Small Cell Lung Cancer
Treatment planning
Treatments for small cell lung cancer (SCLC) are focused on managing the disease while extending life expectancy and improving quality of life. SCLC has historically had fewer treatment options than NSCLC, but that is beginning to change through research developments. New drug therapies and combinations of drug treatments are now available for both first-line and second-line use. Ongoing research is continuing to show some positive results for future treatments. As a result, a clinical trial may also be a good option for consideration.
Your treatment plan will be based on many factors:
- Whether you are newly diagnosed or are experiencing a recurrence
- The presence of symptoms
- The aggressiveness of the cancer
- Your goals of treatment
- Your lung health and overall health
You may also want to seek a second opinion or advice from an SCLC specialist. A second opinion is a way to make sure your pathology, diagnosis and staging are accurate and that you are aware of all of your treatment options.
Many SCLC patients smoked and also have chronic obstructive pulmonary disease (COPD) in the non-cancer tissues of the lung, which may interfere with lung function and alter therapeutic options. A pulmonologist, who specializes in diseases of the lung, may assess your overall lung function at diagnosis. If you currently smoke, know that stopping will help your treatment be more effective.
Treatment Types
The goal is curative when using surgery or radiation therapy to treat limited-stage SCLC that is confined to the chest. Extensive-stage SCLC is treated to prevent progression and minimize symptoms. Ask questions and share your concerns with your multidisciplinary team so you feel informed about all your treatment options. For example, if first-line therapy fails, ask about the second-line therapies that are available.
Your doctor will monitor you regularly, and you will be responsible for communicating with your health care team and keeping follow-up appointments. Keep in mind that cancer treatment plans are commonly adjusted as the cancer or your response to treatment changes. Cancer treatment is a fluid process — patience is a good asset to have.
Drug therapy is systemic therapy that may be given through an IV into a vein or a port in your body. It may also be given as an injection (shot) or orally as a pill or liquid. Types of drug therapy used to treat SCLC include chemotherapy, immunotherapy and, in some neuroendocrine tumors of the lung, targeted therapy.
Chemotherapy is systemic drug therapy that kills rapidly multiplying cells throughout the body. Because of how quickly the disease can spread, chemotherapy is the primary treatment for all stages of SCLC. It is usually delivered in cycles, with treatment periods followed by recovery periods in an on-again, off-again manner. Treatment typically consists of a combination of two drugs for SCLC.
It may be given in pill form or as a solution injected or infused intravenously (IV). Injections and IV treatments may take place at your doctor’s office or an outpatient cancer center. Additional fluids and medication may be given with IV chemotherapy to prevent side effects. Most often four to six cycles are given at three-week intervals.
In extensive-stage SCLC, chemotherapy is often combined with immunotherapy. Chemotherapy is also used for second-line treatment. If a recurrence occurs, depending on how quickly the cancer returns, the first chemotherapy combination may be used again in the second-line setting if there was a good and long lasting response to therapy. If there was not, other chemotherapies are approved to treat SCLC as second-line therapy, or a different combination of chemotherapies may be used.
Chemoimmunotherapy combines chemotherapy with immunotherapy. It is the preferred treatment for extensive-stage SCLC. Once the initial cycles are complete and testing shows no signs of cancer, you may continue on immunotherapy as continuation maintenance for up to one year.
Chemoradiation, also called chemoradio-therapy or concurrent chemoradiation, combines chemotherapy with radiation therapy. It makes cancer cells more sensitive to radiation, making it easier for the radiation therapy to kill them. Patients with limited-stage SCLC are usually treated with both chemotherapy and radiation therapy given concurrently for two of four chemotherapy cycles.
Immunotherapy stimulates the immune system to find and attack cancer. It most often is used in combination with chemotherapy (chemoimmunotherapy) as first-line therapy for extensive-stage SCLC. Its use with chemoradiation as initial therapy in limited-stage SCLC is being explored.
Immune checkpoint inhibitors are a type of immunotherapy approved to treat SCLC. Checkpoints keep the immune system “in check,” preventing an attack on normal cells by using regulatory T-cells. When the correct proteins and cell receptors connect, a series of signals is sent to the immune system to slow down once an immune response is finished. Immune checkpoint inhibitors prevent the immune system from slowing down, allowing it to keep up its fight against the cancer.
Radiation therapy, also called radiotherapy, uses high-energy radiation to destroy cancer cells and shrink tumors. It is used to treat SCLC, prevent its spread to the brain and relieve symptoms.
Radiation therapy is used for limited-stage SCLC that has not spread to the lymph nodes and that cannot be treated with surgery. It is often combined with chemotherapy in a treatment called chemoradiation.
If a complete or partial remission is seen after first-line treatment for limited-stage cancer, your doctor may offer prophylactic cranial irradiation to prevent the spread of SCLC to the brain. Before moving forward, talk with your doctor about the potential advantages and risks of this preventive approach for your specific situation.
External-beam radiation therapy (EBRT) is the most common form of radiation therapy used to treat SCLC. It delivers radiation from a machine outside the body. Types of EBRT include three-dimensional conformal radiation therapy (3D-CRT), stereotactic body radiotherapy (SBRT), intensity-modulated radiation therapy (IMRT) and volumetric arc-based therapy (VMAT), which delivers IMRT in an arc shape around the tumor.
Another type of radiation therapy that may be used is proton beam radiation therapy. It uses protons (tiny particles with a positive charge) to kill tumor cells. This type of treatment can reduce the amount of radiation damage to healthy tissue near a tumor.
Surgery is not commonly used for treating SCLC and is typically reserved for very early-stage disease. In this case, chemotherapy is administered after the surgery. However, surgery may be used more often for neuroendocrine tumors of the lung. A board-certified thoracic surgeon experienced in lung cancer should determine whether this type of tumor can be removed successfully. The procedure selected will depend on how much of your lung is affected, tumor size and location, and your overall health.
Clinical trials may offer the opportunity to try an innovative treatment that is testing drug therapies or types of surgery or radiation therapy before they are widely available. Some trials are even underway to find improved methods to quit smoking (see Clinical Trials).
Treating a Recurrence
Even with successful treatment, SCLC often returns. This is called a recurrence. Should this happen, your doctor may run more diagnostic tests to determine the next treatment option. This is a good time to discuss any questions about the second-line treatments available. Second-line therapies include other types of chemotherapy. If the cancer has progressed, immunotherapy may be added if you have not previously received it.
In rare cases, non-small cell lung cancer (NSCLC) cells can transform into SCLC. Known as transformed small cell lung cancer (tSCLC), it most often occurs in NSCLC that has the EGFR biomarker and usually contains both NSCLC and SCLC cells. Treatments may consist of combined therapies used to treat both NSCLC and SCLC.
On the Horizon
Scientists have recently discovered that SCLC has several subtypes that respond differently to chemotherapy and immunotherapy. One subtype (SCLC-I) tends to respond more to immunotherapy. More research is needed to understand how treatment affects each of these subtypes.
Research in clinical trials holds promise for new treatments to come. Several novel medications, including a new type of immunotherapy, are currently in trials and could be approved in the future. Novel anti-bodies targeting a receptor called DLL3, which is frequently expressed in SCLC, has shown promising results in clinical trials.Other research is studying chimeric antigen receptor (CAR) T-cell therapy, another type of immunotherapy. In this treatment, a patient’s T-cells are taken and a gene for a special receptor is added to the T-cells to bind to a certain protein on the cancer cells. These CARs are grown in a laboratory and given back to the patient by infusion.
Join the Lung Cancer Registry
The Lung Cancer Registry is a database of patient information that is donated by patients or by a loved one of someone who faced lung cancer. It is a direct way to improve the future of lung cancer treatment by simply sharing insights and experiences.
Participants provide data by answering questions from a home computer or mobile device about the patient, their medical history and diagnosis, treatment, outcomes and quality of life. They decide how the information will be used and whether they want to be contacted by Registry staff. No medical visits are required, and no biopsies or specimens are needed. It is free to join. To get involved, go to www.lungcancerregistry.org.
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Common Drug Therapies for SCLC Patients
These therapies may be used alone or in combination. |
| atezolizumab (Tecentriq) |
| carboplatin (Paraplatin) |
| cisplatin (Platinol) |
| doxorubicin (Adriamycin) |
| durvalumab (Imfinzi) |
| etoposide (Etopophos) |
| irinotecan (Camptosar) |
| lurbinectedin (Zepzelca) |
| topotecan (Hycamtin) |
| trilaciclib (Cosela) |
| Some Possible Combinations |
| atezolizumab (Tecentriq) with carboplatin (Paraplatin)and etoposide (Etopophos) |
| durvalumab (Imfinzi) with etoposide (Etopophos) and either carboplatin (Paraplatin) or cisplatin (Platinol) |
| etoposide (Etophophos) with cisplatin (Platinol) |
Common Treatment Terms
As you learn about your diagnosis and treatment options, you will hear many terms you may be unfamiliar with. These explanations may help you feel more informed as you make the important decisions ahead.
First-line therapy is the first treatment used.
Second-line therapy is given when the first-line therapy does not work or is no longer effective.
Standard of care refers to the widely recommended treatments known for the type and stage of cancer you have.
Progression of cancer is growth of cancer to the degree that the growth can be detected by physical exam or scans such as CT, PET or MRI.
Recurrence means cancer has returned or cancer cells have been detected again, usually after a period of time during which it could not be detected.
Response to therapy means that the cancer has reduced in size or lost its blood supply in a manner that can be measured by CT or MRI.
Partial response is a decrease in the size of a tumor, or in the extent of cancer in the body, in response to treatment.
Systemic treatments travel throughout the body and are typically drug therapies, such as chemotherapy, targeted therapy and immunotherapy.
Maintenance therapy is given to help keep cancer from coming back after it has disappeared following the initial therapy. It may include treatment with drugs, vaccines or antibodies that kill cancer cells, and it may be given for a long time.
Measurable disease indicates the amount of cancer that can be accurately measured in size. This information can be used to judge response to treatment.
Local treatments are directed to a specific organ or limited area of the body and include surgery and radiation therapy.
Maximize drug treatment benefits
Taking medication on time every time is referred to as medication adherence, and it applies to every type of treatment, including taking oral therapies at home and receiving intravenous treatments at your doctor’s office or cancer clinic. Taking your medication correctly is important because it can influence the effectiveness of the treatment and the management of side effects.
Most therapies are designed to maintain a specific level of medication in your system for a certain time based on your symptoms, overall health and other factors. If your medications are not taken exactly as prescribed, the consequences can lead to unnecessary or unrelieved side effects, physician visits, hospitalizations and even cancer progression.
For SCLC, most systemic treatments are given intravenously at an office or clinic. Keeping your schedule of treatment appointments is important for achieving the best outcome.
Medication adherence also applies to taking medications that help manage treatment side effects. People who are being treated for SCLC are often prescribed anti-nausea medications, white blood cell growth factors and drugs to combat myelosuppression, which is a decrease of red blood cells, white blood cells and platelets. Download a medication journal to keep track of your medications at PatientResource.com/Medication_Journal.
Following are suggestions to help you take medications on time:
- Ask your pharmacist to explain how to take your medications and discuss possible drug interactions.
- If the dosing schedule is complicated or you are also managing additional medications for other conditions, ask the pharmacist or your doctor whether it can be simplified so medications can be taken at the same time of day or around meals.
- Keep a treatment diary. Track each treatment, including missed doses or appointments, and detail any side effects. If you miss a dose or appointment, let your health care team know so they can determine whether you should make it up immediately or wait until your next scheduled time.
- Set up reminders for taking your medications and scheduling refills. A reminder can be an alarm on your clock or phone. Some pharmacies offer automatic refill programs.
- Try weekly pill organizers to keep track of and organize your medications.
- Find out whether you can order a 90-day prescription to lessen trips to the pharmacy, or ask whether the pharmacy offers home delivery so you don’t have to go out if you aren’t feeling well.
