has become a major part of lung cancer treatment over the past decade. Immunotherapy works by removing brakes from the patient’s immune system so it can attack the cancer. Key uses:

• First-line for advanced NSCLC with high PD-L1 expression (TPS ≥50 percent): pembrolizumab monotherapy.
• First-line in combination with chemotherapy for advanced NSCLC across PD-L1 levels.
• Adjuvant after surgery for Stage II-III resected NSCLC.
• Consolidation after chemoradiation for unresectable Stage III NSCLC (durvalumab).
• First-line in combination for extensive-stage small cell lung cancer.

Immunotherapy has changed the long-term-survival picture for a meaningful subset of advanced lung cancer patients. It is not effective for everyone, and side effects (immune-related adverse events affecting lungs, liver, thyroid, colon, or skin) can be significant. The decision to use immunotherapy and which agent depends on PD-L1 testing and clinical judgment.

Targeted therapy

Targeted therapy uses oral or infusion drugs that block specific molecular drivers in cancers with the matching mutation. For lung cancer, the most important targets are:

• EGFR mutations (osimertinib first-line; common in adenocarcinoma, especially in non-smokers and Asian patients but found across populations)
• ALK rearrangements (alectinib, brigatinib, lorlatinib)
• ROS1 rearrangements (entrectinib, crizotinib, repotrectinib)
• BRAF V600E mutations (dabrafenib + trametinib)
• KRAS G12C mutations (sotorasib, adagrasib) — historically considered “undruggable” until recently.
• MET exon 14 skipping mutations (capmatinib, tepotinib)
• RET rearrangements (selpercatinib, pralsetinib)
• NTRK fusions (larotrectinib, entrectinib)
• HER2 mutations (trastuzumab deruxtecan)

The genomic test ordered at diagnosis is what reveals whether any of these targets are present. For patients with an actionable target, targeted therapy is often preferred over chemotherapy or immunotherapy as first-line treatment because response rates and side effect profiles are typically more favorable.

Where US veterans typically receive treatment

VA medical centers

The VA system has thoracic oncology programs at most major medical centers. The VA also has a National TeleOncology program that connects veterans at smaller VA facilities to specialists at major centers. Veterans rated 100 percent service-connected receive care at Priority Group 1 with no copays. See VA disability rating for what a 100 percent rating includes.

VA Community Care

The VA Community Care program allows veterans to receive care at non-VA facilities under specific circumstances (geographic distance, wait time exceeded, or care not available at the local VA). For complex cancers like asbestos-related lung cancer, Community Care often covers treatment at major academic centers.

Major academic cancer centers

Centers with high-volume thoracic oncology programs that frequently treat veterans include MD Anderson Cancer Center (Houston), Memorial Sloan Kettering (New York), Dana-Farber Cancer Institute (Boston), Mayo Clinic (Rochester, Phoenix, Jacksonville), and several others. Many of these have dedicated programs for veterans and military families.

Brigham and Women’s / International Mesothelioma Program

For mesothelioma specifically (separate from lung cancer), Brigham and Women’s Hospital in Boston has the International Mesothelioma Program founded by the late Dr. David Sugarbaker. The program continues to be a leading center for multimodal mesothelioma care.

Clinical trials

Clinical trials are the right path for many patients with advanced lung cancer, including patients whose tumor genomics do not match an approved targeted therapy and patients whose disease has progressed on standard therapies. The VA, NCI Community Oncology Research Program (NCORP), and academic cancer centers all enroll trials.

The NIH ClinicalTrials.gov database is the standard reference for finding trials by disease, geography, and patient eligibility. The VA’s National TeleOncology program can help match veterans to trials at distant centers.

Palliative care

Palliative care is medical care focused on quality of life, symptom management, and decision-support during serious illness. It is appropriate at any stage of treatment, not only end-of-life. Studies in lung cancer have shown that early palliative care — concurrent with active treatment — improves quality of life and in some cases extends survival.

The VA system has palliative care programs at most major medical centers. For end-of-life support, see end-of-life support for veterans.

What to ask the oncology team

Useful questions when starting the conversation:

• What is the histology of the cancer (adenocarcinoma, squamous, large cell, or small cell)?
• What is the stage at diagnosis, and what is the goal of treatment (curative, control, palliative)?
• Has tumor genomic testing been ordered? When will results be back?
• What is the PD-L1 expression level?
• Is the cancer operable? If so, is minimally invasive surgery an option?
• What is the recommended first-line treatment, and what are the alternatives?
• Is palliative care available concurrently with active treatment?
• Are there clinical trials for this specific situation?
• Can the VA or VA Community Care cover treatment at this center?

What this site is and is not

This site is run by Mesothelioma Funds Administration. We help veterans and their families navigate the asbestos compensation pathways. We are not the oncology team. Treatment decisions belong to the patient, family, and oncology team. We can help with the benefit pathways that fund treatment and support the family during it: VA disability, asbestos trust funds, DIC, and the PACT Act for Camp Lejeune cases.

Related resources

• Asbestos lung cancer in veterans (the pillar)
• Asbestos lung cancer vs mesothelioma
• Asbestos lung cancer statistics for veterans
• VA benefits (covers lung cancer)
• How to file a VA claim
• End-of-life support for veterans
• Asbestos trust funds for veterans
• Medical reviewer

If you have questions about how the VA covers lung cancer treatment, what evidence supports a service-connection claim, or how to coordinate the asbestos trust fund pathway with active treatment, you can call the office at (800) 763-9692. The phone line is staffed during business hours.