Chest
Treatment of Small Cell Lung Cancer: Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines
Section snippets
Summary of Recommendations
2.4.1 In patients with small cell lung cancer (SCLC) (proven or suspected), a staging evaluation is recommended consisting of a medical history and physical examination, CBC and comprehensive chemistry panel with renal and hepatic function tests, CT of the chest and abdomen with intravenous contrast or CT scan of the chest extending through the liver and adrenal glands, MRI or CT of the brain, and bone scan (Grade 1B).
2.4.2. In patients with clinically limited-stage (LS)-SCLC, PET imaging is
Methods
To identify relevant studies, a team of research librarians and authors conducted a comprehensive literature search using SCLC terms and an adapted therapy hedge from MEDLINE's Clinical Queries, optimized for sensitivity.4 The search was conducted in MEDLINE, Embase, and five Cochrane databases (Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, Health Technology Assessment, and NHS Economic Evaluation Database).
Staging Systems
The Veterans Administration Lung Study Group (VALSG) two-stage classification scheme has been used routinely for the clinical staging of SCLC.5 The VALSG system defines LS disease as (1) disease confined to one hemithorax, although local extension may be present; (2) no extrathoracic metastases except for ipsilateral supraclavicular lymph nodes; and (3) primary tumor and regional nodes that can be encompassed adequately in a reasonably safe radiation portal. ES disease is defined as disease
Role of Surgery
A prospective randomized trial comparing surgery and radiotherapy in the 1960s and two subsequent meta-analyses demonstrating the benefits of radiotherapy led to the initial abandonment of surgery in the treatment of SCLC.38, 39, 40 After analyzing two randomized and eight nonrandomized comparative observational studies, the second edition of the ACCP Lung Cancer Guidelines found inadequate objective evidence to categorically support any recommendation regarding surgery for SCLC, although the
Use of RT for SCLC
The use of RT for SCLC can be thought of in terms of TRT, prophylactic cranial irradiation (PCI), and RT used for the palliation of various metastases. RT has long been established as an effective palliative therapy for metastases and thus will not be reviewed here (see the symptom management article of the lung cancer guidelines53).
Use of Chemotherapy for SCLC
Two randomized phase 3 trials evaluated doxorubicin-based chemotherapy compared with platinum-based chemotherapy in SCLC. Baka and associates72 enrolled patients with either LS- or ES-SCLC who were randomized to either doxorubicin, cyclophosphamide, and etoposide (ACE) or EP for six cycles. There were no differences in response rates (72% vs 77%) or MST for LS (10.9 months vs 12.6 months) or ES (8.3 months vs 7.5 months). More grade 3/4 neutropenia and infections occurred on the ACE regimen. A
Novel Therapies
Thalidomide, believed to be an antiangiogenic agent, was tested in two trials. In a trial from the United Kingdom, 724 patients with LS (51%) or ES (49%) were randomized to thalidomide, 100 to 200 mg daily for 2 years, or placebo.89 All patients received etoposide and carboplatin every 3 weeks for six cycles. The median overall survival was 10.5 months (placebo) and 10.1 months (thalidomide) with an HR of 1.09 (95% CI, 0.93-1.27; P = .28). Among patients with LS disease there was no difference
Second-line Treatment of SCLC
Most patients who present with LS-SCLC and nearly all with ES-SCLC will develop recurrent disease. Patients with recurrent SCLC can be divided into two categories based on the likelihood of response to second-line therapy: refractory/resistant disease (primary progression or recurrence within 3 months of initial therapy) or relapsed/sensitive disease (recurrence > 3 months after initial therapy). Patients with refractory/resistant disease exhibit much lower response rates with second-line
Treatment of SCLC in the Elderly
The definition of “elderly” varies throughout the oncology literature, but most studies, including the majority of those dealing with lung cancer, define elderly as 70 years of age or older. Among patients diagnosed with SCLC, about 43% are ≥ 70 years old and 10% are ≥ 80 years old.108 Unfortunately, despite the frequent occurrence of SCLC in the elderly, the enrollment of elderly patients in clinical trials is low, and few high-quality, randomized trials have specifically focused on the
Acknowledgments
Author contributions: Dr Jett had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Dr Jett: contributed to the uniform development of the guidelines and contributions from each contributing author and is responsible for the final manuscript.
Dr Schild: contributed to the writing of all sections related to radiotherapy.
Dr Kesler: contributed to the writing of sections related to thoracic surgery.
Dr Kalemkerian:
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Funding/Sponsors: The overall process for the development of these guidelines, including matters pertaining to funding and conflicts of interest, are described in the methodology article.1 The development of this guideline was supported primarily by the American College of Chest Physicians. The lung cancer guidelines conference was supported in part by a grant from the Lung Cancer Research Foundation. The publication and dissemination of the guidelines was supported in part by a 2009 independent educational grant from Boehringer Ingelheim Pharmaceuticals, Inc.
COI Grids reflecting the conflicts of interest that were current as of the date of the conference and voting are posted in the online supplementary materials.
Disclaimer: American College of Chest Physician guidelines are intended for general information only, are not medical advice, and do not replace professional medical care and physician advice, which always should be sought for any medical condition. The complete disclaimer for this guideline can be accessed at http://dx.doi.org/10.1378/chest.1435S1.
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