Communication With the Treatment Team, Self-Advocacy Play Important Roles in Small Cell Lung Cancer

Small cell lung cancer, which makes up approximately 15% of lung cancer diagnoses, can present differently depending on what stage it is diagnosed, leading to different treatment approaches, according to Dr. Wade T. Iams.

Iams, assistant professor of medicine in the division of hematology/oncology at Vanderbilt University Medical Center in Nashville, Tennessee, recently discussed small cell lung cancer during CURE®’s Educated Patient® Lung Cancer Summit.

In an interview with CURE®, Iams differentiated small cell lung cancer from other subtypes of lung cancer, the importance of preventative radiation for potential spread to the brain and how a strong treatment team can help you especially when side effects arise.

CURE®: What exactly is small cell lung cancer and how does it differ from other types of lung cancer?

Iams: Small cell lung cancer is a subtype of lung cancer. The two most common categories of cancer that arises from the lung are non-small cell and small cell. The difference is the type of lung cell that they start from. And small cell lung cancer starts from the neuroendocrine cells in the lung, so it's a little different cell type than the other major type of lung cancer. And small cell lung cancer tends to be more aggressive than non-small cell lung cancer. Overall, it makes up 15% of lung cancer diagnoses.

Can you go over how the stages of small cell lung cancer are treated differently?

There is a unique staging categorization in small cell lung cancer, but I'll put it in context of the typical stages 1 through 4 of cancer. So in small cell lung cancer, we uniquely refer to stages 1 through 3 as limited stage, individuals who have the cancer still in the lung or lymph nodes in that side of the lung where it started.

In contrast to those with extensive stage or stage 4 disease, the three categories of treatment generally break down to individuals who have stage 1 small cell lung cancer, if there's only one spot within the lung that we see, may be eligible for surgery, followed by chemotherapy for four cycles or three months after that. Individuals with stage 2 or 3 small cell lung cancer are typically treated with chemotherapy plus radiation. And individuals with stage 1, 2 and 3 small cell lung cancer are recommended to receive preventative radiation to the brain.

Individuals with stage 4 small cell lung cancer, or extensive stage disease, are treated with a combination of chemotherapy plus immunotherapy. And we recommend discussions on an individual basis regarding using preventative brain radiation or additional radiation to the lung in people with stage 4 or extensive stage small cell lung cancer.

You kind of touched on my next question, and also in your presentation, you mentioned that small cell lung cancer has a tendency to spread to the brain. So can you discuss what exactly needs to be done to prevent potentially prevent that from happening? And are certain stages of this type of cancer more likely to be prone to this compared with others?

So when we think about stages 1 through 3 small cell lung cancer, getting through the initial treatment of either surgery followed by chemotherapy, or a combination of chemotherapy plus radiation over the course of three months, is the first priority, making sure that we're treating all the cancer that we're seeing. At the completion of that treatment, we do recommend doing a brain MRI to reevaluate the brain, making sure there's no cancer in that location. And even if there's not, we recommend considering doing preventative radiation to the brain.

In individuals with stage 4 small cell lung cancer, we recommend the same three months of chemotherapy plus immune therapy, followed by brain MRI to make sure that the small cell lung cancer has not gotten to the brain. And at that point, having the discussion with the radiation doctor and medical oncologist about whether to pursue preventative radiation to the brain.

Now that we're on the topic of treatment, what are some of the side effects that are associated with treatment for this type of cancer? And how can patients either lower their risk for the side effects or alleviate them once they do arise?

So the best way to minimize the risk of side effects of any type, whether its side effects that go along with surgical resection, which are primarily around the risks of surgery and then recovery of the several weeks that follow surgery, or the cumulative fatigue that accompanies radiation, and then sometimes some skin burn at the site where radiation is administered, when it's administered to the chest.

Another big area to monitor is the esophagus and difficulty and pain with swallowing, or chemotherapy and immune therapy, which are IV infusions. Chemotherapy typically results in a cyclical pattern of fatigue, potential intestinal side effects, nausea, maybe some vomiting, diarrhea, lower blood counts and a risk for infection that increases over the course of one week and then improves over the ensuing one to two weeks.

And then immune therapy, where most patients experience just mild fatigue. And then we monitor for autoimmune reactions in those individuals.

The best way as a whole to minimize the risk of side effects before starting is to be as active as possible, to be eating a healthy diet in individuals with small cell lung cancer is critical, that they quit smoking, which is very difficult but important and really helps minimize the risk of side effects.

And the biggest piece of advice, I would say, to minimizing side effects once treatment is initiated, is a strong line of communication with the treatment team. And knowing that we have a lot of different supportive medications to address side effects. So not to let things drag on, whether it's nausea or vomiting or diarrhea, be in communication with your treatment team, or difficulty swallowing, we can typically help patients through those as long as we know they're occurring, following the severity and trying the medicines that we have to alleviate them.

What are some important points that patients should keep in mind with regards to either recurrence or progression?

Recurrence is at the highest risk during the first two years after individuals with stage 1 to 3 small cell lung cancer complete treatment. So we keep a close eye on that interval, and then we tend to check.

And then disease progression, I'm going to approach that a little bit differently than recurrence. Those recurrence comments, let's say, pertain to the stage 1 to 3 patients. Patients with stage 4 small cell lung cancer have a prognosis that we need to improve. It's a very difficult to treat cancer that we often initially shrink. But disease progression, even with the newest combination chemotherapy plus immune therapy in patients with stage 4 disease, on average, occurs within six months of starting that treatment. So progression often happens much earlier than any of us would like with this type of cancer.

Regardless of what stage a patient may have, what type of advice would you give them to potentially have improved outcomes?

Being proactive in communication with the treating team is the best thing that patients can do. Make sure that the treatment team is aware of any side effects that you're having. And many times, the logistics of our health care system are such that patients advocating for themselves for getting things scheduled and done in a timely fashion is often an important part of making sure that care goes smoothly and promptly.

Those are basically all the questions that I prepared, but was there anything else you wanted to mention about this topic?

We have a lot of work to do in improving small cell lung cancer care. And so I'll admit my bias, being in a university, is to be heavily engaged in research, but I do strongly encourage all patients with small cell lung cancer to think about ways that they can engage with research, whether it's clinical trials or specimens, contributing blood for studying tumor tissue for study. There is a huge need for improvement and also patient engagement in working with the medical community, and trying to find ways to do better.

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