Lung cancer is the most frequently diagnosed cancer in the United States. There are two main types of lung cancer: small cell lung cancer accounts for about 15% of all lung cancers; non-small cell lung cancer accounts for the other 85%.
If you have been diagnosed with small cell lung cancer (SCLC), you probably have many questions about your disease, how it is likely to be treated, and what happens when treatment is completed. These treatment summaries for cancer patients, which are based on the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™), will help you understand the best available treatments for SCLC. Talk with your doctors about these therapies so that together you can decide on a plan that is right for you.
Background
The lungs are a pair of cone-shaped organs that bring oxygen into the body as you breathe in and that release carbon dioxide when you breathe out. This oxygen is transported through the blood stream to cells throughout the body. The lungs are covered with layers of thin tissue called pleura. The left lung has two lobes, while the right lung, which is slightly larger, has three. Air reaches the lungs through the windpipe (trachea), which splits into an upside-down-Y shape. Each arm is called a bronchus and feeds air from the trachea into the lungs. Tiny air sacs called alveoli and small tubes called bronchioles make up the insides of the lungs. Chains of lymph nodes are found around the trachea and inside the lungs.
The characteristics of small cell lung cancer are very different from non-small cell lung cancer (see the non-small cell lung cancer patient treatment summaries). The two subtypes of SCLC are small cell carcinoma and combined small cell carcinoma. This summary discusses the treatments for both limited-stage (i.e., localized) and extensive-stage (i.e., widespread) SCLC, and applies to both small cell carcinoma and combined small cell carcinoma.
Nearly all cases of small cell lung cancer are caused by cigarette smoking. If you currently smoke, it is very important that you stop (tips on quitting smoking). Smoking can further reduce your lung function, which is already impaired by lung cancer and its treatments.
Small cell lung cancer is often diagnosed in a late stage (i.e., extensive or advanced stage), when it has spread beyond the lungs. About two thirds of patients with small cell lung cancer have extensive-stage disease. However, if lung cancer is found early (i.e., limited stage), it can sometimes be removed surgically before it has spread to other parts of the body. Scientists are working to develop screening tests to detect early stage lung cancer in people who do not have symptoms but are at high risk of developing cancer (for example, current or past smokers). The chance that lung cancer can be cured is better when it is found at an early stage.
Small cell lung cancer, even when it has spread beyond the lungs, is very sensitive to initial chemotherapy and radiation therapy (also called radiotherapy). However, the disease very often recurs (comes back) in the lungs or other organs.
Diagnosis of Small Cell Lung Cancer
Lung cancers may be found accidentally when a patient has a chest x-ray or CT scan for any number of health reasons. Very limited stage SCLC usually has few symptoms. However, patients with extensive-stage SCLC often have a cough that does not go away, wheezing, chest discomfort, and/or weight loss and see their doctor for these problems.
To diagnose lung cancer, the doctor will usually start with tests, including imaging tests (such as a chest x-ray or chest CT scan), to see whether there is a spot or mass in the lungs. Because a mass or spot in the lungs can be caused by benign conditions (e.g., infection, scar tissue), the only sure way to confirm or rule out cancer is with a biopsy, a procedure in which a sample of tissue from the suspicious area in the lung is removed and examined under a microscope. A sample of tissue also may be taken from nearby lymph nodes to determine whether the cancer is spreading. These samples are sent to a pathologist to determine whether cancer is present and, if so, the type of cancer and whether there is evidence of cancer in the lymph nodes. The pathology results show:
- Whether the cancer started in the lung or in some other part of the body
- Where the lung cancer began, for example, in the bronchi or alveoli
- The type of cell in which the cancer started
Your doctor will also need to know about your general health and will recommend tests to determine how well your lungs and other vital organs function. This information will help him or her recommend the treatments that are likely to be safest and most effective for you.
Small Cell Lung Cancer Staging
A formal system called staging is used to describe whether your cancer is localized or widespread. Staging is an important part of developing the best treatment plan for you because staging helps your doctors make treatment decisions and provides you and your doctors with information about what typically happens to patients with cancers most like yours.
Most doctors describe the stages of SCLC as follows:
-
Limited-stage SCLC: cancer is found in only one lung, the tissues between the lungs, and in nearby lymph nodes.
-
Extensive-stage SCLC: cancer has spread outside of the lung in which it began or to other parts of the body (metastasized).
To stage your cancer, your doctors will do several tests. Some tests are designed to find out whether the cancer has spread to sites in your body, and others are to help decide which treatments are likely to be safe and effective for you based on your general health and medical history. These tests include:
- A thorough physical exam, including questions about any symptoms you might have had, your general health, and your medical history
- Blood tests
- Chest and upper abdominal imaging such as computerized tomography (also called CT or a CAT scan)
- Brain imaging such as magnetic resonance imaging (MRI)
- Bone scan
- Pulmonary (lung) function tests if your doctor feels they are needed
- Optional PET/CT scan
To find out whether the cancer has spread to the lymph nodes near your tumor, your doctor may order surgical removal of some of the lymph nodes through a procedure called mediastinoscopy.
Treatment for Small Cell Lung Cancer
No single lung cancer treatment is right for everyone. You can make the best decision by discussing the benefits, risks, and possible side effects of each treatment described below with your doctor. The goal of treatment for patients with local disease is to cure the cancer. Sometimes several treatments working together are needed to increase the chance that you can be cured.
Treatment for small cell lung cancer involves a number of specialists who plan and work as a team to coordinate a patient’s care; treatment often uses a combination of several approaches (multidisciplinary care).
The effectiveness of treatment depends on how localized the cancer is, whether or how far it has spread in your body, and whether it is newly diagnosed or has recurred. Your treatment may involve several approaches, depending on the stage of your disease and the other indicators discussed above, and your age and general health. Many of these approaches are meant to cure or slow the progression of the disease, while others are given to reduce symptoms (especially when cancer has spread) and provide you with the best quality of life.
Your doctor should provide you with a written care plan explaining what treatments you will have, when and how often they will occur (if you will have chemotherapy or radiation), and what side effects you may experience. Some side effects can be anticipated, and treatment may reduce their severity. You will be asked to sign an informed consent document indicating that you have been told about your treatment and what to expect. It is very important that you ask your doctor or nurse every question you have. Lung cancer and its treatment are complicated, and many patients have questions.
In general, treatments rely on the following approaches:
-
Surgery: removing diseased parts of your lung
-
Chemotherapy: using drugs to kill or slow the growth of cancer cells including any that have broken away from the original tumor and spread to other parts of your body
-
Radiation therapy (or radiotherapy): using high-energy beams to kill tumor cells
-
Chemoradiation: chemotherapy drugs may be used in combination with radiation therapy in some cases
These treatments are frequently used in combination to give you the best possible chance that your lung cancer can be cured and to enable you to live a longer life.
Surgery
Surgery is only used for patients with very localized SCLC (i.e., those with very limited stage). Surgery is an option if the tumor is small and has not spread to the lymph nodes. If the tumor is larger or lymph nodes are involved, surgery is not an effective treatment for this type of lung cancer.
Your surgeon will remove the lobe of your lung where the cancer is located, including all visible tumor and many lymph nodes near the tumor. After surgery, if the cancer has not spread to the lymph nodes, your doctor will probably recommend that you have chemotherapy to remove any cancer cells that may have spread beyond the tumor. If cancer is found in some lymph nodes, you doctor will recommend combined chemotherapy and radiation.
Chemotherapy
Chemotherapy drugs are given to destroy or slow the growth of cancer cells. All small cell lung cancer patients who are in reasonably good health (aside from their cancer) require some type of systemic chemotherapy. A single drug or a combination of drugs, such as etoposide and cisplatin, is given. Some chemotherapy drugs are given by injection into a vein; others can be taken orally.
Although SCLC is usually very sensitive to the first chemotherapy that is given, most people with SCLC will eventually experience further spread of the disease.
If one type of chemotherapy becomes ineffective over time, you and your doctor may decide on a different course of therapy using different drugs. Over time, you may have several different chemotherapy regimens; usually, patients receive each type of chemotherapy until it becomes ineffective or the side effects become too great and then move on to another. See Guide to Chemotherapy.
Radiation Therapy
For most patients with limited-stage SCLC and good performance status (ability to take care of daily functions), NCCN physicians recommend that chemotherapy be accompanied by radiation therapy directed at the chest. Radiation is given to shrink the tumor; it may also be used to relieve pain and decrease symptoms. Chemotherapy drugs may be used at the same time to improve the chance for cure.
For extensive-stage SCLC, radiation therapy plays an important role in the relief (or palliation) of symptoms of the lung tumor. Radiation therapy may also relieve the symptoms of the spread of SCLC to other parts of the body, including the brain, skin, and bones.
In more than half of patients with small cell lung cancer, the cancer will eventually spread to the brain. For this reason, doctors often recommend that patients who respond well to initial chemotherapy have radiation to the brain before the cancer spreads there (this is called prophylactic treatment). Radiation will help keep the cancer from spreading to the brain and for many patients will improve their quality of life. Prophylactic brain irradiation is not recommended for patients with poor performance status or impaired mental function.
Recurrent Small Cell Lung Cancer
If your SCLC recurs, you may be a candidate for further treatment (called second-line treatment). You will probably receive a different kind of chemotherapy than you did in your initial treatment. The likelihood of responding to second-line chemotherapy depends a great deal on how much time passed between the initial treatment and relapse. If relapse occurs soon after initial treatment (less than 3 months), additional treatment will be less effective. Second-line treatment is more likely to be effective if the recurrence occurs many months after initial treatment. If the cancer recurs in the central nervous system or brain, radiation therapy or additional chemotherapy may help reduce some symptoms of the cancer in these locations.
Side Effects of Lung Cancer Treatment
Lung cancer treatments may result in uncomfortable side effects. Talk to your doctor about what to expect from each treatment and how to manage the possible effects. For example:
- After conventional surgery, people often have pain. There is also a potential for wound infections, bleeding, pneumonia, and shortness of breath. Ask the doctor in advance how these can be avoided or minimized and what will be done to treat them if they occur. Any troubling side effect should be reported right away to your doctor or oncology nurse. You should stop smoking for at least several weeks before undergoing surgery to decrease your chances of having complications after surgery.
- After radiation therapy, people are often fatigued, and some may have shortness of breath or difficulty swallowing. Your healthcare provider can use the NCCN Guidelines™ for Cancer-Related Fatigue (see NCCN Guidelines) to help you reduce fatigue due to cancer treatments. Also, see Fighting Cancer Fatigue.
- After chemotherapy or chemoradiation, people may have nausea and/or vomiting, mouth sores, hair loss, fatigue, and/or loss of appetite.
- Your doctor may give you drugs (antiemetics) to decrease or prevent nausea and/or vomiting. The NCCN Guidelines for Antiemesis can help your doctor determine the most appropriate anti-nausea treatment for your situation.
Talk to your doctor or oncology nurse about the best ways to manage side effects. It is important for you to discuss any possible side effects as soon as they appear, so that your cancer care team can take steps to relieve them or investigate them further, if necessary.
Supportive Care
Your doctor may recommend that you receive treatment to relieve disease- or treatment-related symptoms and to control pain (called supportive care or palliative care). See Palliative Care Gets New Life.
Clinical Trials
New therapies and combinations of therapies are enabling people with cancer to live longer, better-quality lives than ever before. You may want to find out whether you are eligible to participate in a clinical trial, in which new and experimental therapies are compared with standard treatments. More information is available in the Guide to Clinical Trials and Demystifying Common Clinical Trial Myths.
Life After Treatment for Lung Cancer
Once your treatment is completed, you will visit your doctor at regular intervals, which is called follow-up. Your doctor will perform a physical exam, ask you about how you are feeling, and order tests to ensure your continued good health. If cancer recurs, these visits will help your doctor to find where the cancer has recurred so that you can begin treatment. See Taking Charge of Follow up Care.
Prognosis
In determining a prognosis—the likely course or outcome of a disease and its treatment—a doctor may look at lung cancer survival statistics taken from studies of large groups of patients. However, such statistics:
- Are estimates only
- Can vary widely with each cancer stage
- Are sometimes based on older data that do not reflect recent advances in early detection and treatment
- Cannot be used to precisely predict your survival
Your individual prognosis will be affected by many factors, including:
- Your age
- Your overall health
- The stage and grade of your cancer
- Your response to the treatment(s) being used
New therapies and combinations of therapies are enabling people with cancer to live longer, better quality lives than ever before. Ask your doctor which treatment(s), in his or her judgment, will give you the best life expectancy and quality of life. Most of the improvements in the survival of patients with SCLC can be attributed to clinical trials. Eligible patients with SCLC are encouraged to enter a clinical trial.