Extensive-stage small cell lung cancer (ES-SCLC) is notoriously difficult to treat due to its aggressive nature and poor prognosis. The complexities of this cancer can lead even seasoned oncologists to overlook a few of the best practices in management unintentionally.

The use of immune checkpoint inhibitors (ICIs) in combination with chemotherapy has become the standard first-line treatment for ES-SCLC. Atezolizumab (paired with etoposide and carboplatin) got the green light in 2019, followed by durvalumab (with etoposide and cisplatin/carboplatin) in 2020. Both have shown modest but meaningful survival benefits.

Hart L, Ogbonnaya A, Boykin K, et al. Burden of chemotherapy-induced myelosuppression among patients with extensive-stage small cell lung cancer: A retrospective study from community oncology practices. Cancer Medicine. 2023;12(8):10020–10030.

As Dr. Landau puts it, “Patients who receive immunotherapy may also survive longer than people who don’t.” 

 

“Most patients do respond to the chemotherapy alone, and the cancer will usually shrink or even disappear," he continues. "We can then use immunotherapy to help prevent cancers from returning,” suggesting that oncologists adhere to the National Comprehensive Cancer Network (NCCN) guidelines to ensure standardized care. 

 

Being proactive about managing side effects

 

Chemotherapy’s side effects are a well-known challenge—hair loss, weakness, nausea, and fatigue are just the start. We’ve gotten better at managing nausea, but other side effects, particularly myelosuppression, remain a big hurdle. 

 

A review from Cancer Medicine points out that patients are being given granulocyte colony-stimulating factor (G-CSF) for neutropenia, red blood cell (RBC) transfusions or erythropoiesis-stimulating agents (ESAs) for anemia, and platelet transfusions for thrombocytopenia.

Hart L, Ogbonnaya A, Boykin K, et al. Burden of chemotherapy-induced myelosuppression among patients with extensive-stage small cell lung cancer: A retrospective study from community oncology practices. Cancer Medicine. 2023;12(8):10020–10030.

 

Plus, each treatment comes with its own set of issues: G-CSF can lead to bone pain, ESAs carry an increased risk of blood clots, and transfusions come with risks of infections and immune reactions. We must continue to focus on preventing these side effects rather than just treating them after the fact.

 

Expanding screening beyond smokers

Lung cancer screening has traditionally zeroed in on heavy smokers, but what about the 25% of lung cancer cases that occur in non-smokers?

Stephens EKH, Guayco Sigcha J, Lopez-Loo K, et al. Biomarkers of lung cancer for screening and in never-smokers-a narrative review. Translational Lung Cancer Research. 2023;12(10):2129–2145.

A 2022 JAMA Network commentary suggests that SCLC might be on the rise among never-smokers, possibly due to factors like indoor radon exposure.

Ruano-Raviña A, Provencio-Pulla M, Pérez-Ríos M. Small Cell Lung Cancer—A Neglected Disease With More Data Needed. JAMA Network Open. 2022;5(3):e224873.

 

Environmental pollutants and genetic predispositions are also likely culprits, but current screening protocols don’t fully account for these risks. Oncologists and primary care physicians need to broaden their counseling to include these lesser-known risk factors.

Stephens EKH, Guayco Sigcha J, Lopez-Loo K, et al. Biomarkers of lung cancer for screening and in never-smokers-a narrative review. Translational Lung Cancer Research. 2023;12(10):2129–2145.

 

 

Consistent definition of chemotherapy sensitivity

Chemotherapy sensitivity—essentially, how long the cancer stays at bay after first-line treatment—guides second-line therapies. However, not all centers are using the same criteria to define sensitivity.

Mennecier B, Khalifa J, Descourt R, et al. Real-life clinical management patterns in extensive-stage small cell lung cancer across France: a multi-method study. BMC Cancer. 2024;24:421.

Different treatment approaches can lead to a possible 3-month cutoff, while others have a 6-month cutoff. 

 

Dr. Landau recommends adhering to NCCN guidelines, which use a 6-month cutoff.

National Comprehensive Cancer Network. NCCN Guidelines Version 2.2024: Small Cell Lung Cancer. June 11, 2024.

 

 

Holistic approach to patient care

Dr. Landau emphasizes, “Some patients will have a weakened immune system as a result of chemotherapy. Following a diet that provides the calories and protein necessary for supporting the body, but also avoiding exposing people to infection, is important.”

He advises, "Chemotherapy is not a time to eat a rare steak or enjoy raw sushi. Foods need to be cooked thoroughly and washed. This helps to avoid exposing us to bacteria that our bodies could normally handle easily, but someone undergoing chemotherapy treatment cannot.”

Oncologists should ensure patients receive clear guidance on safe dietary practices and lifestyle modifications to minimize infection risks during treatment.