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Extensive-Stage SCLC Treatment

Extensive-Stage SCLC Treatment





·         Standard Treatment Options for Patients With Extensive-Stage SCLC
o    Combination chemotherapy
o    Radiation therapy
·         Treatment Options Under Clinical Evaluation
·         Current Clinical Trials

Standard Treatment Options for Patients With Extensive-Stage SCLC

Standard treatment options for patients with extensive-stage small-cell lung cancer (SCLC) include the following:
  1. Combination chemotherapy.
  2. Radiation therapy.
  3. Thoracic radiation therapy for patients who respond to chemotherapy.
  4. Prophylactic cranial irradiation (PCI).

Combination chemotherapy

Chemotherapy for patients with extensive-stage disease (ED) SCLC is commonly given as a two-drug combination of platinum and etoposide in doses associated with at least moderate toxic effects (as in limited-stage [LD] SCLC).[1] Cisplatin is associated with significant toxic effects and requires fluid hydration, which can be problematic in patients with cardiovascular disease. Carboplatin is active in SCLC, is dosed according to renal function, and is associated with less nonhematological toxic effects.
Other regimens appear to produce similar survival outcomes but have been studied less extensively or are in less common use.

Table 2. Combination Chemotherapy For Extensive-Stage SCLC
Standard treatment
Etoposide + cisplatin

Etoposide + carboplatin

Other regimens
Cisplatin + irinotecan

Ifosfamide + cisplatin + etoposide

Cyclophosphamide + doxorubicin + etoposide

Cyclophosphamide + doxorubicin + etoposide + vincristine

Cyclophosphamide + etoposide + vincristine

Cyclophosphamide + doxorubicin + vincristine

Doses and schedules used in current programs yield overall response rates of 50% to 80% and complete response rates of 0% to 30% in patients with ED.[2,3][Level of evidence: 1iiA]
Intracranial metastases from small cell carcinoma may respond to chemotherapy as readily as metastases in other organs.[4,5]
Evidence (standard regimens):
  1. Two meta-analyses evaluating the role of platinum combinations versus nonplatinum combinations have been published.
o    A Cochrane analysis did not identify a difference in 6-, 12-, or 24-month survival.[6]
o    A meta-analysis of 19 trials published between 1981 and 1999 showed a significant survival advantage for patients receiving platinum-based chemotherapy compared with those not receiving a platinum agent.[3][Level of evidence: 1iiA]
  1. The Hellenic Oncology Group conducted a phase III trial comparing cisplatin and etoposide with carboplatin plus etoposide.[7] The median survival was 11.8 months in the cisplatin arm and 12.5 months in carboplatin-treated patients.[7][Level of evidence: 1iiA] Although this difference was not statistically significant, the trial was underpowered to prove equivalence of the two treatment regimens in patients with either LD or ED.
Evidence (other combination chemotherapy regimens):
  1. Irinotecan. Five trials and two meta-analyses have evaluated the combination of etoposide and cisplatin versus irinotecan and cisplatin. Only one of the trials showed the superiority of the irinotecan and cisplatin combination.[8][Level of evidence: 1iiA] Subsequent trials and the meta-analyses support that the regimens provide equivalent clinical benefit with differing toxicity profiles.[9-14][Level of evidence: 1iiA] Irinotecan and cisplatin regimens led to less grade 3 to 4 anemia, neutropenia, and thrombocytopenia but more grade 3 to 4 vomiting and diarrhea than etoposide and cisplatin regimens. Treatment-related deaths were comparable between the two groups.
  2. Topotecan. In a randomized trial of 784 patients, the combination of oral topotecan given with cisplatin for 5 days was not found to be superior to etoposide and cisplatin.[15] The 1-year survival rate was 31% (95% confidence interval [CI], 27%–36%) and was deemed to be noninferior, as the difference of -0.03 met the predefined criteria of no more than 10% absolute difference in 1-year survival.[15][Level of evidence: 1iiA]
  3. Paclitaxel. No consistent survival benefit has resulted from the addition of paclitaxel to etoposide and cisplatin.[16,17]
Evidence (duration of treatment):
  1. The optimal duration of chemotherapy is not clearly defined, but no obvious improvement in survival occurs when the duration of drug administration exceeds 6 months.[7,18,19]
  2. No clear evidence is available from reported data from randomized trials that maintenance chemotherapy will improve survival duration.[20-22][Level of evidence: 1iiA] However, a meta-analysis of 14 published, randomized trials assessing the benefit of duration/maintenance therapy reported an odds ratio of 0.67 for both 1- and 2-year overall survival (OS) of 0.67 (95% CI, 0.56–0.79; P < .001 for 1-year OS and 0.53–0.86; P < .001 for 2-year OS). This corresponded to an increase of 9% in 1-year OS and 4% in 2-year OS.[23][Level of evidence: 1iiA]
Evidence (dose intensification):
  1. The role of dose intensification in patients with SCLC remains unclear.[24-28] Early studies showed that under-treatment compromised outcome and suggested that early dose intensification may improve survival.[24,25] A number of clinical trials have examined the use of colony-stimulating factors to support dose-intensified chemotherapy in SCLC.[26-34] These studies have yielded conflicting results.
o    Four studies have shown that a modest increase in dose intensity (25%–34%) was associated with a significant improvement in survival with no compromise in quality of life (QOL).[26-29][Level of evidence: 1iiA]
o    Two of three studies that examined combinations of the variables of interval, dose per cycle, and number of cycles showed no advantage.[29-32][Level of evidence: 1iiA]
o    The European Organization for Research and Treatment of Cancer trial (EORTC-08923) reported a randomized comparison of standard-dose cyclophosphamide, doxorubicin, and etoposide given every 3 weeks for five cycles versus intensified treatment given at 125% of the dose every 2 weeks for four cycles with granulocyte colony-stimulating factor (G-CSF) support.[32] The median dose intensity delivered was 70% higher in the experimental arm; the median cumulative dose was similar in both arms. There was no difference between treatment groups in median or 2-year survival.
o    A randomized, phase III trial compared ifosfamide, cisplatin, and etoposide (ICE), which was given every 4 weeks, with twice weekly ICE with G-CSF and autologous blood support.[33] Despite achieving a relative dose intensity of 1.84 in the dose-accelerated arm, there was no difference in response rate (88% vs. 80%, respectively), median survival (14.4 vs. 13.9 months, respectively), or 2-year survival (19% vs. 22%, respectively) for dose-dense treatment compared with standard treatment.[33][Level of evidence: 1iiA] Patients who received dose-dense treatment spent less time on treatment and had fewer episodes of infection.
o    A randomized, phase II study of identical design reported a significantly better median survival for the dose-dense arm (29.8 vs. 17.4 months, respectively; P = .02) and 2-year survival (62% vs. 36%, respectively; P = .05).[34] However, given the small study size (only 70 patients), these results should be viewed with caution.
Factors influencing treatment with chemotherapy
Performance status
More patients with ED SCLC have greatly impaired performance status at the time of diagnosis than patients with LD. Such patients have a poor prognosis and tolerate aggressive chemotherapy or combined-modality therapy poorly. Single-agent intravenous, oral, and low-dose biweekly regimens have been developed for these patients.[30,35-41]
Prospective, randomized studies have shown that patients with a poor prognosis who are treated with conventional regimens live longer than those treated with the single-agent, low-dose regimens or abbreviated courses of therapy. A study comparing chemotherapy every 3 weeks with treatment given as required for symptom control showed an improvement in QOL in those patients receiving regular treatment.[38][Level of evidence: 1iiDii]
Other studies have tested intensive one-drug or two-drug regimens. A study conducted by the Medical Research Council demonstrated similar efficacy for an etoposide plus vincristine regimen and a four-drug regimen.[39] The latter regimen was associated with a greater risk of toxic effects and early death but was superior with respect to palliation of symptoms and psychological distress.[39][Level of evidence: 1iiC] Studies comparing a convenient oral treatment with single-agent oral etoposide versus combination therapy showed that the overall response rate and OS were significantly worse in the oral etoposide arm.[35,40][Level of evidence: 1iiA]
Age
Subgroup analyses of phase II and phase III trials of SCLC patients by age showed that myelosuppression and doxorubicin-induced cardiac toxic effects were more severe in older patients than in younger patients and that the incidence of treatment-related death tended to be higher in older patients.[41] About 80% of older patients, however, received optimal treatment, and their survival was comparable to that of younger patients. The standard chemotherapy regimens for the general population could be applied to older patients in good general condition (i.e., performance status of 0–1, normal organ function, and no comorbidity). There is no evidence of a difference in response rate, disease-free survival (DFS), or OS in older patients compared with younger patients.

Radiation therapy

Radiation therapy to sites of metastatic disease unlikely to be immediately palliated by chemotherapy, especially brain, epidural, and bone metastases, is a standard treatment option for patients with ED SCLC. Brain metastases are treated with whole-brain radiation therapy.
Chest radiation therapy is sometimes given for superior vena cava syndrome, but chemotherapy alone, with radiation reserved for nonresponding patients, is appropriate initial treatment. (Refer to the PDQ summary on Cardiopulmonary Syndromes for more information.)
Thoracic radiation therapy for patients who respond to chemotherapy
Patients with ED treated with chemotherapy who have achieved a response can be considered for thoracic radiation therapy.
Evidence (thoracic radiation therapy):
  1. A randomized trial of 498 patients who responded after receiving four to six cycles of chemotherapy compared thoracic radiation therapy with 30 Gy in 10 fractions versus no radiation therapy. All patients received PCI.[42][Level of evidence: 1iiA]
o    OS was the primary study endpoint and not statistically different between the two groups at 1 year (33% for the thoracic radiation therapy group vs. 28% for the control group, P = .066).
o    However, in a secondary analysis, 2-year OS was 13% in the thoracic radiation group (95% CI, 9–19) versus 3% in the control group (95% CI, 2–8; P = .004). The OS during the entire course of follow-up was not reported.
o    Thoracic radiation therapy resulted in 6-month progression-free survival of 24% in the thoracic radiation group (95% CI, 19–30) versus 7% in the control group (95% CI, 4–11; P= .001).
o    Intrathoracic recurrences, both isolated (19.8% vs. 46.0%) and in combination with recurrences at other sites (43.7% vs. 79.8%), were reduced by approximately 50%.
o    Thoracic radiation therapy was well tolerated.
PCI
Patients with ED treated with chemotherapy who have achieved a response can be considered for administration of PCI.
Evidence (PCI):
  1. A randomized trial of 286 patients who responded following four to six cycles of chemotherapy compared PCI versus no further therapy.[43][Level of evidence: 1iiD
o    The cumulative risk of brain metastases within 1 year was 14.6% in the radiation group (95% CI, 8.3–20.9) and 40.4% in the control group (95% CI, 32.1– 48.6).
o    Radiation was associated with an increase in median DFS from 12.0 weeks to 14.7 weeks and in median OS from 5.4 months to 6.7 months after randomization.
o    The 1-year survival rate was 27.1% (95% CI, 19.4–35.5) in the radiation group and 13.3% (95% CI, 8.1–19.9) in the control group.[43]
o    Radiation had side effects but did not have a clinically significant effect on global health status.[43]
o    Only 29% of the randomly assigned patients had brain imaging at diagnosis.[44]
Combination chemotherapy and radiation therapy
Combination chemotherapy plus chest radiation therapy does not appear to improve survival compared with chemotherapy alone in patients with ED SCLC.

Treatment Options Under Clinical Evaluation

Treatment options under clinical evaluation for patients with ED SCLC include the following:
·         New drug regimens.
·         Alternative drug doses and schedules.

Current Clinical Trials

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients withextensive stage small cell lung cancer. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.

References

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