Understanding Barriers to Immunotherapy Uptake in Extensive-Stage SCLC

Despite strong evidence supporting chemoimmunotherapy as first-line standard of care for extensive-stage small cell lung cancer (SCLC) from the CASPIAN and IMpower133 trials, real-world data indicates that only 40% to 50% of patients receive immunotherapy. This utilization gap surprises the expert panel, as all 3 specialists report much higher immunotherapy usage rates in their practices and affiliated community networks. Dr Leal attributes some of this underutilization to therapeutic nihilism surrounding SCLC treatment, emphasizing the need for continued education about the subset of patients who can achieve durable responses with immunotherapy combinations.

The experts identify several barriers to optimal immunotherapy utilization, including lack of urgency in treatment initiation and inadequate recognition that immunotherapy represents the best opportunity for exceptional outcomes in SCLC. Dr Sands emphasizes that virtually any patient with adequate baseline performance status should receive platinum-based therapy with immunotherapy, even those with significant disease burden or organ dysfunction from their cancer. The panel stresses that immunotherapy offers the potential for long-term survival in a subset of patients, making access to these treatments crucial.

Practical implementation strategies focus on addressing treatment delays and optimizing inpatient care coordination. The experts recommend initiating chemotherapy during hospitalization when patients present with symptomatic disease, rather than discharging patients before obtaining pathology results. This approach prevents clinical deterioration during the transition to outpatient oncology care and ensures more patients receive optimal first-line therapy. Insurance coverage has not emerged as a significant barrier, as guideline-recommended treatments typically receive approval, making education and clinical decision-making the primary areas needing improvement.