Small Cell Lung Cancer
Treatment planning
Having an open and honest conversation with your doctor will be important as you begin making decisions with your health care team about the best treatment for you and your desired quality of life. Your treatment plan will be based on whether you are newly diagnosed or are experiencing a recurrence, the symptoms you have, how aggressive the cancer is, the stage of the cancer, your goals for treatment as well as your ability to travel for treatment, if necessary, and your overall health.
This is also a good time to discuss the risks and benefits of specific treatments and procedures. Share any concerns you have with your care team and ask about potential side effects, both physical and emotional that you may experience.
While you are making decisions about which path forward is the best for you, this may be a good time to seek a second opinion or advice from a small cell lung cancer (SCLC) specialist. You are encouraged to get another opinion from a doctor who is experienced in treating SCLC. Getting a second opinion is also a way to discover whether your pathology, diagnosis and staging are accurate.
Types of Treatment
Your doctor will develop your treatment plan starting with stage (see Staging, page 4). Limited-stage SCLC, which includes Stages I to III, is typically treated with chemotherapy, radiation therapy and/or immunotherapy to cure the cancer. Extensive-stage SCLC, which is Stage IV, is treated to prevent progression and minimize symptoms.
As you discuss your options with your doctor, keep in mind that it is common for the first therapy given to stop working at some point. Before you begin treatment, talk to your doctor about maintenance therapy, which will be an important part of your overall treatment plan. In some cases, you may receive second-line therapy as well. The goal of maintenance therapy is to delay a recurrence. It is very common to have to adjust a care plan. Knowing this in advance, and being patient when changes are necessary, is a good strategy to have.
Drug therapy is a type of treatment given intravenously (IV) into a vein or port in your body, as an injection (shot), under the skin (subcutaneously) or orally as a pill or liquid. 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. Following are the types of drug therapy that may be used to treat SCLC.
Chemotherapy, which kills rapidly multiplying cells, is the primary treatment for all stages of SCLC because of how quickly the disease can spread. It may be given alone or in combination with surgery, radiation therapy or immunotherapy. For limited-stage SCLC, chemotherapy may be combined with radiation therapy to the chest. In extensive-stage SCLC, chemotherapy may be combined with immunotherapy. Chemotherapy is also used for second-line and maintenance treatment. Most often chemotherapy is given at three-week intervals for four to six cycles. This therapy is used to destroy cancer cells, prevent progression or slow the cancer’s growth.
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 maintenance. This treatment is typically given intravenously, but one drug has been approved to be given beneath the skin (subcutaneously).
Immunotherapy stimulates your immune system to find and attack cancer. Most often it is used in combination with chemotherapy (chemoimmunotherapy) as first-line therapy for extensive-stage SCLC. It may also be combined with chemoradiation. It may also be used for limited-stage SCLC after chemotherapy.
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. Immune checkpoint inhibitors prevent the immune system from slowing down, allowing it to keep up its fight against the cancer.
Another type of immunotherapy uses a bispecific T-cell engager to attack the cancer from two angles. A laboratory-made molecule is connected to a T-cell, which is part of the immune system, and to the cancer cell. When the T-cell and cancer cell are linked, it triggers the T-cell to attack and destroy the cancer cell. It may be used as a second-line treatment for extensive-stage SCLC after chemotherapy and the cancer has returned.
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 cannot be treated with surgery. It is often combined with chemotherapy. It is also approved for extensive-stage SCLC.
If a complete or partial remission is seen after first-line treatment for limited-stage cancer, your doctor may offer prophylactic (preventive) cranial irradiation (PCI) to prevent the spread of SCLC to the brain. Before moving forward, talk with your doctor about the potential advantages and risks of this 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), tereotactic body radiotherapy (SBRT), intensity-modulated radiation therapy (IMRT) and volumetric arc-based therapy (VMAT), which delivers IMRT in an arc shape around the tumor.
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 (Stage I), which is uncommon. In this case, chemotherapy is administered after the surgery. A board-certified thoracic surgeon, who has special training in operating on organs inside the chest and is experienced in lung cancer surgery, 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 are research studies that may offer the opportunity to try an innovative treatment being tested, such as drug therapies, types of surgery or radiation therapy, before they are widely available. Some trials are even underway to find improved methods to quit smoking. Patients with SCLC that returns after first-line therapy may be considered for a clinical trial. Treatment advances for SCLC have been slow. Joining a clinical trial may be a valuable option. All of the treatments available to treat cancer today are a result of someone participating in a clinical trial and contributing to the future of cancer care.
Several new drugs and drug combinations are being tested in clinical trials. The newest chapter in SCLC treatment includes antibody drug conjugates (ADCs) and PARP inhibitors as well as other novel therapies. An ADC is a type of monoclonal antibody (mAb) that binds to specific proteins or receptors found on certain types of cells, including cancer cells. The linked chemotherapy drug enters these cells and kills them without harming other cells. PARP inhibitors are a type of targeted therapy that blocks an enzyme in cells called PARP, which helps repair DNA when it becomes damaged. Blocking PARP may help keep cancer cells from repairing their damaged DNA, causing them to die.
Understanding Recurrence
Recurrence happens when some tiny cancer cells remain in your body after treatment. Over time, these cells divide and grow into cancer again. It may come back in your lungs or a different part of your body, such as the brain, opposite lung, bone or liver.
SCLC is an aggressive form of cancer that usually responds well initially to treatment with chemoradiation therapy. But after a period of time, the cancer develops resistance to chemotherapy and returns. This is called a recurrence, and it is common in SCLC patients. Should this happen, your doctor may run more diagnostic tests to determine the next treatment option.
Being aware that the cancer may return after your initial therapy is important. Treatment options after first-line therapy failure will depend on how soon the recurrence happens after treatment ended as well as whether the cancer is limited-stage or extensive-stage.
Catching a recurrence as soon as possible will help your doctor determine the next best treatment for you. A recurrence may be caught through routine follow-up screening with scans or bloodwork. Or, you may experience symptoms that you should share with your health care team right away, including:
- A cough that doesn't go away
- Chest pain
- Shortness of breath
- Lung infections, such as bronchitis and pneumonia
- Blood when you cough
- Pain
- Fatigue
- Skin issues
- Fever
- Unexplained weight loss
Get immediate help for sudden or serious symptoms, such as high fever, severe pain or difficulty breathing.
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.
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) |
| atezolizumab and hyaluronidase-tqis (Tecentriq Hybreza) |
| carboplatin (Paraplatin) |
| cisplatin (Platinol) |
| doxorubicin (Adriamycin) |
| durvalumab (Imfinzi) |
| etoposide (Etopophos) |
| irinotecan (Camptosar) |
| lurbinectedin (Zepzelca) |
| tarlatamab-dlle (Imdelltra) |
| 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) |
Understanding the treatment order for people with SCLC
Knowing the order in which treatments are given is important. You will likely hear the following terms.
- Front-line therapy, sometimes called initial or first-line therapy, is the first treatment given for a disease. It is often part of a standard set of treatments, such as chemotherapy and radiation therapy. If it does not cure the disease or causes severe side effects, other treatment may be added or used.
- Maintenance therapy can be given after first-line therapy. It is given to help keep cancer from coming back after it has disappeared following therapy.
- Second-line therapy is treatment given when initial treatment or initial treatment plus maintenance therapy does not work or stops working.
It is important for you to realize there are treatment options past the first line. Some people mistakenly believe that if the first treatment fails or stops working, they have no other options. However, recent advances in treatment now offer several second-line options.
It is a good idea to discuss your full treatment plan with your doctor before treatment even begins. If your doctor does not bring it up, ask them what options may be available if the cancer were to return after the first treatment.
