Extensive Stage Small-Cell Lung Cancer - Episode 7
Naiyer A. Rizvi, MD: Small cell lung cancer [SCLC] is an aggressive disease with a dismal 5-year survival rate. However, after decades without any significant improvement in outcomes, we are beginning to see progress with immuno-oncology—based combination therapies.
In this OncLive® Peer Exchange discussion, my colleagues and I, all experts in the field of thoracic oncology, will discuss current treatment approaches for small cell lung cancer and emerging strategies.
I am Dr Naiyer Rizvi, a professor of medicine and the director of thoracic oncology at Columbia University Medical Center in New York, New York. Joining me today on this distinguished panel are Dr Taofeek Owonikoko, a professor of hematology and medical oncology at the Winship Cancer Institute of Emory University in Atlanta, Georgia; Dr Ticiana Leal, an assistant professor of hematology and oncology at the University of Wisconsin Carbone Cancer Center in Madison, Wisconsin; and Dr Jamie Chaft, an associate attending physician at Memorial Sloan Kettering Cancer Center in New York, New York.
Thank you so much for joining us. Let’s begin.
We’re going to go through a discussion of how we approach small cell lung cancer—initially discussing extensive stage, how we approach the patient, how we incorporate immunotherapy [I/O] into our treatment paradigm—and then talk a little about limited-stage disease and then some of the other treatment options that are available. Starting with Jamie, maybe you can discuss how you approach a small cell patient who you see in your office.
Jamie E. Chaft, MD: Sure. Thank you. The issue with our patients with small cell, more so than our typical patients with non—small cell lung cancer [NSCLC], is that universally these patients are quite sick. And most of them have been heavy smokers; therefore, they come with a list of comorbidities that we have to address in the clinic. The most pressing issue with most of our small cell lung cancer, particularly extensive stage, is how sick they are and how quickly we need to get things squared away for treatment. Big decisions initially are about platinum, whether we approach patients with cisplatin or carboplatin. For most patients with extensive stage, I would say the field has shifted more toward carboplatin. But getting them squared away and started on chemotherapy quickly and addressing their comorbidities are probably the largest of our challenges.
Naiyer A. Rizvi, MD: Most of the patients who we do see are extensive-stage disease for, I guess, 30/70, 80/20 extensive limited-stage disease.
Jamie E. Chaft, MD: Yeah.
Naiyer A. Rizvi, MD: Their first presentation might be hospital admission for pulmonary problems, so you’re starting chemotherapy in the hospital. It’s not uncommon for these patients to have a lot of liver metastases and a bilirubin of 5 mg/dL. What do you do for patients who have compromised organ function, and how do you handle those situations?
Jamie E. Chaft, MD: Starting chemotherapy quickly often requires dose adjustments, dose modifications for organ function. But the key here is speed: getting them staged as quickly as possible, biopsied as quickly as possible, and treated.
Naiyer A. Rizvi, MD: I think that’s right. From my experience, unlike non—small cell—where maybe you could wait and start them on treatment in the following week—they need to start the same day or the next day. Let’s say we do have a patient who we start on chemotherapy for extensive-stage disease, and they have a nice response to therapy. Taofeek, maybe you can give us your approach in terms of the number of cycles of therapy you use, which platinum you use, whether you use PCI [prophylactic cranial irradiation] in extensive-stage patients, whether you use consolidation chest RT [radiotherapy] in patients. Once you get through that initial hump, where do we go?
Taofeek K. Owonikoko, MD, PhD: Thank you, Naiyer. My approach with a lot of our patients with small cell, as Jamie already discussed, is to get them on treatment as quickly as we can and as safely as we can. From my experience treating these patients over time, I’ve tended to go with the minimum amount of chemotherapy that will get the job done, because they’re generally frail with a lot of comorbid illnesses. As we know, this is strongly associated with tobacco use, so these patients will come with a lot of cardiac as well as pulmonary compromise. And I tend to go with 4 cycles of chemotherapy for the majority of my patients with extensive-stage disease. Very rarely do I go out to 6 cycles. Occasionally when I’ve done that, it has generally been for younger patients, probably in their 40s with limited comorbid conditions, who benefited strongly after 4 cycles of treatment with ongoing response. And I try to give them just 2 additional cycles, more as insurance against something bad happening very soon. But for older patients, I go in general and I do 4 cycles of chemotherapy.
With the choice between carboplatin and cisplatin, I think while we’ve never had a head-to-head comparison of this agent to say which is better, the received wisdom has always been that we thought cisplatin would be better. But if you actually look at the meta-analysis, which looked at close to 700 patients with small cell lung cancer, some of them treated with cisplatin, some treated with CARBO [carboplatin], there did not seem to be any survival difference between them. So I tended to go with carboplatin for majority of my patients. Having said that, there are unique patient features that will make me consider cisplatin. When you have extensive marrow replacement with a lot of cytopenias, that will be 1 instance in which cisplatin perhaps would lend itself better in terms of anticipating likely toxicities.
Transcript Edited for Clarity