Dr. Devarakonda on Second-line Treatment Options in Small Cell Lung Cancer

Siddhartha Devarakonda, MD, MBBS, assistant professor, Department of Medicine, Oncology Division, Medical Oncology, Washington University School of Medicine in St. Louis, discusses second-line treatment considerations for patients with small cell lung cancer (SCLC).

Rechallenging patients with platinum-based chemotherapy and etoposide in the second-line setting represents one potential course of action. After previously relying on only retrospective studies, prospective data demonstrated the potential benefit of rechallenging patients with platinum-sensitive relapses, Devarakonda says.

A prospective phase 3 trial (NCT02738346) conducted in France enrolled patients with histologically or cytologically confirmed advanced stage IV or locally relapsed SCLC who responded to first-line, platinum-based chemotherapy plus etoposide, but who had disease relapse or progression at least 90 days after the completion of first-line treatment.

Patients were randomly assigned to receive either carboplatin plus etoposide or oral topotecan (Hycamtin). Patients rechallenged with chemotherapy and etoposide in the second line experienced a median progression-free survival of 4.7 months (90% CI, 3.9-5.5), compared with 2.7 months (90% CI, 2.3-3.2) for those given topotecan.

However, not all patients can tolerate the chemotherapy and etoposide doublet, Devarakonda notes. Therefore, single agents may represent a better option for patients who did not tolerate platinum-based chemotherapy and etoposide well in the frontline setting, even if they are eligible for a rechallenge.

Moreover, SCLC is associated with a high rate of central nervous system (CNS) activity, as a high percentage of patients develop CNS metastases. Depending on when patients receive whole brain radiation, an intracranial response can be achieved with frontline chemotherapy, Devarakonda explains. 

Devarakonda notes that at Washington University School of Medicine, most patients receive whole brain radiation at the time of relapse. Whole brain radiation can affect performance status and may cause cytopenias, which impact a patient’s ability to tolerate chemotherapy, and this should be considered when making treatment decisions in the second-line setting, Devarakonda concludes.