This bit of news slipped under the radar for the past six weeks, but oral topotecan was approved by the FDA for the treatment of SCLC that has recurred at least 45 days after the last chemotherapy had been given. I'm a little embarrassed to say that I hadn't noted this, but it really got very little airplay. Part of it is that topotecan was already available and approved for recurrent SCLC in its IV form.

I wrote about the drug amrubicin in a prior post, after it demonstrated provocative activity in clinical trials out of Japan that were presented at ASCO 2007. Additional result on amrubicin in previously treated ED-SCLC were presented at a NYC meeting last week, and it's continued to look very encouraging in a clinical setting in which we could really use more options.

We've always been tempted to see if we can add more to standard approaches to improve our outcomes. In SCLC, people have attempted to add taxol to cisplatin and etoposide as part of the PET regimen (platinum + etoposide + taxol). Although heavily tested, it clarified that triplet therapy with standard chemo for SCLC appears to be associated with no improvement in outcomes but with a very significant improvement in side effects, including risk of dying from treatment.

The fact is that lung cancer, like many others, is a disease disproportionately affecting older populations, with the median age now in the 69-70 range.

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I recently received a question on the Q&A Forum about the use of cisplatin vs. carboplatin in SCLC. In contrast to the smoldering debate about cisplatin vs. carboplatin in NSCLC that I described in a recent post, there's been very little study and not as much debate about SCLC.

In a talk at ASCO 2007, I was asked to present some commentary on a couple of phase II, single arm trials of patients with ED-SCLC that were reported by two different cancer cooperative groups in the US, each adding the anti-angiogenic agent Avastin (bevacizumab) to standard chemotherapy options in this setting.

As I described in prior post, prophylactic cranial irradiation (PCI) is established as a treatment approach for patients with LD-SCLC who have had a complete or "good partial" response to chemo and radiation. Some physicians also recommend PCI for patients with ED-SCLC who have experienced a very good response, since about 10% of the patients on the PCI trials that led to our current recommendations had ED-SCLC.

The AVAiL trial in first-line advanced NSCLC, based in Europe, was designed to confirm the role of avastin with chemo using a different regimen of cisplatin and gemcitabine with a placebo or Avastin at 7.5 or 15 mg/mg every three weeks (the European trial was placebo-controlled, unlike the US-based Avastin trial with carbo/taxol). I described it in a prior post that described a glimpse of the results that were reported in a press release a few months ago, but we received more information at ASCO.

A member recently asked me whether treatment in the second-line or later setting for advanced lung cancer would potentially improve survival at a cost of quality of life, or whether patients can benefit not only in terms of how long they live but also how they live during that time. Since advanced lung cancer, both NSCLC and SCLC, aren't generally able to be approached with curative intent, it's important for the treatment not to be worse than the disease. Ideally, patients will even feel better with treatment, rather than have to choose between quality of life (QoL) and quantity of life.

Small cell lung cancer (SCLC) has been a very challenging disease for patients and physicians, and unfortunately one in which our improvements in treatment have been few and far between. In fact, a recent educational session at ASCO was titled "Small Cell Lung Cancer: What's New Since 1978?". The decreasing frequency of SCLC has also made it increasingly difficult to study, but even when the studies are completed, many emerging potential therapies have proven to have no benefit.