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How Do I Treat a Patient with Extensive-Stage Small-Cell Lung Cancer?

Socinski, Mark A. MD

doi: 10.1097/01.COT.0000393679.53681.dc
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MARK A

MARK A

When I am asked to evaluate a patient with newly diagnosed extensive-stage small cell lung cancer (SCLC), I do make sure that a baseline imaging of the brain is done, since brain metastasis is so common in patients with SCLC. I order a bone scan only in the presence of symptoms of bony involvement. I do not believe PET scans offer additional useful information in patients with extensive stage SCLC.

A quick note about pathology: Patients with large-cell carcinoma with neuroendocrine features should be treated more like non-small cell lung cancer (NSCLC).

My preferred regimen, not surprisingly, for patients with ECOG PS 0-2 ES-SCLC patients is carboplatin and etoposide. I do not feel that cisplatin, with the additional associated toxicities, offers any additional benefits here (for limited-stage SCLC, a topic of a future piece in this series, my own choice of platinum will be cisplatin when possible).

I re-evaluate after two cycles of chemotherapy and in the absence of progression, I continue up to a minimum of four cycles. For those who continue to show response after the fourth cycle of therapy, I would give perhaps two additional cycles of carboplatin and etoposide.

I have rarely, if ever, gone past six cycles of therapy. Based on what we have seen over the past few years from studies conducted in North America, I do not see any value in replacing etoposide with irinotecan in the front-line setting.

However, irinotecan and platinum combination would be reasonable in those rare patients who develop allergy to etoposide. I may consider using single-agent etoposide in the frail elderly or those with a performance status of 3 or worse.

I try my best to avoid using systemic chemotherapy concurrent with whole brain radiation. I usually wait for a week or so after the whole brain radiation has been completed. I would be watchful for tumor lysis syndrome with the first cycle of therapy when patients have large volume disease. I prefer to admit them to the hospital for the first cycle in those instances.

After their initial therapy, usually four to six cycles of platinum/etoposide therapy, I would revaluate them fully with CT of the chest and abdomen and a brain MRI. For those with a response, I arrange for a consultation with a radiation oncologist to discuss prophylactic cranial irradiation (PCI).

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Thoracic Radiation Remains Controversial

Thoracic radiation remains controversial as to its impact on survival outcomes, but in my opinion is certainly a consideration in those patients who have very robust responses outside the thorax and are otherwise fit.

How Do I Treat

How Do I Treat

As this disease is not curable, at some point (typically with two to four months) the disease will progress and patients will develop recurrent disease-related symptoms. I am particularly discouraged when patient develop progressive disease during initial therapy or within two to three months of completion of therapy (so-called “resistant disease”).

I discuss the limited benefits with further therapy and encourage our patients to pursue the best supportive care/hospice care options or offer them topotecan orally or intravenously. I use either a three-day regimen of topotecan or weekly topotecan regimen in this setting.

I am little bit more optimistic in offering therapy for those who progress three months after the completion of their initial therapy. Once again my choice is to use topotecan or irinotecan. I have occasionally used taxanes, vinorelbine, gemcitabine, and doxorubicin in treating patients with SCLC.

It is unfortunate that a disease that typically responds so well to begin with becomes so refractory to therapy in such a short time. I do not ever use erlotinib, imatinib, or bevacizumab in the treatment of SCLC.

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A Few Glimmers of Hope

While the past three decades of our search for a better systemic agent has drawn a blank, I do see a few glimmers of hope on the horizon—amrubicin and picoplatin, to mention a few. Let us continue to work hard and enroll patients in clinical trials.

© 2011 Lippincott Williams & Wilkins, Inc.
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