Addressing the Aggressive Nature of SCLC

Transcript: Benjamin P. Levy, MD: Small-cell lung cancer is a little different from non—small-cell lung cancer. It’s historically quite aggressive. It’s unforgiving, in fact. There is an urgent need such that once we make a diagnosis and there’s been a formal pathologic assessment that this is indeed small-cell lung cancer, we are mindful to get treatment started right away. I think with non–small-cell lung cancer we have a little more time sometimes. It’s not as rapidly growing, and we have to wait for molecular markers.

With small-cell lung cancer, it’s a little different. I think the goal is to make a diagnosis rapidly and then get the patient on the right treatment regimen. There are no molecular markers we’re waiting for, and all patients should receive some sort of platinum-based chemotherapy with etoposide or irinotecan regimens, now of course with immunotherapy. But the game is a little different. There’s an urgent need, and we need to be mindful of formal staging. We need to do an MRI [magnetic resonance imaging] scan of the brain, but we need to get going with platinum-based chemotherapy, with immunotherapy, as soon as possible for these patients. Oftentimes, that occurs in the hospital. Patients are admitted to the hospital for clinically decompensating from their small-cell lung cancer, and we oftentimes start chemotherapy in the hospital for these patients. This is 1 of the few types of thoracic malignancies where we will start chemotherapy in the hospital because patients do get better in a rapid fashion after chemotherapy.

We’ve tried many times to improve the outcomes for patients with extensive-stage small-cell lung cancer. Multiple different strategies have been employed. They’ve looked at adding a third drug, a chemotherapy drug, to the 2 drugs that already exist with platinum-etoposide-irinotecan. They’ve looked at novel vaccine therapies. They’ve looked at maintenance therapy. All these trials, unfortunately, have failed. Some of these have had uptake in other malignancies, but we’ve learned that this is a recalcitrant and very difficult tumor to treat.

This is why it’s so exciting to see, for the first time, an advancement in the outcomes for patients with small-cell lung cancer with the advent of immunotherapy. We’ve waited a long time. The year 1985 is really when platinum-etoposide was the standard of care for first-line treatment of extensive-stage small-cell lung cancer, and we’ve waited quite a long time to make an advancement with the advent of immunotherapy. The strategies of adding new drugs, high-dose chemotherapy, maintenance strategies, or particular targeted therapy agents, have all failed. For the first time, immunotherapy has really moved the needle. It’s a small movement in the needle, but a movement nonetheless that we should be excited about.

For patients with extensive-stage small-cell lung cancer, we need to remember that of course we’re trying to treat them with these novel immunotherapies, with chemotherapies. But we also need to institute supportive care for these patients. This really just mirrors the supportive care we offer all our patients with lung cancer. We want to make sure their pain is controlled optimally. We want to assess their appetite and make sure their appetite is addressed. Obviously, cough and shortness of breath are quite common in small-cell lung cancer, so it is important to come up with regimens that we can institute to help with that. And then we remember that small-cell lung cancer is a smoking disease, and we try very hard to institute smoking cessation. I think it’s important for patients with extensive-stage small-cell lung cancer to have discussions about goals of care. We always try to have a formal evaluation by our supportive-care team at our institution. We have those conversations in parallel, “We can treat you, but at the same time there are supportive-care needs that we need to address and be mindful of.”

Transcript Edited for Clarity