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.