Lung Cancer / Mesothelioma
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Loading ...The treatment of relapsed SCLC isn’t especially controversial, because this is an area where there aren’t enough breakthroughs. In someone fit enough to perform their own activities of daily living and getting out of the house, the main question is how long it has been since they completed their first line treatment. Although some oncologists use a threshold of 6 months and others 12 months, most oncologists are inclined to recommend returning to the initial chemo regimen (most commonly cisplatin or carboplatin with etoposide), and I do the same, with a 6 month progression-free interval as my trigger. That’s definitely a minority of patients, and for the rest I usually recommend topotecan, if we decide to pursue additional chemotherapy. Irinotecan is another reasonable option, although without a proven second line benefit, but it certainly has activity in SCLC. One of the limitations of topotecan until recently has been that it’s been available only as an IV formulation, and the standard and well studied way of giving it has been for 5 days in a row every three weeks. That’s a real pain, frankly, and the new and recently FDA-approved oral tablets that have also been shown to have the same activity will make it a far more convenient therapy for everyone.
Additional alternatives, either instead of or after topotecan, include the aforementioned irinotecan, as well as gemcitabine, the taxanes, as well as navelbine (although not alimta, as this agent has been shown to be very dependent on histology and quite underwhelming against SCLC, as described in a prior post). Among options that I might particularly consider as off the beaten path but particularly intriguing for unusually fit patients with relapsed SCLC is a combination of carboplatin/irinotecan given every three weeks, based on a clinical trial in which I participated (abstract here, manuscript submitted for publication. But this wouldn’t be considered a standard approach.
There’s also little question that clinical trials are especially appealing for relapsed SCLC, where we all hope to do better and develop newer treatments. Amrubucin has certainly generated a good deal of deserved enthusiasm (as described in a prior post), as well as some hope for picoplatin (see prior post).
That said, many of my patients with relapsed SCLC have had a marginal/poor performance status, or a disinclination to pursue aggressive anticancer therapy for relapsed SCLC when the benefits are more subtle than we’d want them to be. A significant proportion have elected to focus on maximizing their comfort and foregoing more treatment, a reasonable decision that I’ve also been happy to support.
Posted in: Extensive Disease Small Cell Lung Cancer (ED-SCLC), Lung Cancer, SCLC, Extensive Disease and Recurrent, Small Cell Lung Cancer (SCLC), Targeted therapies, Treatment
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Thank you Dr West for your approach here. It seems to me that there is precious little evidence for an advantage of one treatment over another, especially in ED-SCLC. The Japanese studies seem to be the pace-setters, but who knows whether the differences are genetic, or perhaps associated with concurrent PSK treatment. It will be interesting to see the results of the non-Japanese amrubicin trials, though I suspect that any outcome will be too late for many of us.
My wife (49) is now 2 years post diagnosis with ED-SCLC, so she is doing pretty well by most standards. She had first-line carbo/etopophos and WBR, followed by some chest radiation. Her cerebellar tumour is now cystic and the chest tumours appear stable. I was never really convinced of the effects of the chemo, rather than that the radiation was working. She has had second-line treatment with CAV after 13 months, which was largely to treat bone and liver tumours. She has just had her 9th treatment with that, but has had one episode of neutropaenic sepsis, and another recent admission for pain control from the hepatic disease. Seems the chemo is no longer working as well, so we are considering our next options. It is a shame that radiation is so toxic to livers, as the tumours seem to be quite radiosensitive. In the absence of amrubicin/picoplatin as an option, I guess paclitaxel would be the next best choice. At least there is a bit more data on it’s use. Our oncologist is not very keen on topotecan for its likely severe myelosuppressive effects. That and the unpleasant 5 day dosing regime you mentioned above. Cost/benefit doesn’t add up. She has also been on pravastatin for 18 months and zoledronic acid for 12 months.
Could you please comment on your experience with paclitaxel as a palliative second/third line treatment, and whether you would combine it with platinum?
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I haven’t used much paclitaxel in relapsed SCLC, but I think it’s likely to be in a similar range as other options — just not well tested. I have tended to favor topotecan or perhaps irinotecan in patients who hadn’t received either previously. Topotecan is certainly likely to drop blood counts, but the annoyance of a 5-day IV infusion is now neutralized by a new oral formulation. It’s also possible to give it on a weekly basis and monitor counts. Finally, irinotecan can potentially be given IV every week, two weeks, or three weeks. None of these options is especially well-studied as salvage therapy for SCLC, but these schedules for irinotecan have been used and are feasible in other oncology settings, so I’ve sometimes borrowed from literature with other cancers.
My feeling is that if I were concerned about marrow toxicity, I’d be disinclined to consider a doublet chemo regimen, especially since we just don’t have much data to support it as a treatment in the relapsed SCLC setting.
-Dr. West
-Dr. West
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