Treatment Choices for Small Cell Lung Cancer, by Stage

Small cell lung cancer (SCLC) is usually staged as either limited or extensive. For treatment of limited-stage SCLC, a combination of chemotherapy and radiation is usually given. For treatment of extensive-stage SCLC, a combination of chemotherapy and immunotherapy is usually given.

Treating limited-stage SCLC

If you only have one small tumor in your lung and there is no evidence of cancer in lymph nodes or elsewhere, your doctors might 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 part of a lung removed.

Before the operation, the lymph nodes in your chest will be checked for cancer with mediastinoscopy or other tests, because surgery is unlikely to be a good option if the cancer has spread there.

Surgery is generally followed by chemotherapy. If cancer is found in the lymph nodes that were removed, radiation therapy to the chest is also usually recommended. 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. If you already have severe lung disease (in addition to your cancer) or other serious health problems, you might not be given radiation therapy.

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 lobes in the same 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 a 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.

People who aren’t healthy enough for chemoradiation are usually treated with chemo by itself. This may be followed by radiation to the chest.

After giving concurrent chemoradiation to people with limited-stage SCLC and if the lung cancer has not worsened at that point, they may benefit from treatment with durvalumab (Imfinzi). Durvalumab is a type of immunotherapy drug.

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 (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.

In most people with limited-stage SCLC, tumors treated with chemo (with or without radiation) will shrink significantly. In many, the tumor 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 drugs atezolizumab (Tecentriq) or durvalumab (Imfinzi) can be used along with etoposide and a platinum drug (cisplatin or carboplatin) for initial treatment and can then be continued alone as maintenance therapy. The cancer will shrink significantly with treatment in most people, and in some, the cancer might no longer be seen on imaging tests. This combination of PD-L1 immunotherapy with chemotherapy also seems to help some people with SCLC live longer. Unfortunately, the cancer often returns at some point in almost all people with extensive-stage SCLC.

If cancer growth in 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, brain, or spinal cord.

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.

Because these cancers are hard to treat, clinical trials of newer chemo drugs and combinations, as well as other new treatments, could 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.

SCLC 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. You should understand if it’s to try to cure the cancer, to slow its growth, or to help relieve symptoms. It is also important to understand the benefits and risks.

If a cancer continues to grow during the initial chemotherapy treatment or if a cancer starts to grow after chemo has been stopped for less than 6 months, another type of chemo, such as topotecan may be tried, although it may be less likely to help. In these cases, if you are healthy enough, clinical trials are usually recommended.

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 who have already received chemo might be the immunotherapy drug tarlatamab (Imdelltra).

For more on dealing with a recurrence, see Coping With Cancer Recurrence.