Treatment Options for Extensive-Stage Small Cell Lung Cancer
My 51-year-old husband has just been diagnosed with small cell lung cancer that has metastasized to his liver. They are treating him with three days of chemotherapy every third Monday. No radiation therapy, no surgery. Yet the doctor says he has not probably had this even 6 months. What else should we do? Are they giving up on my husband before the fight even begins?
Charles B. Simone II, Radiation Oncologist at Penn Medicine, responds:
Small cell lung carcinoma is a type of lung cancer that grows very quickly if untreated. Unlike its counterpart, non-small cell lung carcinoma (such as squamous cell or adenocarcinoma), small cell lung carcinoma usually "responds" well initially to chemotherapy. This means that chemotherapy almost always works at shrinking a small cell lung carcinoma. Unfortunately, after some time period (which can vary between several weeks and several years), the cancer typically grows back and/or spreads throughout the body.
Small cell lung carcinoma is said to be "limited stage" if tests show that it has not spread beyond one side of the chest. If it has spread elsewhere, such as the liver (as in your husband's case), opposite lung or brain, it is considered "extensive stage." It is important to do appropriate testing to determine whether the cancer is limited stage or extensive stage. This always includes CT and/or MRI scans of the head, chest, liver and adrenal glands, as well as a PET/CT scan. It is sometimes also necessary to perform a biopsy of the bone marrow, liver and/or adrenal gland to make a final conclusion about stage.
There is little role for surgery in small cell lung carcinoma, unless the cancer is in a single, small and isolated spot (in other words, extremely limited-stage cancer). For most patients with limited-stage disease, radiation therapy is combined with chemotherapy – preferably soon after diagnosis. However, for extensive stage disease, the standard treatment is chemotherapy alone. There are many schedules and combinations of chemotherapy; the standard combination in the U.S. includes the drugs etoposide and a platinum drug (cisplatin or carboplatin) as described in your husband's case. In extensive-stage small cell carcinoma, radiation therapy cannot be given safely to all areas that contain cancer; thus, most physicians believe that radiation therapy should generally be reserved for management of patient symptoms, such as to treat an area that is causing pain, bleeding or other distressing symptoms. Additionally, radiation therapy to the chest in patients who have had an excellent response to chemotherapy and no residual disease outside the chest has also been shown to increase survival in one European study, but the results of this study have never been replicated in the United States. Potential benefits of thoracic radiation therapy for extensive-stage disease are currently being investigated in a multi-center clinical trial under the direction of the Radiation Therapy Oncology Group (RTOG). The addition of radiation therapy to chemotherapy can increase side effects, some of which can be serious and even life threatening. These side effects include difficulty swallowing and eating, fatigue, lowering of the blood counts (which can lead to infections and/or bleeding), skin redness, cough, pneumonia, and decreased lung function from scarring of the lungs. In limited-stage small cell lung carcinoma, the proven benefits of adding radiation therapy to chemotherapy outweigh the risks. In extensive-stage small cell lung carcinoma, the risks often outweigh possible benefits.
Instead, chemotherapy is the primary treatment for extensive-stage small cell lung cancer. Fortunately, there are a wide number of chemotherapy drugs from which to choose, and new drugs are being developed that may provide more targeted therapy with potentially fewer side effects than standard cytotoxic chemotherapy. Finally, there are treatments (both medications and non-drug therapies) to improve quality of life for people with this illness. Patients should talk frankly with their doctors about possible options for treatment, including clinical trials.