Best-practices in the treatment of small cell lung cancer

This article reviews current evidence on best treatment options for small cell lung cancer.

Small cell lung cancer represents about 15% of all lung cancer cases. Unfortunately, small cell lung cancer is aggressive, with fast development of metastases to other parts of the body. Currently, there are several therapeutic options for patient which have been proven to delay disease progression. Chemotherapy is usually employed as first-line treatment, given as one of several regimens. Radiation treatment can be directed at the affected side of the chest. It may also be directed at the brain, to prevent or delay the appearance of brain metastases.

The present review analyzed data from large clinical trials to determine best-treatment options for small cell lung cancer patients.

For the treatment of extensive small-cell disease, although only limited clinical data exists, data supports the use of chemotherapy instead of symptomatic supportive care. Research supports the use of a platinum-based chemotherapy regimen, which includes drugs such as cisplatin (Platinol) or carboplatin (Paraplatin). If these regimens are not tolerated, patients should receive a non-platinum regimen. Cisplatin and carboplatin were found to have similar benefits, and one should consult with a physician regarding the possible side-effects and tolerance of each. In the treatment of patients with extensive disease, the recommended first-line chemotherapy regimen should also contain an etoposide.

For the treatment of limited stage small-cell disease, radiation therapy (directed at the affect chest) plus chemotherapy is the current standard of care. Best clinical results were achieved when radiotherapy was given early and in combination with chemotherapy rather than sequentially, but combination therapy was associated with significantly more side-effects.

Prophylactic cranial irradiation, radiation therapy directed at the head and brain, intended to prevent or delay the appearance of brain metastases, was thoroughly investigated. Research supports the use of prophylactic cranial irradiation in all patients who respond to initial treatment. However, the long-term effects of prophylactic cranial irradiation on brain function have not been adequately investigated, mostly due to limited survival.

Among patients who respond to initial treatment, current research does not support continuing low dose chemotherapy, known as maintenance chemotherapy. Maintenance chemotherapy so far has not been shown to significantly delay disease progression. The addition of hematopoietic progenitors, or colony-stimulating factor, to chemotherapy is thought to allow for larger therapeutic doses with fewer side effects. However, evidence does not support the use of colony-stimulating factor in small-cell lung cancer as a protective measure.

Among patients who experience cancer relapse after treatment, only few have proven effective in further delaying disease progression. Options include the use of chemotherapeutic agents such as topotecan and doxorubicin or amrubicin in patients who have not yet been treated with these agents. However, evidence suggests that additional chemotherapy after relapse only offers limited benefit compared to best supportive care.