Use of radiation therapy among patients with Extensive-stage Small-cell lung cancer receiving Immunotherapy: Canadian consensus recommendations

Retrospective cohort study assessing clinical outcomes of patients with extensive-stage small cell lung cancer treated with and without consolidative thoracic radiotherapy at the Princess Margaret Cancer Centre

OBJECTIVES

Most patients with small cell lung cancer present with extensive-stage (ES-SCLC) disease. An international randomised trial demonstrated a survival benefit in patients treated with consolidative thoracic radiotherapy (cTRT). We report our institutional experience with this regimen.

METHODS

A retrospective review was conducted on patients with ES-SCLC who were candidates for cTRT at our institution between 2013 and 2022. The patients included in our study had biopsy-proven ES-SCLC, received ≥4 cycles of chemotherapy and achieved complete response, partial response or stable disease as per Response Evaluation Criteria in Solid Tumors V.1.1. Overall survival, progression-free survival (PFS) and recurrence patterns were compared between patients who received cTRT and those who did not. For patients who received cTRT, treatment tolerability was assessed.

RESULTS

We identified 123 patients with ES-SCLC who received ≥4 cycles of chemotherapy and were candidates for cTRT. Of those, 49 patients received cTRT, and 74 patients did not. From the end of chemotherapy, the control group had a median OS of 0.6 years with a 1- and 2-year OS of 23.5% and 11.0%. Within the cTRT group, the median OS was 0.9 years with a 1- and 2-year OS of 46.7% and 26.3%. Within the control group, the median PFS was 0.2 years compared with 0.4 years within the cTRT group. Intrathoracic failures in the cTRT group were lower compared with the control group (16.3% vs 29.7%). cTRT was well tolerated with no grade 3+ toxicities.

CONCLUSION

The improved clinical outcomes of cTRT for patients with ES-SCLC were comparable to the reported the Chest Radiotherapy Extensive-Stage Small Cell Lung Cancer Trial (CREST) outcome, with a low rate of side effects in our study cohort.

Current and future perspectives in extensive-stage small-cell lung cancer

Small-cell lung cancer (SCLC) is a highly aggressive and rapidly proliferative malignancy that has historically had limited therapeutic advancements. Recent advancements in the understanding of SCLC have led to attempts at subtyping the disease based on transcription factor characteristics, offering new insights into its biology and potential therapeutic targets. In addition, significant progress has been made in developing treatment regimens, providing new hope for improved patient outcomes. The introduction of immune checkpoint inhibitors, such as atezolizumab and durvalumab, in combination with traditional chemotherapy, has marked a significant advancement, demonstrating improved overall survival and progression-free survival compared to chemotherapy alone. Despite these advancements, the prognosis for extensive-stage SCLC (ES-SCLC), the more advanced form of SCLC, remains poor, highlighting the critical need for ongoing research and the development of novel therapeutic strategies. New treatment modalities, such as lurbinectedin and anti-Delta-like Canonical Notch Ligand 3 antibodies, are now included in the treatment options for refractory SCLC, and many more treatment strategies involving combination therapies are being studied. Advances in molecular profiling and the identification of biomarkers are aiding in the development of personalized treatment approaches. This review focuses on these recent advancements and emerging strategies in the treatment of ES-SCLC.

Real-world evidence in extensive disease small cell lung cancer: The missing piece of the puzzle

Small cell lung cancer (SCLC) is a highly aggressive disease, often diagnosed at an advanced stage and with limited treatment options. In recent years, immunotherapy has been approved in combination with chemotherapy in the first line setting of extensive stage disease (ES-SCLC). However, only 10-15 % of patients with ES-SCLC treated with chemoimmunotherapy (CT-IO) experience a long-term benefit. In addition, patients are often clinically frail due to advanced age, comorbidities, and disease-related symptoms, making SCLC a challenging condition. Real-world evidence (RWE) becomes particularly valuable in this scenario, not only to confirm the results of pivotal trials, but also to evaluate the outcomes of CT-IO in populations that are generally excluded from clinical trials. RWE could also define the role of integrative treatments such as thoracic consolidation radiotherapy and prophylactic cranial irradiation, which are used in selected patients in the clinical practice but were scarcely applied in pivotal trials. In this review, we focused on RWE in ES-SCLC, with the aim of improving clinical decision making. Notably, real-world data have largely confirmed the efficacy and safety of CT-IO observed in pivotal clinical trials, with a possible benefit even in more fragile patients. However, these studies also highlight that a significant proportion of the ES-SCLC population remains untreated due to poor clinical conditions.

Real-world outcomes of prophylactic cranial irradiation utilization and efficacy for patients with extensive-stage small cell lung cancer treated with consolidative thoracic radiotherapy

Background

The role of prophylactic cranial irradiation (PCI) is not well-defined in extensive-stage SCLC (ES-SCLC), with conflicting results from randomized trials and a lack of relevant data for patients who received consolidative thoracic radiotherapy (CTRT). We sought to evaluate the impact of PCI on the outcomes of ES-SCLC patients who were all treated with CTRT.

Methods

A retrospective analysis of ES-SCLC patients without brain metastases who were all treated with CTRT between 2013-2021 at our institution was conducted. Overall survival (OS) and incidence of brain failure (BFR) were estimated using Kaplan-Meier estimation and cumulative incidence function. Multivariable Cox or Fine-Gray's proportional hazard regression analysis (MVA) were performed to determine association between PCI and OS.

Results

47 patients met inclusion criteria and were theoretically eligible for PCI, 27 (57.4 %) received PCI and CTRT while 20 (42.6 %) received CTRT alone. Baseline characteristics were similar except for age, where patients receiving PCI were younger (median age 62) compared to patients who did not receive PCI (median age 72). Median OS with PCI was 19.2 months, compared to 10.8 months without PCI (P = 0.0334). This improved OS remained apparent in patients who received post-chemotherapy MRI restaging (P = 0.0245). BFR was reduced with PCI (HR = 0.22 [0.09-0.52], P = 0.0004). On MVA, PCI was significantly and independently associated with improved OS (HR = 0.39 [0.19-0.80], P = 0.01) and reduced BFR (HR = 0.20 [0.09-0.44], P = < 0.001).

Conclusion

This real-world study found PCI was independently associated with improved OS and reduced BFR in ES-SCLC patients treated with CTRT compared to patients treated with CTRT not receiving PCI, including after post-chemotherapy brain MRI. The role of PCI with CTRT should be evaluated in prospective studies.

The Efficacy and Safety of Albumin-Bound Paclitaxel Combined With Anlotinib and PD-1/L1 Inhibitors For Treating Patients With Extensive-Stage Small Cell Lung Cancer and Brain Metastasis: A Retrospective Cohort Study

OBJECTIVES

Extensive-stage small cell lung cancer (ES-SCLC) suffering from brain metastases (BM) has a poor prognosis and lacks effective treatment selection. In this study, we explored the efficacy and safety of combination treatment of albumin-bound paclitaxel (nab-ptx), anlotinib, and PD-1/L1 inhibitors for such special population.

METHODS

A total of 55 patients diagnosed with ES-SCLC and BM were enrolled in this retrospective study. Patients received a combination therapy consisting of nab-ptx, anlotinib, and PD-1/L1 inhibitors. The primary endpoints included overall response rate (ORR), progression-free survival (PFS), overall survival (OS), and adverse events (AEs).

RESULTS

The results demonstrated promising efficacy of the combination therapy for such patients, with an ORR of 36.36%, median PFS and OS of 5.0 and 10.0 m, correspondingly. Subgroup analyses indicated that treatment efficacy closely correlated with patients' Ds-GPA (Diagnosis-specified Graded Prognosis Assessment) scores. Mechanistic studies revealed that this regimen likely operates by reducing immune suppression to activate immune function, thereby exerting synergistic anti-tumor effects. The common AEs include decreased appetite, nausea, leukopenia, hypertension, proteinuria, hand-foot syndrome, peripheral neuropathy, rash, and thyroid toxicity, most of which are generally mild and can be alleviated with symptomatic treatment.

CONCLUSION

The combination of nab-ptx, anlotinib, and PD-1/L1 inhibitors exhibited substantial efficacy and acceptable safety in the treatment of BM from ES-SCLC. This novel therapeutic approach holds promise for improving the outcomes for patients with this challenging disease. Further studies are needed to validate these findings and investigate the long-term benefits of this combination regimen.

Brain metastasis burden and management in patients with small cell lung cancer in Canada: a retrospective, population-based cohort study

Background

Patients with small cell lung cancer (SCLC) have historically been characterised by poor overall survival (OS) and high risk for brain metastasis (BM), but large-scale real-world evidence on clinical presentation and treatment in this population is lacking. Our aim was to describe the clinical characteristics and outcomes of patients with SCLC and BM in Ontario, Canada.

Methods

This population-based, retrospective cohort study included all patients in Ontario, Canada, who were diagnosed with SCLC between April 1, 2010, and March 31, 2018. Data were analysed between June 2, 2022, and December 20, 2023. Patients with second cancer diagnosis were excluded. Patients were identified and data retrieved from the Institute for Clinical Evaluative Sciences (ICES) databases. Kaplan-Meier and multivariable Cox regression analyses were performed to compare OS between patient cohorts stratified by disease stage, BM diagnosis, and intracranial treatment modality. Propensity score-matching based on age, disease stage, time to BM, and receipt of chemotherapy was performed to compare OS between intracranial treatment modalities.

Findings

8705 patients were included (male: 4433, female: 4272). Median age at diagnosis was 68 years (interquartile range, IQR, 61-75). Median OS of all patients was 7.46 months (95% confidence interval, CI, 7.23-7.69). 32% (n = 2686) of patients developed BM (synchronous, 43.7%; asynchronous, 56.3%) with median OS of 9.76 months (95% CI, 9.36-10.22). 102 (4%), 1654 (62%), and 930 (35%) patients received stereotactic radiosurgery (SRS), whole brain radiation therapy (WBRT), or no treatment, respectively, for their BM in the first-line setting or after prophylactic cranial irradiation (PCI). In propensity score-matched analyses, OS from time of BM diagnosis was non-inferior between SRS- and WBRT-treated cohorts among patients who did not receive PCI (hazard ratio, HR, 0.68, 95% CI, 0.44-1.06, p = 0.091, n = 86) and in favour of SRS for those who received PCI prior to BM development (HR, 0.47, 95% CI, 0.31-0.72, p = 0.0042, n = 112).

Interpretation

OS for patients with SCLC remains poor, and many patients present with BM. With careful selection, patients with SCLC and BM may benefit from SRS treatment. Future research should incorporate information on burden of intracranial disease and novel immunotherapies.

Funding

None.

Current Radiotherapy Management of Extensive-Stage Small-Cell Lung Cancer in the Immunotherapy Era: An Italian National Survey on Behalf of the Italian Association of Radiotherapy and Clinical Oncology (AIRO)

BACKGROUND

Extensive-stage small-cell lung cancer (ES-SCLC) treatment has recently been revolutionized by the advent of immune checkpoint inhibitors. This survey was conducted to evaluate the current pattern of care among Italian clinicians, in particular about the integration with radiation therapy (RT).

METHODS

In June 2023, 225 Italian cancer care professionals were invited to complete a 21-question web-based survey about ES-SCLC management through personal contacts and the Italian Association for Radiotherapy and Clinical Oncology (AIRO) network.

RESULTS

We received 90 responses; the majority were radiation oncologists (89%) with more than 10 years of experience (51%). The preferred management of ES-SCLC in patients with a good performance status was concomitant chemo-immunotherapy (84%). Almost all respondents recommended prophylactic cranial irradiation (PCI) (85%), taking into account age and thoracic response; PCI was performed mainly between the end of chemotherapy and before starting immunotherapy (37%), with a three-dimensional conformal technique (46%). Furthermore, 83% of respondents choose to deliver thoracic RT in the case of both an intrathoracic and extrathoracic response, with an RT schedule of 30 Gy/10 fractions. Stereotactic RT is increasingly being used in oligoprogressions.

CONCLUSIONS

Our analysis showed the variability of real-world management of ES-SCLC. Future clinical trials and developments are needed to improve the multidisciplinary treatment of these patients.

Durable Response to Combined Nivolumab, Lenvatinib, and Radiation Therapy Against Oligometastatic Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the most common type of liver cancer and is associated with major risk factors such as hepatitis B virus (HBV), hepatitis C virus (HCV), alcoholic fatty liver disease, and metabolic dysfunction-associated steatotic liver diseases. Despite the recent progress in systemic treatment regimens involving immunotherapies and targeted therapeutics, advanced HCC remains difficult to control. Moreover, with several treatment modalities currently available for HCC such as radiation therapy, transarterial chemoembolization (TACE), checkpoint immunotherapies, and multi-tyrosine kinase inhibitors, it is unclear what combination yields the greatest treatment efficacy and durability. Here, we present the case of a male patient in his 60s with HCV-associated cirrhosis diagnosed with HCC with a metastatic lesion to the T9 spine. Treatment with nivolumab and subsequently lenvatinib in addition was complicated by adverse effects including hand rash and kidney injury. Systemic therapy was stopped, and consolidative stereotactic body radiation therapy (SBRT) was delivered to the sites of the disease. The combination proved to be highly durable without any evidence of progression for over three years despite having stopped all therapy. All toxicities have resolved since, and the patient remains very active. This case demonstrates the feasibility of combining therapeutic modalities to achieve exceptional disease control in the setting of oligometastatic disease.

Impact of thoracic radiotherapy on first-line treatment outcomes in ES-SCLC patients

BACKGROUND

The therapeutic advantage of thoracic radiotherapy (tRT) as an adjunct to first-line immunotherapy and chemotherapy in patients with extensive-stage small cell lung cancer (ES-SCLC) remains unclear. We sought to elucidate this in a retrospective cohort study comparing the effectiveness and safety of tRT in combination with first-line immunotherapy and chemotherapy.

METHODS

Our retrospective study included patients with ES-SCLC, treated at the West China Hospital between January 2019 and December 2022. They received first-line immunotherapy and chemotherapy and were categorized into two cohorts based on the administration of tRT. The primary outcomes were overall survival (OS) and progression-free survival (PFS). Cox regression analysis was utilized to identify potential independent predictors of prognosis and to compare the treatment outcomes across various patient subgroups. Treatment-related toxicities across both cohorts were compared using the Chi-squared test.

RESULTS

A total of 99patients were eligible for the study, out of which 55 received tRT. The medianduration of follow-up was 39 months. Remarkably, patients who received tRTdemonstrated superior OS and PFS in comparison to those who did not (P < 0.05). Subgroup analysis further confirmed these findings. Multivariate analysisidentified treatment group and liver metastasis as independent prognosticfactors (P < 0.05). The incidence of grade 3-4 adverse events showed nostatistically significant difference between the two cohorts.

CONCLUSIONS

Thus, weconfirmed that the addition of tRT to the conventional regimen of first-linechemotherapy and immunotherapy yields better survival outcomes without asignificant increase in toxicity.

Real-world evaluation of first-line treatment of extensive-stage small-cell lung cancer with atezolizumab plus platinum/etoposide: a focus on patients with brain metastasis

PURPOSE

A previous real-world study conducted in China confirmed that first-line atezolizumab, in combination with etoposide/platinum (EP), leads to significantly longer progression-free survival (PFS) compared to EP alone in patients with extensive-stage small-cell lung cancer (ES-SCLC). The present study aimed to provide updated survival outcome data and evaluate the clinical efficacy of atezolizumab plus chemotherapy in ES-SCLC patients with brain metastasis (BM).

METHODS

This retrospective study included 225 patients with ES-SCLC who were treated with EP alone (EP group) or a combination of EP + atezolizumab (atezolizumab group). Survival outcomes for the total study sample and patients in the BM subgroup were estimated using the Kaplan-Meier method.

RESULTS

The atezolizumab group continued to demonstrate significantly longer PFS than the EP group (hazard ratio [HR], 0.68). The median overall survival (OS) was 26.2 months in the atezolizumab group vs. 14.8 months in the EP group (HR, 0.63). Additionally, among the BM patients in our study, the median PFS was found to be longer in the atezolizumab group (7.0 months) than in the EP group (4.1 months) (HR, 0.46). The OS of the BM patients did not differ significantly between the two treatment groups.

CONCLUSIONS

The addition of atezolizumab to EP as a first-line treatment for ES-SCLC was found to improve survival outcomes. This treatment combination may also prolong PFS in patients with BM, regardless of the administration of cranial irradiation. However, among the BM patients in our study, there was no significant difference in OS between the two treatment groups.

Durable Response to Atezolizumab in Extensive-Stage Small-Cell Lung Cancer Leading to 60 Months Overall Survival: A Case Report

Small-cell lung cancer (SCLC) remains a disease with poor prognosis, particularly in extensive-stage SCLC (ES-SCLC). Current standard-of-care treatment includes chemotherapy with platinum agents and etoposide plus immunotherapy with atezolizumab or durvalumab, which has achieved a mean overall survival of 12-13 months in clinical trials. However, long-term survival in ES-SCLC, even with the addition of immunotherapy, continues to be rare. We present the case of a middle-aged male patient diagnosed with ES-SCLC who was treated with four cycles of induction chemotherapy (carboplatin and etoposide) and atezolizumab, starting maintenance atezolizumab every 21 days thereafter, and thoracic radiotherapy. After 9 months, he experienced mild disease progression and was rechallenged with six cycles of carboplatin and etoposide with continued atezolizumab. Subsequent imaging showed near-complete disease resolution which has been sustained since. He has continued on maintenance atezolizumab since diagnosis and has achieved 60 months overall survival and 44 months progression-free survival. Throughout treatment, he has maintained a high functional capacity and only experienced one immune-related adverse event. Our patient is representative of a small subset who are capable of achieving durable responses to immunotherapy and his case highlights the need for further research to elucidate the clinical and biological factors driving this response.

Consolidative thoracic radiation therapy for extensive-stage small cell lung cancer in the era of first-line chemoimmunotherapy: preclinical data and a retrospective study in Southern Italy

Background

Consolidative thoracic radiotherapy (TRT) has been commonly used in the management of extensive-stage small cell lung cancer (ES-SCLC). Nevertheless, phase III trials exploring first-line chemoimmunotherapy have excluded this treatment approach. However, there is a strong biological rationale to support the use of radiotherapy (RT) as a boost to sustain anti-tumor immune responses. Currently, the benefit of TRT after chemoimmunotherapy remains unclear. The present report describes the real-world experiences of 120 patients with ES-SCLC treated with different chemoimmunotherapy combinations. Preclinical data supporting the hypothesis of anti-tumor immune responses induced by RT are also presented.

Methods

A total of 120 ES-SCLC patients treated with chemoimmunotherapy since 2019 in the South of Italy were retrospectively analyzed. None of the patients included in the analysis experienced disease progression after undergoing first-line chemoimmunotherapy. Of these, 59 patients underwent TRT after a multidisciplinary decision by the treatment team. Patient characteristics, chemoimmunotherapy schedule, and timing of TRT onset were assessed. Safety served as the primary endpoint, while efficacy measured in terms of overall survival (OS) and progression-free survival (PFS) was used as the secondary endpoint. Immune pathway activation induced by RT in SCLC cells was explored to investigate the biological rationale for combining RT and immunotherapy.

Results

Preclinical data supported the activation of innate immune pathways, including the STimulator of INterferon pathway (STING), gamma-interferon-inducible protein (IFI-16), and mitochondrial antiviral-signaling protein (MAVS) related to DNA and RNA release. Clinical data showed that TRT was associated with a good safety profile. Of the 59 patients treated with TRT, only 10% experienced radiation toxicity, while no ≥ G3 radiation-induced adverse events occurred. The median time for TRT onset after cycles of chemoimmunotherapy was 62 days. Total radiation dose and fraction dose of TRT include from 30 Gy in 10 fractions, up to definitive dose in selected patients. Consolidative TRT was associated with a significantly longer PFS than systemic therapy alone (one-year PFS of 61% vs. 31%, p<0.001), with a trend toward improved OS (one-year OS of 80% vs. 61%, p=0.027).

Conclusion

Multi-center data from establishments in the South of Italy provide a general confidence in using TRT as a consolidative strategy after chemoimmunotherapy. Considering the limits of a restrospective analysis, these preliminary results support the feasibility of the approach and encourage a prospective evaluation.

Treatment patterns and clinical outcomes in 157 patients with extensive-stage small cell lung cancer: real-world evidence from a single-center retrospective study

Background

Immune checkpoint inhibitors (ICIs) have changed the therapeutic options for extensive-stage small-cell lung cancer (ES-SCLC). In this real-world study, we analyzed the treatment patterns in patients with ES-SCLC and evaluated the efficacy of chemotherapy combined with immunotherapy as first-line therapy.

Methods

A retrospective analysis was performed on patients with ES-SCLC who received treatment at China-Japan Friendship Hospital (Beijing, China) between August 1, 2020, and April 30, 2023. The treatment patterns appeared in the form of Sunburst Chart and Sankey diagram. The survival analyses were conducted by Kaplan-Meier curves.

Results

A total of 157 patients with ES-SCLC were retrospectively included. According to first-line therapy, patients were divided into the chemotherapy (CT) group (n=82) and chemo-immunotherapy (CIT) group (n=75). The median treatment lines were 2[1, 2] and cycles were 8[5, 12], respectively. 82 patients received the second line of therapy, followed by 37 for the third, 15 for the fourth, 11 for the fifth, and 5 for the sixth. Overall, the treatment patterns involved 11 options including 12 chemotherapy regimens, 11 ICIs, and 4 targeted agents. The second-line treatment pattern had the most options (9) and regimens (43). In the first 3 lines, chemotherapy was the largest proportion of treatment options. The addition of ICIs prolonged progression-free survival from 6.77 (95% confidence interval [CI], 6.00-7.87) to 7.33 (95% CI, 6.03-9.80) months (hazard ratio [HR]=0.67, 95% CI, 0.47-0.95; P=0.025), overall survival from 12.97 (10.90-23.3) to 14.33 (12.67-NA) months without statistically significant difference (HR=0.86, 95% CI, 0.55-1.34; P=0.505).

Conclusion

The treatment options of patients with ES-SCLC are more diversified. Combination therapy is the current trend, where chemotherapy is the cornerstone. Meanwhile, ICIs participate in almost all lines of treatment. However, the clinical efficacy remains barely satisfactory. We are urgently expecting more breakthrough therapies except immunology will be applied in the clinic.

Real-world predictors of survival in patients with extensive-stage small-cell lung cancer in Manitoba, Canada: a retrospective cohort study

Background

Extensive-stage small-cell lung cancer (ES-SCLC) is an incurable cancer with poor prognosis in which characteristics predictive of long-term survival are debated. The utility of agents such as immune checkpoint inhibitors highlights the importance of identifying key characteristics and treatment strategies that contribute to long-term survival and could help guide therapeutic decisions.

Objective

This real-world analysis examines the characteristics, treatment patterns, and clinical outcomes of patients receiving chemotherapy without immunotherapy for ES-SCLC in Manitoba, Canada.

Methods

A retrospective cohort study assessed patient characteristics, treatment, and survival duration (short: <6 months; medium: 6-24 months; long: >24 months) using the Manitoba Cancer Registry and CancerCare Manitoba records. Eligible patients were aged >18 years with cytologically confirmed ES-SCLC diagnosed between January 1, 2004, and December 31, 2018, and received cytotoxic chemotherapy (CT). The one-, two-, and five-year probabilities of overall survival (OS) were assessed relative to patient, disease, and treatment characteristics using Kaplan-Meier methods and Cox proportional hazards models.

Results

This analysis included 537 patients. Cisplatin was used in 56.1% of patients, 45.6% received thoracic radiotherapy (RT), and few received prophylactic cranial irradiation (PCI). In the overall cohort, one-, two- and five-year OS rates were 26%, 8%, and 3%, respectively. For patients with Eastern Cooperative Oncology Group Performance Status (ECOG PS) 0, OS rates at one, two, and five years were 43%, 17%, and 10%, respectively, vs. 27%, 8%, and 2% for those with ECOG PS 1-2, and 16%, 3%, and 3% for those with ECOG PS 3-4. In long-term survivors, ECOG PS scores were lower and abnormal laboratory test results were less frequent. Overall, 74.4% of long-term survivors received thoracic RT and 53.5% received PCI. Known poor prognostic factors - including brain/liver metastases, high lactate dehydrogenase (LDH), abnormal sodium, and low hemoglobin levels - were less common but still seen in long-term survivors.

Conclusion

Although rare, patients with ES-SCLC may experience long-term survival with CT ± thoracic RT ± PCI. Factors predicting long-term survival include traditional prognostic factors such as ECOG PS, LDH level, and receipt of thoracic RT or PCI. These findings support current treatment algorithms for ES-SCLC and provide baseline survival estimates to assess the real-world impact of adding immune checkpoint inhibitors in the future.

Canadian Consensus Recommendations on the Management of Extensive-Stage Small-Cell Lung Cancer

Small-cell lung cancer (SCLC) is an aggressive, neuroendocrine tumour with high relapse rates, and significant morbidity and mortality. Apart from advances in radiation therapy, progress in the systemic treatment of SCLC had been stagnant for over three decades despite multiple attempts to develop alternative therapeutic options that could improve responses and survival. Recent promising developments in first-line and subsequent therapeutic approaches prompted a Canadian Expert Panel to convene to review evidence, discuss practice patterns, and reach a consensus on the treatment of extensive-stage SCLC (ES-SCLC). The literature search included guidelines, systematic reviews, and randomized controlled trials. Regular meetings were held from September 2022 to March 2023 to discuss the available evidence to propose and agree upon specific recommendations. The panel addressed biomarkers and histological features that distinguish SCLC from non-SCLC and other neuroendocrine tumours. Evidence for initial and subsequent systemic therapies was reviewed with consideration for patient performance status, comorbidities, and the involvement and function of other organs. The resulting consensus recommendations herein will help clarify evidence-based management of ES-SCLC in routine practice, help clinician decision-making, and facilitate the best patient outcomes.