Currently, the treatment for small cell lung cancer (SCLC) involves a combination
of different chemotherapy drugs and most likely radiation therapy. It is important
to discuss current treatments with your oncologist, including the possibility
of finding a clinical trial that might be right for you. A clinical trial may
give you the opportunity to participate in the most advanced treatment available
today. The decisions that need to be made regarding your treatment should be
made in partnership with your health care team. Once you are well informed,
it is important for you to make decisions about what you want for your quality
of life and your future.
Cancer survival statistics are generally based on 5-year survival rates. You
have the best chances for long term survival if you are diagnosed with limited-stage
SCLC disease. As the disease progresses, your chances for long-term survival
may be reduced. With treatment, the median survival time for patients with
limited SCLC is 14 to 20 months. Of people diagnosed with limited-stage SCLC,
20% live 5 years or more. With treatment, the median survival time for patients
with extensive disease is 8 to 13 months. Only 1% to 5% of people diagnosed
with extensive-stage SCLC live 5 years or more. While statistics for SCLC are
discouraging, there are many people who live meaningful and productive lives
with good quality of life in the face of serious illness.
Overview of Small Cell Lung Cancer
When viewed under a microscope, small cell lung cancer cells look small and
round or oval-shaped like oat grains. The difference between small cell lung
cancer and non-small cell lung cancer (NSCLC) has to do with the specific points
of genetic mutation of the tumor that cause the cells to become cancerous in
the first place. It also involves the appearance of the cells, how quickly
each cell spreads to other parts of the body, and how each tumor cell responds
to treatment. SCLC tends to spread throughout the body more quickly and is
usually more responsive to chemotherapy than NSCLC.
SCLC is predominantly diagnosed in smokers or former smokers. Only 2% of people
diagnosed with SCLC do not have a history of actively smoking tobacco. SCLC
is an aggressive type of lung cancer. However, with treatment, people with
limited-stage disease may have long-term survival. Nonetheless, many people
diagnosed with SCLC will already have evidence of metastasis (cancer spread)
in the lymph nodes in the chest or other organs.
Small Cell Lung Cancer:
- Represents 15% of all lung cancer diagnoses
- About 98% of SCLC is attributed to cigarette smoking
- Usually starts in one of the bronchi (airway tubes) of the lungs
- Tends to grow rapidly, with tumor cells doubling every 30 days, much faster
than NSCLC
- Has commonly spread by the time of diagnosis and is considered a systemic
disease at the time of diagnosis, meaning that the cancer can spread and
affect any part of the body
- Is more responsive to chemotherapy than NSCLC
Staging of Small Cell Lung Cancer
Accurate staging of SCLC is critical, as many treatment decisions will be
based on the stage. “Limited-stage” SCLC tumors typically are on
one side of a lung, and any cancer spread is located within the area that can
be treated by radiation. Tumors that have spread outside one lung to the other
lung or other areas of the body are considered “extensive” stage.
[See the Staging Lung Cancer.]
Treatment Options for SCLC
For those with limited-stage SCLC, the primary treatment is usually combination
chemotherapy with radiotherapy to the chest. The treatment recommendations
you receive from your oncologist and the final decisions you make in partnership
with your health care team will depend in part on the stage of your disease,
your age, your general health status, and your personal goals related to treatment.
It is important to note that clinical trials generally represent state-of-the-art
treatment for SCLC, so participation in clinical trials is highly encouraged.
There is no one treatment for SCLC that has been proven effective for every
person with SCLC, so your treatment will be as individual as you are.
The following is a review of the current types of treatment as well as some
of the new therapeutic options being studied that may become available in the
future.
Surgery
Surgery is only appropriate for certain patients with early-stage (limited)
disease. As a treatment option, surgery is uncommon because frequently, SCLC
is often too widespread at diagnosis to be helped by surgically removing the
tumors.
Chemotherapy
Chemotherapy, either a single agent or multiple agents combined, is the standard
treatment for SCLC patients. SCLC appears to be very responsive to chemotherapy,
even though there is a high probability that the disease may recur. Combining
chemotherapy with radiotherapy may cure some patients with limited disease
or may simply lengthen survival and improve quality of life.
Chemotherapy drugs are usually given through a vein (intravenously) or taken
by mouth (orally). Chemotherapy travels through the body via the bloodstream
(systemically). Chemotherapy drugs destroy cells that are dividing rapidly,
which includes cancer cells. It interferes with the cell-division cycle so
that cells cannot divide or are damaged and cannot repair themselves. Chemotherapy
drugs also affect normal cells of the body, such as blood cells, skin and hair
cells, and the cells lining the mouth and intestines.
Chemotherapy treatment regimens are tailored to the needs of each person.
You and your doctor will develop a chemotherapy treatment plan based on the
type of lung cancer you have, how widespread it is, and your general state
of health. It is important for you to have an open and direct conversation
with your doctor about your goals of therapy and potential treatment options,
weighing both the potential effectiveness of the treatment with the potential
side effects.
Even if chemotherapy does not cure the disease, studies have shown that it
can help people with SCLC live longer and more comfortably.
Chemotherapy can be used to:
- Shrink the tumor
- Slow cancer’s growth
- Keep the cancer from spreading
- Relieve disease-related symptoms
- Prolong life
Radiation for SCLC
Radiation therapy combined with chemotherapy can cure some patients with limited
disease, and may lengthen survival and improve quality of life in others. Many
people with SCLC need radiation therapy at some time during their illness,
either as an attempt at curative treatment or as a means of providing symptom
relief (palliation) when cure is not possible. Cancer specialists, called radiation
oncologists, provide this specialized treatment.
The amount of radiation used varies, based on the size and location of the
tumor and the sensitivity of the normal tissue surrounding the tumor. The timing
and dosing of radiation (called fractionation) in treating SCLC is now the
subject of study in clinical trials. This includes evaluation of using fractionated
radiation therapy once daily or twice daily.
Treatment of Small Cell Lung Cancer by Stage
Limited-Stage SCLC Treatment
The National Cancer Institute (NCI) recommends the following treatment options
for limited-stage SCLC:
The current standard treatment for patients with limited-stage small
cell lung cancer (SCLC) should be a combination containing etoposide and
cisplatin plus chest radiation therapy that is usually administered during
the first or second cycle of chemotherapy administration.
Standard treatment options:
(revised 01/07/04, based on NCI's Small
Cell Lung Cancer: Treatment for Limited-Stage Small Cell Lung Cancer)
- Combination chemotherapy with one of the following regimens and chest irradiation
(with or without prophylactic cranial irradiation given to patients with
complete responses)
The following regimens produce similar survival outcomes:
- EC: etoposide (Vepesid®) + cisplatin (Platinol®) + 4000-4500
cGy chest radiation therapy
- Combination chemotherapy (with or without prophylactic cranial irradiation
in patients with complete responses), especially in patients with impaired
pulmonary function or poor performance status.
- Surgical resection followed by chemotherapy or chemotherapy plus
chest radiation therapy (with or without prophylactic cranial irradiation
in patients with complete responses) for patients with limited-stage disease.
Extensive-Stage SCLC Treatment
The National Cancer Institute (NCI) recommends the following as possible treatment
protocols for extensive-stage SCLC:
Standard treatment options:
(revised 01/07/04, based on NCI's Small
Cell Lung Cancer: Treatment for Extensive-Stage Small Cell Lung Cancer)
- Combination chemotherapy with one of the following regimens, with or without
prophylactic cranial radiation in patients with complete responses:
- CAV: cyclophosphamide (Cytoxan®)
+ doxorubicin (Adriamycin®) + vincristine
(Oncovin®)
- CAE: cyclophosphamide (Cytoxan®)
+ doxorubicin (Adriamycin®) + etoposide (Vepesid®)
- EP or EC: etoposide (Vepesid®)
+ cisplatin (Platinol®) or carboplatin (Paraplatin®)
- ICE: ifosfomide (IFEX®)
+ carboplatin (Paraplatin®) + etoposide (Vepesid®)
- Cisplatin (Platinol®)
+ irinotecan (Campto®)
Other regimens that appear to produce similar survival outcomes
but have been studied less extensively or are in less common use include:
- Cyclophosphamide (Cytoxan®) + doxorubicin (Adriamycin®) + etoposide
(Vepesid®) + vincristine (Oncovin®)
- CEV: Cyclophosphamide (Cytoxan®) + etoposide (Vepesid®) + vincristine
(Oncovin®)
- Single-agent etoposide (Vepesid®)
- PET: cisplatin (Platinol®) + etoposide (Vepesid®) + paclitaxel
(Taxol®)
- Radiation therapy to sites where the cancer has spread to reduce the size
of tumors and relieve symptoms, especially brain, spine, or bone
metastases
- Various drugs are currently being investigated in clinical trials for the
first-line treatment of SCLC, such as topotecan (Hycamtin®)
and paclitaxel (Taxol®)
Second-Line SCLC Treatment
If cancer is found again within 2 years, it is assumed to be a recurrence
of the original cancer and treated with second-line chemotherapy, assuming
you are healthy enough and willing to tolerate any additional side effects.
The goal of therapy for patients with progressive or recurrent small cell lung
cancer is generally more focused on quality of life and symptom management
than cure.
The National Cancer Institute (2002) states that while no single chemotherapy
regimen should be considered standard, there are some treatment options that
have shown promise if small cell lung cancer continues to grow during or after
initial chemotherapy. For some patients, phase I or phase II clinical trials
may provide the best treatment options for recurrent SCLC disease.
The treatment for recurrent small cell lung cancer may include the
following:
- Palliative radiation therapy to relieve symptoms and improve quality of
life
- Chemotherapy treatment with any of the following:
- Topotecan (Hycamtin®)
- Oral etoposide (Vepesid®)
- EC: etoposide (Vepesid®) + cisplatin (Platinol®)
- CAV: cyclophosphamide (Cytoxan®) + doxorubicin (Adriamycin®)
+ vincristine (Oncovin®)
- Paclitaxel (Taxol®)
- Irinotecan/CPT-11 (Camptosar®)*
*Although not listed in the current NCI Guidelines,
this drug is in widespread use for recurrent SCLC based on increased
benefit found in clinical trials.
- Lomustine (CeeNU®)/methotrexate**
**Although listed in the NCI Guidelines, lomustine/methotrexate
is an old regimen that is almost never used in the treatment of recurrent
SCLC.
Although not listed in the current NCI Guidelines,
some other drugs are currently in clinical trials, including some
of the following: ifosfamide (Ifex®), vinorelbine (Navelbine®),
gemcitabine (Gemzar®), irinotecan/CPT-11 (Camptosar®) and docetaxel
(Taxotere®).
References for the treatment of small cell lung cancer are
from the National Cancer Institute, Treatment for Small Cell Lung Cancer
2002 and from
the medical consultants for Frankly Speaking About Lung
Cancer. A current listing
of clinical trials in small cell lung cancer can be found at the National
Cancer Institute.
As you can see, there are a variety of chemotherapy drugs used to treat recurrent
small cell lung cancer. It is important to discuss any symptoms or concerns
with your health care team. Remember that while many side effects can be prevented
or controlled, it is still important to take into account your goal of therapy
and the potential side effects when devising your treatment plan with your
oncologist.
