The professional community has divided lung cancer into small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC), a word that makes a big difference. SCLC accounts for 20% to 30% of all lung cancers, compared to NSCLC. In addition, SCLC is more malignant, rapidly progressive, more prone to recurrence and bloodstream metastasis, and often ineffective with targeted therapy, which can be described as “small cells, but all five toxins”, so treatment principles are different from NSCLC.
So, how do you treat small cell lung cancer? Here’s a look at the story of Grandpa Cao, who made a miraculous difference.
Two years ago, bad news came out of nowhere. He went to the hospital with a recurrent dry cough and was finally diagnosed with small cell lung cancer in his upper left lung, which had invaded the pleura and was in an advanced (extensive) stage [cT2bN2M1a (pleural), stage IVa].
At that time, Cao was still very strong, and his physician gave him a Performance Status (PS) score of 1 (able to walk freely and perform light physical activity).
First-line treatment – EP protocol opens the way
Grandpa Cao listened carefully to his medical oncologist, thoracic surgeon, and radiation therapist, and knew that surgery was not an option. The family discussed and decided to accept the first-line chemotherapy regimen recommended by the doctors — the EP regimen (etoposide + cisplatin).
Every 21 days is a course of treatment, with the first 3 days of chemotherapy followed by 18 days of rest at home; a total of 6 courses of treatment. After every two treatments, his doctor did a chest CT to see if the tumor had changed. The best result was that the tumor shrank by nearly half (46%), which the doctor called a PR (partial response), or “partial remission.
After treatment, he went home to recuperate and had regular chest CTs, and the tumor was stable in size and had not metastasized to other parts of his body.
Second-line treatment — try nabumab
More than a year (13 months) after the last round of chemotherapy, a repeat CT of the chest and abdomen showed a problem with a significantly larger lung mass, more than 20% larger than the smallest. The doctor said this was called PD (progressive disease), which means that the “Progression-Free Survival” (PFS) from first-line treatment was 17 months. In other words, after first-line chemotherapy, the time to stabilization is close to 1.5 years.
The doctors made two recommendations: either to continue treatment with a different chemotherapy regimen, which is second-line chemotherapy, or to join the hospital’s clinical trial of Nivolumab, a new immunotherapy drug available in the United States, for second-line treatment of small cell lung cancer.
Cao’s grandfather was lucky enough to be selected for this clinical trial. He was treated every 14 days, with treatment on day 1 of each cycle. After the first cycle, a repeat chest CT showed that the tumor had shrunk by 36% and was in “partial remission” again.
Thereafter, treatment continued until 26 cycles later, when Cao’s cough worsened and his voice became hoarse, and a chest and abdominal CT showed that the disease had progressed again, with Nivolumab delivering a 1-year PFS.
He withdrew from the clinical study.
He withdrew from the clinical study.
Third-line therapy — IP regimen first seen
The doctor reassured Grandpa Cao: “Although the first- and second-line treatments failed, we still have a third-line treatment option. You’re in good shape, and it’s been well over six months since first-line chemotherapy, so we can try the first-line EP regimen again, or switch to IP (irinotecan + cisplatin) regimen chemotherapy.
After discussing with his family, Cao chose the IP regimen. The IP regimen was chosen in 28-day cycles, with irinotecan+cisplatin infusion on day 1 and irinotecan-only infusion on days 8 and 15. He was happy that his cough was significantly reduced by the end of chemotherapy on day 15 of the first cycle.
He has now completed his 1st cycle of chemotherapy and no local symptoms or brain metastases have been detected. The doctor told the family that if complications of lung cancer such as superior vena cava obstruction syndrome, obstructive pulmonary atelectasis, or distant metastases such as bone or brain develop in the future, local radiotherapy and symptomatic support therapy can also be added to chemotherapy.
It is a matter of celebration that Grandpa Cao has persevered for 2.5 years from his diagnosis of advanced small cell lung cancer to now.
Summary: The path to treatment for extensive-stage small cell lung cancer
From Grandpa Cao’s story, we can see the typical “treatment trajectory” of patients with extensive-stage SCLC, which is in line with the recommendations of our current professional guidelines.
According to the Chinese Society of Clinical Oncology (CSCO) 2017 edition of the Guidelines for the Management of Primary Lung Cancer, chemotherapy-based combination therapy is used for extensive stage SCLC. If the patient is in good health, the EP (etoposide + platinum) regimen is the classic first-line regimen, and the IP (irinotecan + platinum) regimen is also an option.
If the disease has relapsed or progressed after first-line therapy, what second-line therapy should be used? There is no uniform protocol in the profession. The National Comprehensive Cancer Network (NCCN) guidelines recommend second-line chemotherapy with topotecan if relapse or progression occurs within 6 months of first-line chemotherapy, and again with the initial regimen if it occurs after 6 months.
A subset of patients can try to participate in clinical trials of new drugs and therapies. However, it is important to note that new treatments are not effective for everyone.
The diagnosis of extensive-stage small cell lung cancer may seem desperate, but Grandpa Cao’s story tells us that we now have more and more sophisticated weapons to fight it. But having good health is the only way to tolerate multiple rounds of chemotherapy, so building confidence, maintaining a good “body count,” and actively cooperating with doctors to fight the disease to the end can work wonders.
Disclaimer:
Tumor disease and treatment options are extremely complex, and treatment should be fully individualized, and this case does not represent a treatment decision for a “similar patient. Please seek professional advice from your supervising physician regarding your specific treatment plan.
Co-authors: Dr. Yue-Li Sun Dr. Ming-Feng Zhang, Guangdong Provincial People’s Hospital, Guangdong Lung Cancer Institute