Treatment Options for Recurrent Small Cell Lung Cancer
I am a 42-year-old male who has been treated for small cell lung cancer. I had a large tumor in my right upper lobe, as well as cancerous lymph nodes on both sides of my neck. I received 6 cycles of chemotherapy with carboplatin and etoposide on a 3-week cycle, along with radiation therapy to my upper lung and chest beginning with my fourth cycle of chemotherapy. I then received radiation therapy for the lymph nodes in my neck. My last chemotherapy was 4 months ago. Today, I was told that I have a massive amount of nodes in my chest and 3 tiny spots on my liver. My oncologist has put me on a schedule to receive a one-day treatment of chemotherapy for this but admits it will be more for quality of life than for any kind of cure. Are there any other options for me?
Barbara Campling, MD, Medical Oncologist, responds:
The two chemotherapy drugs that you received are fairly standard treatment for small cell lung cancer. Usually small cell lung cancer responds very quickly to chemotherapy and radiation therapy. When this happens patients usually feel much better, despite the unpleasant side effects of the treatment.
Your story is quite typical of the way that small cell lung cancer behaves. Initial responses to treatment are often quite dramatic, but when the tumor is more extensive at diagnosis, such as in both sides of the neck in your case, it almost invariably recurs. When that happens, the cancer is more difficult to treat, because the tumor cells become resistant to chemotherapy. Even drugs that have completely different mechanisms of action from the drugs used during your initial course of chemotherapy do not work as well. After recurrence, the chance of responding to further chemotherapy is higher if the interval from the initial treatment to the recurrence has been prolonged. Responses to "second-line" chemotherapy are typically not as dramatic as the initial responses. If it has been many months from the time of initial treatment to the time of recurrence, often the drugs that were used initially can be used again.
In someone that has completed therapy less than 6 months ago, it is unlikely that the same chemotherapy agents, such as carboplatin and etoposide, will work again. There is some chance of response to other chemotherapy drugs, although the chances are not high. Much has been learned about how lung cancer cells acquire resistance to chemotherapy. Unfortunately, however, there is not currently a successful way to overcome drug resistance for small cell lung cancer. A number of different chemotherapy drugs could be used as second-line therapy, including irinotecan, topotecan, gemcitabine, or taxol. It would also be worth looking into if there are any clinical trials being done in your area for patients with recurrent small cell lung cancer. However, regardless of the treatment that you pursue, these agents do not offer realistic hope of long-term response or cure.
What would happen if you decided not to have any treatment at this point? The goal of further chemotherapy is to make you feel better, delay the development of symptoms related to your cancer, and potentially prolong your life. If you are free of symptoms at the moment, there is no urgency to receive second-line treatment. On the other hand, small cell lung cancer often grows rapidly and can quickly cause symptoms. If you are interested in chemotherapy in the future, you would want to make sure you do not delay treatment too long, at which point the cancer may cause you more advanced symptoms and you may not be well enough to tolerate additional therapy.
If you decide against any further chemotherapy, there are other measures that can make you more comfortable, control pain, or help with any other symptoms that you might be having.