Extensive-stage small cell lung cancer

PD-L1: programmed cell death ligand 1; WBRT: whole-brain radiation therapy; CT: computed tomography; MRI: magnetic resonance imaging; PS: performance status; ECOG: Eastern Cooperative Oncology Group; SCLC: small-cell lung cancer.
* Cross-trial comparisons suggest similar efficacy and toxicities between atezolizumab and durvalumab (off-label), when paired with chemotherapy, and a choice between them depends on provider preference and insurance coverage. If atezolizumab is chosen, we use carboplatin-etoposide, as atezolizumab has not been evaluated in combination with cisplatin-etoposide. Durvalumab may be paired with either carboplatin-etoposide or cisplatin-etoposide. Immunotherapy is initiated with chemotherapy and continued as maintenance treatment until progression or undue toxicity.
For patients who are not eligible for immunotherapy (eg, active autoimmune disease, concurrent immunosuppression, prior immunotherapy), chemotherapy alone is appropriate, and platinum-etoposide, or other platinum-based doublets may be offered. Although cisplatin-etoposide is associated with higher response rates, carboplatin-etoposide has a better toxicity profile, and is preferred by most clinicians in the United States.
¶ Brain MRI should be repeated after every two cycles of systemic therapy, with consideration of WBRT for evidence of progression.
Δ Although the standard approach to patients with SCLC and brain metastases has been WBRT, promising data exist for stereotactic radiosurgery, which may be considered an appropriate alternative for those with brain metastases.
◊ Although we proceed expeditiously, some experts wait one to two weeks in initiating WBRT after systemic therapy, or vice-versa.
§ CT scans of chest, abdomen, and pelvis with contrast should be performed after every two to three cycles of systemic therapy. If progression occurs, subsequent-line therapy (ie, single-agent chemotherapy) should be considered. Refer to UpToDate topic on treatment of recurrent or refractory SCLC.
¥ Single-agent chemotherapy options include topotecan, irinotecan, and others. Refer to UpToDate topic on recurrent or refractory SCLC for further details.
‡ For those with stable disease or response after initial treatment, we typically follow up initially every three months during years 1 and 2, and every six months during year 3. At each visit, we obtain history and physical exam, and CT scans of the chest, abdomen, and pelvis. We also assess brain MRI every three months during year 1, and every six months during year 2.
† On the days that anti-PD-L1 antibody is given, we do not administer radiation, in order to limit toxicity. However, we recognize that there is a paucity of data to inform this strategy, and in this setting, other approaches may be reasonable.
** In the era of modern imaging, regular surveillance brain MRI with contrast is an alternative to prophylactic cranial radiation.