|
|
|
Optimal Duration of Therapy for First-Line Advanced Lung Cancer
The guidelines from the American Society for Clinical Oncology (ASCO) for NSCLC start the discussion on how long to continue first-line chemo as follows: “The optimal duration of chemotherapy remains a matter of debate.” Just in case you thought it was only me saying that we don’t know the exact answer for one issue or another, the evidence-based guidelines are filled with hedge comments like this. So I’ll cover what we know and what we don’t know, and how it leads most oncologists to give between 4 and 6 cycles of platinum-based doublet chemotherapy for either advanced NSCLC (“wet” stage IIIB with a malignant pleural effusion or metastatic/stage IV) or ED-SCLC. Continue reading
Treatment of Recurrent SCLC: Evidence for Survival Benefit
As I mentioned in my introduction to the topic, SCLC is typically sensitive to chemo and radiation initially, but it tends to be considerably less responsive after recurrence. Unfortunately, most SCLC patients, or about 75-80% of patients with LD-SCLC and nearly 100% of patients with ED-SCLC , do subsequently recur. One key theme is that the longer patients go between ending first-line treatment and developing a recurrence, the better they are likely to do with any treatment. Such patients are generally divided into those with “resistant” or “sensitive” disease, depending on whether recurrence occurs before or after a 2-3 month period (some define the break point at 2 months, others at 3). It is felt that since initial chemo effectively treats the sensitive disease, the time before recurrence essentially measures the proportion of sensitive vs. resistant cancer cells. Oncologists have generally found the treatments for resistant SCLC to be minimally effective (fewer than 10% of patients respond), but even for more sensitive SCLC (where response rates can be in the 30-40% range in some trials), we have not had good evidence that patients receive significant benefit compared with the side effects. Many patients are in pretty marginal condition for more treatment, and the benefits have appeared to be modest. Accumulating evidence, however, now supports single-agent chemo, most often with topotecan/Hycamtin, and a just reported trial shows a significant improvement in survival compared to supportive care alone. Continue reading
Maintenance Chemotherapy for Extensive-Disease Small Cell Lung Cancer (ED-SCLC)?
As I described in a post describing the general principles of SCLC, it is typically responsive to treatment initially, but upon recurrence it is much less likely to respond. Given that pattern, the value of maintenance therapy has been tested in ED-SCLC, where treatment with initial standard doublet chemo was followed immediately by single-agent “maintenance chemotherapy”, in hopes of delaying progression to a point where a resistant, progressive SCLC emerges. Continue reading
Prophylactic Cranial Irradiation for SCLC
Prophylactic cranial irradiation, or PCI, for SCLC, usually limited disease (LD-SCLC), remains a controversial issue, although this is generally recommended for patients with LD-SCLC who have a complete response to treatment (no evidence of disease). However, the idea of radiating the brain of someone who has no evidence of cancer there and may never get it is something that many patients and also some oncologists (radiation oncologists and medical oncologists) may not embrace. So how did we get to a point where we standardly recommend radiation to prevent brain metastases from developing?
Well, as I mentioned in previous posts, the brain is remarkably fertile soil for brain metastases for SCLC, which has a consistent propensity to spread there. In some studies, up to two thirds of patients with SCLC who don’t receive PCI develop brain metastases within two years. Several small trials in the 1970s and 1980s consistently showed a reduced risk of developing brain metastases but no clear improvement in survival from PCI, although these trials were really too small to show any significant benefits. Continue reading
Old and New Approaches to Initial Treatment of Extensive SCLC
While progress in small cell lung cancer (SCLC) has been slow, over the past few years there have been leads in management of extensive disease that have introduced a potential change in the standard of care based on better results. Extensive disease SCLC, or ED-SCLC, is defined by having cancer that has spread outside of the region that can safely be covered by a radiation port (more details and relevant figure in SCLC 101 post), and this accounts for approximately two thirds of SCLC cases. Patients can often show very rapid cancer progression and clinical deterioration, but fortunately initial treatment very often leads to rapid and dramatic improvement, although we are not able to cure ED-SCLC.
Small Cell Lung Cancer 101: An Introduction
After several weeks of posts on other aspects of lung cancer, I am long overdue to write on small cell lung cancer (SCLC). Although it is good to see the number of SCLC cases decreasing over time, and becoming a smaller and smaller percentage of lung cancer cases overall (only about 13% in the US and steadily falling), this has translated into fewer clinical trials and less of a focus on SCLC in the lung cancer community. However, there are some promising developments that may lead to some long overdue progress in the field.
First, this post will start with some general concepts and an introduction to SCLC, and this will be followed in the next few weeks by posts describing current and emerging ideas for the basic stages of small cell lung cancer, and also a discussion of prophylactic cranial irradiation for small cell, where it has been most extensively studied. Continue reading
| Follow us on... |    |
||
Copyright ©2012 GRACE |
|||