Treatment Update: Small Cell Lung Cancer

After diagnosis, you and your health care team will discuss the best way to proceed with your treatment based on the stage of the SCLC and other factors related to your health.

Surgery

Surgery, sometimes in combination with chemotherapy, is the most common treatment option for tumors confined to the lung. Surgery is rarely used as the main treatment for SCLC, as the cancer has usually already spread beyond the lung at the time of diagnosis.

If surgery is part of the treatment plan for SCLC, the type of surgery depends on the size and location of the tumor and the overall function of the lungs. The primary types of surgery are:

• Lobectomy. Lungs are made up of lobes—3 in the right lung and 2 in the left lung. In a lobectomy, the whole lobe that contains the tumor or tumors is removed.

• Segmentectomy (also called wedge resection). In this approach, only the part of the lobe with the tumor or tumors is removed.

• Pneumonectomy. The removal of an entire lung.

• Sleeve lobectomy. Also called a bronchial sleeve resection or sleeve resection, this is a surgical procedure in which the lobe of the lung that contains the tumor(s) is removed, along with part of the bronchi (main airways into the lungs).

Radiation Therapy

In cases where surgery is not possible, radiation therapy is sometimes used, either alone or in combination with chemotherapy. Radiation may also be used before surgery to shrink the tumor or after surgery to help prevent the cancer from recurring (coming back).

“External beam” radiation is commonly used in treating SCLC. Standard external beam radiation uses a machine, called a linear accelerator, that directs multiple beams of radiation to the tumor. The use of CT (computerized tomography) and PET (positron emission tomography) scans allows radiation oncologists to accurately target tumors, shaping the radiation beams to the size and dimensions of the tumor to help spare healthy tissue.

A newer form of radiation called SBRT (stereotactic body radiation therapy) is sometimes used in the treatment of early-stage SCLC or SCLC that has spread to only one site or a small number of sites. SBRT delivers higher doses of radiation to a small area over a shorter period of time, which destroys more cancer cells and minimizes the impact on healthy tissue. Research is ongoing to determine those people with early-stage SCLC who could best benefit from this type of focused radiation as an alternative to surgery.

Another form of radiation therapy uses streams of protons (tiny positively-charged particles located at the center of atoms) to kill tumor cells. With proton beam radiation therapy, precise doses of protons can be delivered to the exact location of the tumor with minimal doses delivered to nearby areas of the body. This type of radiation is especially useful for people whose tumor is close to a critical structure, such as the spinal cord, or who have previously received radiation.

Enhanced technologies, such as image-guided radiation therapy (IGRT) and intensity modulated radiation therapy (IMRT), may be used to help radiation oncologists treat SCLC with greater precision. Prophylactic cranial irradiation (radiation to the head) helps lower the risk of SCLC spreading to the brain. It is mostly used in the treatment of limited stage SCLC, but it may also help some people with extensive stage SCLC.

Chemotherapy

Chemotherapy, the use of drugs to destroy cancer cells by stopping the ability of the cells to grow and divide, has long been a mainstay of SCLC treatment. Chemotherapy can also be helpful for people whose tumors have (or will be) removed by surgery, and in combination with radiation (chemoradiation) for locally advanced cancer. It is also an important part of treatment for many people with advanced stage SCLC.

Chemotherapy drugs approved by the U.S. Food and Drug Administration (FDA) for the treatment of SCLC:

• Cisplatin (Platinol) and carboplatin (Paraplatin). These platinum-based drugs are the most common chemotherapies used in treating SCLC. Most chemotherapy treatment approaches include either cisplatin or carboplatin in combination with another chemotherapy drug, often etoposide (Etopophos, Vepesid) or irinotecan (Camptosar).

• Lurbinectedin (Zepzelca) and Topotecan (Hycamtin). These chemotherapies are for the treatment of metastatic SCLC that has progressed after platinum-based chemotherapy.

Immunotherapy

Our immune system is constantly working to keep us healthy. It recognizes and fights against danger, such as infections, viruses and growing cancer cells. In general terms, immunotherapy uses our own immune system as a treatment against cancer. Immune checkpoint inhibitors are a type of immunotherapy that work by releasing a molecular “brake” that prevents the body’s immune system from attacking tumors. Atezolizumab (Tecentriq) and durvalumab (Imfinzi) do this by targeting a protein called PD-L1. They are used in the first-line treatment of extensive stage SCLC, in combination with etoposide and either carboplatin or cisplatin.

All cancer treatments can cause side effects. It’s important that you report any side effects that you experience to your health care team so they can help you manage them. Report them right away—don’t wait for your next appointment. Doing so will improve your quality of life and allow you to stick with your treatment plan. It’s important to remember that not all people experience all side effects, and people may experience side effects not listed here.

Side Effects of Radiation Therapy

Fatigue is the most common side effect of radiation. Additionally, changes to the skin can frequently occur. The changes can include dryness, swelling, peeling, redness and (rarely) blistering. If a reaction occurs, contact your health care team so the appropriate treatment can be prescribed. It’s especially important to contact your health care team if there is any open skin or painful area, as this could indicate an infection. Infections can be treated with an oral antibiotic or topical antibiotic cream.

Side Effects of Chemotherapy

The side effects of chemotherapy depend on the type and dose of drugs given and the length of time they are used, and can include:

• Hair loss
• Increased risk of infection (from having too few white blood cells)
• Easy bruising or bleeding
• Changes in memory or thinking
• Peripheral neuropathy (numbness or tingling in hands and feet)

Side Effects of Targeted Therapy

Targeted therapy doesn’t have the same effect on the body as do chemotherapy drugs, but it can still cause side effects. Side effects of targeted therapies can include diarrhea, liver problems (such as hepatitis and elevated liver enzymes), nerve damage, high blood pressure and problems with blood clotting and wound healing.

Side Effects of Immunotherapy

Immunotherapy travels through the bloodstream, helping to prompt an immune response. Because it can trigger an attack on healthy cells as well as cancer cells, certain side effects may be experienced, including fatigue, decreased appetite and digestive tract symptoms.

Some side effects may occur across treatment approaches. This section provides tips and guidance on how to manage these side effects should they occur.

Managing Digestive Tract Symptoms

Nausea and vomiting

• Avoid food with strong odors, as well as overly sweet, greasy, fried or highly seasoned food.

• Eat meals that are chilled, which often makes food more easily tolerated.

• Nibble on dry crackers or toast. These bland foods are easy on the stomach.

• Having something in your stomach when you take medication may help ease nausea.

Diarrhea

• Drink plenty of water. Ask your doctor about using drinks such as Gatorade which provide electrolytes. Electrolytes are body salts that must stay in balance for cells to work properly.

• Over-the-counter medicines such as loperamide (Imodium A-D and others) and prescription drugs are available for diarrhea but should be used only if necessary. If the diarrhea is bad enough that you need medicine, discuss it with your doctor or nurse.

• Choose fiber-dense foods such as whole grains, fruits and vegetables, all of which help form stools.

• Avoid food high in refined sugar and those sweetened with sugar alcohols such as sorbitol and mannitol.

Managing loss of appetite

• Eating small meals throughout the day is an easy way to take in more protein and calories, which will help maintain your weight. Try to include protein in every meal.

• To keep from feeling full early, avoid liquids with meals or take only small sips (unless you need liquids to help swallow). Drink most of your liquids between meals.

• Keep high-calorie, high-protein snacks on hand such as hard-boiled eggs, peanut butter, cheese, ice cream, granola bars, liquid nutritional supplements, puddings, nuts, canned tuna or trail mix.

• If you are struggling to maintain your appetite, talk to your health care team about whether appetite-building medication could be right for you.

Managing Fatigue

Fatigue (extreme tiredness not helped by sleep) is one of the most common side effects of many cancer treatments. If you are taking a medication, your doctor may lower the dose of the drug, as long as it does not make the treatment less effective. If you are experiencing fatigue, talk to your doctor about whether taking a smaller dose is right for you.

There are a number of other tips for reducing fatigue:

• Take several short naps or breaks during the day.
• Take short walks or do some light exercise, if possible.
• Try easier or shorter versions of the activities you enjoy.
• Ask your family or friends to help you with tasks you find difficult or tiring.
• Save your energy for things you find most important.

Fatigue can be a symptom of other illnesses, such as anemia, diabetes, thyroid problems, heart disease, rheumatoid arthritis and depression. So be sure to ask your doctor if they think any of these conditions may be contributing to your fatigue.

Managing Pain

To help your doctor prescribe the best medication, it’s useful to give an accurate report of your pain. Keep a journal that includes information on:

• Where the pain occurs
• When the pain occurs
• How long it lasts
• How strong it is on a scale of 1 to 10, with 1 being the least amount of pain and 10 the most intense
• What makes the pain feel better and what makes it feel more intense

There are a number of options for pain relief, including prescription and over-the-counter medications. It’s important to talk to a member of your health care team before taking any over-the-counter medication to determine if they are safe and will not interfere with your treatments.

Physical therapy, acupuncture and massage may also be of help in managing your pain. Consult with a member of your health care team before beginning any of these activities.

Frequently Asked Questions

Q: My breathing has been affected by surgery and chemotherapy. What can I do about this?

A: When surgery reduces the size of the lungs, you cannot take in as much air. Some medications also change lung function and lead to shortness of breath. Any time you have difficulty breathing, you should report it to your doctor, as there is pulmonary (lung) rehabilitation therapy that may be available to you. To improve lung function, this therapy may include exercise training, energy-conserving techniques, breathing strategies and nutritional counseling.

Q: I have SCLC and recently read about trilaciclib. What is it?

A: Trilaciclib (Cosela) is designed to help protect bone marrow cells from damage caused by certain types of chemotherapy. The first therapy of its type, trilaciclib was approved by the FDA in February 2021. Protecting bone marrow function may help make chemotherapy safer and allow people to complete their course of treatment as prescribed.

Bone marrow is the spongy tissue inside bones where blood cells are made. Mature blood cells include white blood cells that fight infection, red blood cells that carry oxygen and platelets that help with blood clotting. When damaged, the bone marrow produces fewer of these cells, leading to increased risk of infection, bleeding, fatigue and other problems.

Q: What is a treatment summary and why is it important?

A: Keeping your own records up-to-date in the form of a treatment summary can be helpful, as it allows you and your family members to have instant access to the specifics of your thyroid cancer diagnosis and treatment. A treatment summary should include:

• Your name and date of birth
• Date of diagnosis
• Prescribed therapy/therapies, including dates started and stopped and dosages when appropriate
• Dates and types of baseline and post-diagnosis testing and the results of these tests
• Other medications and supplements you are taking
• Names, affiliations and contact information of all members of your health care team

Ask the members of your health care team what they suggest be included. Take your personal record with you when you visit any doctor, not just your oncologist.