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.

I'm going to cover the general concepts of management of brain metastases, a subject that is still evolving because of our growing technology, particularly with stereotactic radiosurgery (SRS), commonly referred to as gamma knife. In many cases, our practice has moved a bit ahead of the data. We'll start with some general issues and then, over several posts, cover issues from surgery to radiation to medical therapy.

In most of the history of lung cancer management, we have been "lumpers" rather than "splitters", tossing together many different kinds of lung cancer together and presuming that they all respond similarly and should be treated similarly.

We've established that bone metastases are common, and now we'll talk about approaches to manage pain that often accompanies them. As I mentioned previously, sometimes a metastases occurs in a weight-bearing bone, in which case we often recommend a prophylactic surgical procedure to stabilize the bone at risk for fracture. Radiation can also reduce the risk for fracture and improve pain.

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.

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.

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.

While SCLC accounts for only about 13% of lung cancer, and only approximately one third of patients with SCLC have limited disease SCLC (LD-SCLC), this remains a high stakes area with the potential for being cured, so it needs to be treated as optimally as possible. I'm going to give a brief history and highlight some of the current principles of what has developed as the current standard of care.

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.

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.