Slow Evolution of Advances in Small Cell Lung Cancer
Edward S. Kim, M.D., FACP, discusses the slow evolution of treatment options for small cell lung cancer over the past 20 years.
PUBLISHED April 30, 2019
Philippa Cheetham, M.D.: We know that small cell lung cancer had a really bad rap in terms of the treatment options that were available, and also those treatments that we were using historically, the outcomes in terms of survival were not too great. We weren’t too proud of those. Looking back 20 years ago versus where we are today, how much has the treatment of small cell lung cancer changed?
Edward Kim, M.D., FACP: If you had asked me that question two years ago, I would have said it was exactly the same. Maybe not exactly, I’m exaggerating a little bit. But it had been the one part of lung cancer that had really lagged behind. And, frankly, it was tough because there were so many advances in the non-small cell realm, both in the adenocarcinoma and squamous populations, that one thought we were never going to actually have advances in patients who were diagnosed with small cell. I think we’ve been able to add different techniques of radiation. We’ve been able to add additional radiation to the brain or to the chest because once you get small cell down, you want to try and really keep it away as best as possible. But now we’ve seen some transformative drugs occur and not just your traditional platinum and etoposide, which has been around for 30-plus years. And that doesn’t make it bad because no other drug has been able to knock it off, and so I say sometimes the oldies are the goodies there. Platinum and etoposide are still our staple, but now we have immunotherapy, which we’ve been waiting for.
Philippa Cheetham, M.D.: No cancer patient wants to hear that there have been no advances in the management of the cancer they’ve just been diagnosed with for 20-plus years. So it’s good to hear that these new treatments are not only on the horizon but are FDA approved for use today. You’ve talked already about chemotherapy, we’ve touched on radiation therapy, and we’ll talk a little bit more about that. And you’ve also already mentioned that patients’ initial reaction often is I’ve got cancer, cut it out. What is the role for surgery in the management of small cell lung cancer, if at all? And if not, why not?
Edward Kim, M.D., FACP: Luckily none of the patients who are watching this will ever have to take the boards for oncology. But the board answer is that if you have what’s determined to be an equivalent stage 1 small cell, then surgical resection is the answer. But in almost every other scenario that is a localized limited stage cancer, you’re going to use a combination of chemotherapy and radiation.
Philippa Cheetham, M.D.: So often patients are diagnosed with cancer and they say, what’s my stage? And yet there’s no understanding of what stage means, never mind the different stages. Elaborate a little bit on what you mean by stage 1 and why stage 1 is the kind of exception to the rule, if you will, for surgical resection.
Edward Kim, M.D., FACP: It’s just as you mentioned, in small cell we don’t even classify it as stages. In non-small cell, we would classify it as stage 1, 2, 3 or 4, [with] 1 meaning that it’s a single tumor or single nodule that can be safely surgically resected. Stage 2 means it could be a little larger or possibly a lymph node. Stage 3, about a third of those can have surgery, but most of them will be given radiation plus chemotherapy in the locally advanced setting. And then in stage 4, we really don’t use surgery. We use some palliative radiation but it’s mostly systemic therapy, either chemotherapy or some of the biologic agents. If you look at small cell, I clump stage 1, 2 and 3 into limited stage small cell. So that is what would encompass it, and only the exception of that stage 1A small cell. It’s not called 1A, but it’s a single nodule that’s sitting there. The woman I described earlier who had that nodule sitting for years in Louisiana, we resected it. It was one of the two resectable small cells I’ve seen in my lifetime. They just don’t happen that often.