Chemoradiotherapy for Limited-disease Small-cell Lung Cancer in Elderly Patients Aged 75 Years or Older

A retrospective evaluation of therapeutic efficacy and safety of chemoradiotherapy in older patients (aged ≥ 75 years) with limited-disease small cell lung cancer: insights from two institutions and review of the literature

BACKGROUND

The standard treatment for patients in good general condition with limited-disease small cell lung cancer (LD-SCLC) is concurrent platinum/etoposide chemotherapy and thoracic radiotherapy (TRT). However, the efficacy and safety of chemoradiotherapy (CRT) in older patients with LD-SCLC has not been fully explored; moreover, the optimal treatment for this patient group remains unclear. This study aimed to investigate the feasibility and efficacy of CRT in older patients with LD-SCLC.

PATIENTS AND METHODS

From April 2007 to June 2021, consecutive older patients (aged ≥ 75 years) with stage I to III SCLC who received concurrent or sequential CRT at two institutions were retrospectively evaluated for efficacy and toxicity of CRT.

RESULTS

A total of 32 older patients underwent concurrent (n = 19) or sequential (n = 13) CRT for LD-SCLC. The median ages of the patients in the concurrent and sequential CRT groups were 77 (range: 75-81) years and 79 (range: 76-92) years, respectively. The median number of chemotherapeutic treatment cycles was four (range, 1-5), and the response rate was 96.9% in all patients (94.7% in concurrent and 100% in sequential CRT groups). The median progression-free survival (PFS) and median overall survival (OS) for all patients were 11.9 and 21.1 months, respectively. The median PFS was 13.0 and 9.0 months in the concurrent CRT and sequential CRT groups, respectively, with no statistically significant difference (p = 0.67). The median OS from the initiation of CRT was 19.2 and 23.5 months in the concurrent and sequential CRT groups, respectively (p = 0.46). The frequencies of Grade ≥ 3 hematological adverse events were as follows: decreased white blood cell count, 20/32 (62.5%); decreased neutrophil count, 23/32 (71.9%); anemia, 6/32 (18.8%); decreased platelet count, 7/32 (21.9%); and febrile neutropenia, 3/32 (9.4%). Treatment-related deaths occurred in one patient from each group.

CONCLUSIONS

Although hematological toxicities, particularly reduced neutrophil count, were severe, CRT showed favorable efficacy in both concurrent and sequential CRT groups. However, concurrent CRT may not be feasible for all older patients with LD-SCLC; accordingly, sequential CRT may be considered as a treatment of choice for these patients. Further prospective trials are warranted to identify optimal treatment strategies for this patient group.

A systematic review of survival following anti-cancer treatment for small cell lung cancer

OBJECTIVES

We conducted a systematic review and meta-analysis of survival following treatment recommended by the European Society of Medical Oncology for SCLC in order to determine a benchmark for novel therapies to be compared with.

MATERIALS AND METHODS

Randomized controlled trials and observational studies reporting overall survival following chemotherapy for SCLC were included. We calculated survival at 30 and 90-days along with 1-year, 2-year and median.

RESULTS

We identified 160 for inclusion. There were minimal 30-day deaths. Survival was 99 % (95 %CI 98.0-99.0 %, I²33.9 %, n = 77) and 90 % (95 %CI 89.0-92.0 %, I²79.5 %, n = 73) at 90 days for limited (LD-SCLC) and extensive stage (ED-SCLC) respectively. The median survival for LD-SCLC was 18.1 months (95 %CI 17.0-19.1 %, I²77.3 %, n = 110) and early thoracic radiotherapy (thoracic radiotherapy 18.4 months (95 %CI 17.3-19.5, I²78.4 %, n = 100)) vs no radiotherapy 11.7 months (95 %CI 9.1-14.3, n = 10), prophylactic cranial irradiation (PCI 19.7 months vs No PCI 13.0 months (95 %CI 18.5-21.0, I²75.7 %, n = 78 and 95 %CI 10.5-16.6, I²81.1 %, n = 15 respectively)) and better performance status (PS0-1 22.5 months vs PS0-4 15.3 months (95 %CI 18.7-26.1, I²72.4 %, n = 11 and 95 %CI 11.5-19.1 I²77.9 %, n = 13)) augmented this. For ED-SCLC the median survival was 9.6 months (95 %CI 8.9-10.3 %, I²95.2 %, n = 103) and this improved when irinotecan + cisplatin was used, however studies that used this combination were mostly conducted in Asian populations where survival was better. Survival was not improved with the addition of thoracic radiotherapy or PCI. Survival for both stages of cancer was better in modern studies and Asian cohorts. It was poorer for studies administering carboplatin + etoposide but this regimen was used in studies that had fewer patient selection criteria.

CONCLUSION

Early thoracic radiotherapy and PCI should be offered to people with LD-SCLC in accordance with guideline recommendations. The benefit of the aforementioned therapies to treat ED-SCLC and the use of chemotherapy in people with poor PS is less clear.

Phase I/II study of induction chemotherapy using carboplatin plus irinotecan and sequential thoracic radiotherapy (TRT) for elderly patients with limited-disease small-cell lung cancer (LD-SCLC): TORG 0604

Background

The role of irinotecan for elderly patients with LD-SCLC has been unclear, and the timing of TRT combined with chemotherapy has not been fully evaluated.

Methods

Patients aged > 70 years with untreated, measurable, LD-SCLC, performance status (PS) 0–2, and adequate organ function were eligible. Treatment consisted of induction with carboplatin on day 1 and irinotecan on days 1 and 8, every 21 days for 4 cycles, and sequential TRT (54Gy in 27 fractions). Carboplatin doses were based on AUC of 4 and 5 (levels 1 and 2, respectively), with a fixed irinotecan dose (50 mg/m²). Primary objective of the phase II study was overall responce rate.

Results

Forty-three patients were enrolled and forty-one were finally analyzed (median age: 75 years [range 70–86 years); males 31; PS 0/1/2, n = 22/18/1]. Two patients were excluded because of protocol violation (ascertained to be extensive disease). Twelve patients were accrued at phase I and the number of patients with carboplatin dose-limiting toxicities at levels-1 (n = 6) and −2 (n = 6) were 1(grade 3 hypertension) and 2 (grade 4 thrombocytopenia), respectively. The phase II trial was expanded to 29 additional patients receiving the level 1 carboplatin dose, total of 35 patients. The median number of chemotherapy cycles was 4 (range 1–4), and the median radiation dose was 54Gy (range 36–60). Toxicities were generally mild. There were 4 complete and 27 partial responses (response rate 88.6%). With a median follow-up of 52 months, the median progression-free and overall survival times of phase II were 11.2 and 27.1 months, respectively.

Conclusions

Induction chemotherapy of carboplatin plus irinotecan and sequential TRT was well tolerated and effective for elderly patients with LD-SCLC. Additional confirmatory studies are warranted.

Trial registration

Trial registration number: UMIN000007352

Name of registry: UMIN.

Date of registration: 1/Dec/2006.

Date of enrolment of the first participant to the trial: 6/Feb/2007.

Clinical trial registration date: 1/Feb/2006 (prospective).

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-017-3353-y) contains supplementary material, which is available to authorized users.

Comparison of cisplatin/etoposide versus carboplatin/etoposide concurrent chemoradiation therapy for limited-stage small cell lung cancer (LS-SCLC) in the elderly population (age >65 years) using national SEER-Medicare data

PURPOSE

Standard therapy for limited-stage small cell lung cancer (SCLC) (American Joint Committee on Cancer stages I-III) is concurrent chemoradiation therapy (CRT) with cisplatin/etoposide (EP), but carboplatin/etoposide (EC) is often used in clinical practice. Though a growing proportion of this disease is diagnosed in older patients, there are limited studies of older patients comparing cisplatin to carboplatin. This study compared survival outcomes of elderly patients with limited-stage SCLC treated with concurrent EC or EP and radiation.

METHODS AND MATERIALS

Limited-stage SCLC diagnosed at ages 66 to 80 years during 1992 to 2007 were selected from the Surveillance Epidemiology and End Results-Medicare database to compare EP with EC. Concurrent CRT was defined as starting radiation and cisplatin or carboplatin within 14 days. Study endpoints were overall survival (OS, time from diagnosis until death) and cause-specific survival (CSS, time from diagnosis until death from lung cancer).

RESULTS

Final analysis included 565 cases: 219 EP (39%) and 346 EC (61%), with median age 72 and gender ratio 1.0. A majority of the cases were stage III (85%). Median and 5-year OS were 13.8 months (95% confidence interval [CI], 11.4-15.0 months) and 10.2% (95% CI, 6.2-15.3%) for EP, versus 13.7 months (95% CI, 12.0-15.6 months) and 10.9% (95% CI, 7.6-14.8%) for EC (P = .51). CSS were also similar (P = .91). OS and CSS were not statistically different in single- or multivariable survival analysis.

CONCLUSIONS

EC and EP had similar survival outcomes, suggesting EC could be used with (or instead of) EP as the standard of care, at least in the elderly population.

Efficacy of chemotherapy in limited-disease small-cell lung cancer

SUMMARY Small-cell lung cancer (SCLC) accounts for approximately 13% of all lung cancers, and limited-disease SCLC is defined as a disease that can be encompassed within a tolerable radiation field. Concurrent chemoradiotherapy is considered to be the standard treatment for limited-disease SCLC. In both concurrent and consolidation chemoradiotherapies, the combination of etoposide and cisplatin is considered to be a standard chemotherapy regimen. To develop novel treatment for SCLC, several clinical trials of molecular-targeted therapy or immunotherapy have been reported. However, no molecular-targeted drug has shown clinical activity in limited-disease SCLC. In future studies, understanding the molecular profile of SCLC will be necessary for the development of molecular-targeted therapies for SCLC. This review provides an overview of chemotherapy regimens for limited-disease SCLC.