Treatment Choices by Stage for Small Cell Lung Cancer
For practical reasons, small cell lung cancer (SCLC) is usually staged as either limited or extensive. In most cases, SCLC has already spread by the time it is found (even if the spread is not seen on imaging tests), so chemotherapy (chemo) is usually part of treatment if a person is healthy enough.
If you smoke, one of the most important things you can do to be ready for treatment is to try to quit. Studies have shown that patients who stop smoking after a diagnosis of lung cancer tend to have better outcomes than those who don’t.
Treating limited stage SCLC
Stage I cancers
If you only have one small tumor in your lung and there is no evidence of cancer in lymph nodes or elsewhere, your doctors may recommend surgery to remove the tumor and the nearby lymph nodes.
Very few patients with SCLC are treated this way. This is only an option if you are in fairly good health and can withstand having all or part of a lung removed.
Before the operation, the lymph nodes in your chest will be checked for cancer spread with mediastinoscopy or other tests, because surgery is unlikely to be a good option if the cancer has spread.
Surgery is generally followed by chemotherapy. If cancer is found in the lymph nodes that were removed, radiation therapy to the chest is usually advised as well. The radiation is often given at the same time as the chemo. Although this increases the side effects of treatment, it appears to be more effective than giving one treatment after the other. You might not be given radiation therapy if you already have severe lung disease (in addition to your cancer) or other serious health problems.
In about half of people with SCLC, the cancer will eventually spread to the brain if no preventive measures are taken. For this reason, you may be given radiation therapy to the head (called prophylactic cranial irradiation, or PCI) to try to prevent this. The radiation is usually given in low doses. Still, some patients may have side effects from the radiation.
Other limited stage cancers
For most people with limited stage SCLC, surgery is not an option because the tumor is too large, it’s in a place that can’t be removed easily, or it has spread to nearby lymph nodes or other places in the lung. If you are in good health, the standard treatment is chemo plus radiation to the chest given at the same time (called concurrent chemoradiation). The chemo drugs used are usually etoposide plus either cisplatin or carboplatin.
Concurrent chemoradiation can help people with limited stage SCLC live longer and give them a better chance at cure than giving one treatment (or one treatment at a time). The downside is that this combination has more side effects than either chemo or radiation alone, and it can be hard to take.
People who aren’t healthy enough for chemoradiation are usually treated with chemo by itself. This may be followed by radiation to the chest.
If no measures are taken to prevent it, about half of people with SCLC will have cancer spread to their brain. If your cancer has responded well to initial treatment, you may be given radiation therapy to the head (called prophylactic cranial irradiation, or PCI) to try to prevent this. The radiation is usually given in lower doses than what is used if the cancer had already spread to brain, but some patients may still have side effects from the radiation.
Most people treated with chemo (with or without radiation) for limited stage SCLC will have their tumors shrink significantly. In many, the cancer will shrink to the point where it can no longer be seen on imaging tests. Unfortunately, for most people, the cancer will return at some point.
Because these cancers are hard to cure, clinical trials of newer treatments may be a good option for some people. If you think you might want to take part in a clinical trial, talk to your doctor.
Treating extensive stage SCLC
Extensive stage SCLC has spread too far for surgery or radiation therapy to be useful as the initial treatment. If you have extensive SCLC and are in fairly good health, chemotherapy(chemo), possibly along with an immunotherapy drug, is typically the first treatment. This can often shrink the cancer, treat your symptoms, and help you live longer.
The most common combination of chemo drugs is etoposide plus either cisplatin or carboplatin. The immunotherapy drug atezolizumab (Tecentriq) can be used along with etoposide and carboplatin. Most people will have their cancer shrink significantly with treatment, and in some the cancer might no longer be seen on imaging tests. Unfortunately, the cancer will still return at some point in almost all people with extensive stage SCLC.
If the cancer responds well to the initial treatment, radiation to the chest may be given. This can help people with extensive stage SCLC live longer. Radiation to the brain (known as prophylactic cranial irradiation, or PCI) may also be considered to help prevent cancer progression in the brain.
Because these cancers are hard to treat, clinical trials of newer chemo drugs and combinations, as well as other new treatments, may be a good option for some people. If you think you might be interested in taking part in a clinical trial, talk to your doctor.
If cancer growth within the lungs is causing symptoms such as shortness of breath or bleeding, radiation therapy or other types of treatment, such as laser surgery, can sometimes be helpful radiation therapy can also be used to relieve symptoms if the cancer has spread to the bones or brain.
If your overall health is poor, you might not be able to withstand the side effects of standard doses of chemo. If this is the case, your doctor may treat you with lower doses of chemo or palliative/supportive care alone. This would include treatment of any pain, breathing problems, or other symptoms you might have.
Cancer that progresses or recurs after treatment
If the cancer continues to grow during treatment or comes back, any further treatment will depend on the location and extent of the cancer, what treatments you’ve had, and on your health and desire for further treatment. It’s always important to understand the goal of any further treatment before it starts – if it’s to try to cure the cancer, to slow its growth, or to help relieve symptoms – as well as the likelihood of benefits and risks.
If a cancer continues to grow during the initial chemotherapy treatment, another type of chemo may be tried, although it may be less likely to be effective. For cancers that come back after initial treatment is finished, the choice of chemo drugs depends on how long the cancer was in remission (see Chemotherapy for Small Cell Lung Cancer). Another option for people whose cancer continues to grow after two or more lines of treatment (including chemo with either carboplatin or cisplatin) is the immunotherapy drug nivolumab (Opdivo).