Treatment of limited-stage small cell lung cancer in the elderly, chemotherapy vs. sequential chemoradiotherapy vs. concurrent chemoradiotherapy: that's the question

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.

Adaptive radiation therapy (art) for patients with limited-stage small cell lung cancer (LS-SCLC): A dosimetric evaluation

Background

Adaptive radiation therapy (ART) refers to redesigning of radiation therapy (RT) treatment plans with respect to dynamic changes in tumor size and location throughout the treatment course. In this study, we performed a comparative volumetric and dosimetric analysis to investigate the impact of ART for patients with limited-stage small cell lung cancer (LS-SCLC).

Methods

Twenty-four patients with LS-SCLC receiving ART and concomitant chemotherapy were included in the study. ART was performed by replanning of patients based on a mid-treatment computed tomography (CT)-simulation which was routinely scheduled for all patients 20-25 days after the initial CT-simulation. While the first 15 RT fractions were planned using the initial CT-simulation images, the latter 15 RT fractions were planned using the mid-treatment CT-simulation images acquired 20-25 days after the initial CT-simulation. In order to document the impact of ART, target and critical organ dose-volume parameters acquired from this adaptive radiation treatment planning (RTP) were compared with the RTP based solely on the initial CT-simulation to deliver the whole RT dose of 60 Gy.

Results

Statistically significant reduction was detected in gross tumor volume (GTV) and planning target volume (PTV) during the conventionally fractionated RT course along with statistically significant reduction in critical organ doses with incorporation of ART.

Conclusion

One-third of the patients in our study who were otherwise ineligible for curative intent RT due to violation of critical organ dose constraints could be treated with full dose irradiation by use of ART. Our results suggest significant benefit of ART for patients with LS-SCLC.

Optimal timing of thoracic irradiation for limited stage small cell lung cancer: Current evidence and future prospects

Lung cancer is a global health concern as the leading cause of cancer related mortality worldwide. Small cell lung cancer (SCLC) poses a formidable challenge to the treating physicians with the worst prognosis among all lung cancers. However, limited stage SCLC (LS-SCLC) has a relatively better outcome with multimodality management. Efforts have been focused on optimal integration of treatment modalities to achieve an improved therapeutic ratio for patients with LS-SCLC. While chemotherapy and thoracic radiation therapy (TRT) are primary components of initial management for LS-SCLC, there is no consensus on optimal timing of TRT. Within this context, we herein provide a concise overview of current evidence and future prospects regarding the optimal timing of thoracic irradiation for LS-SCLC in light of the literature.

Small Cell Lung Cancer, Version 2.2022, NCCN Clinical Practice Guidelines in Oncology

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Small Cell Lung Cancer (SCLC) provide recommended management for patients with SCLC, including diagnosis, primary treatment, surveillance for relapse, and subsequent treatment. This selection for the journal focuses on metastatic (known as extensive-stage) SCLC, which is more common than limited-stage SCLC. Systemic therapy alone can palliate symptoms and prolong survival in most patients with extensive-stage disease. Smoking cessation counseling and intervention should be strongly promoted in patients with SCLC and other high-grade neuroendocrine carcinomas. The "Summary of the Guidelines Updates" section in the SCLC algorithm outlines the most recent revisions for the 2022 update, which are described in greater detail in this revised Discussion text.

Effect of prior thoracic radiotherapy on prognosis in relapsed small cell lung cancer patients treated with anlotinib: a subgroup analysis of the ALTER 1202 trial

Background

In ALTER 1202, anlotinib prolonged the progression-free survival (PFS) and overall survival (OS) of patients with relapsed small cell lung cancer (SCLC). The aim of this study was to explore the effect of front-line thoracic radiotherapy (RT) on the benefits of anlotinib as a third-line-or-beyond treatment.

Methods

This was a subgroup analysis of a multicenter, randomized, double-blind, placebo-controlled phase 2 trial (ALTER 1202). The participants were divided into RT (previous thoracic RT) and non-RT subgroups. The outcomes included PFS, OS, objective response rate (ORR), disease control rate (DCR), and safety.

Results

In the ALTER 1202 trial, 68 participants (anlotinib, n=46; placebo, n=22) received RT and 51 participants (anlotinib, n=35; placebo, n=16) did not. PFS was longer for anlotinib versus placebo in both the RT (5.49 vs. 0.69 months; P<0.001) and non-RT (2.83 vs. 0.76 months; P<0.001) subgroups. In the RT subgroup, the OS was longer for anlotinib vs. placebo (9.49 vs. 4.90 months; P=0.039). No differences were found in the ORR, but the DCR was higher in the anlotinib arm of the RT subgroup compared with the placebo arm (73.9% vs. 9.1%, P<0.001) and the non-RT subgroup (68.6% vs. 18.8%; P=0.002).

Conclusions

In relapsed SCLC patients with previous thoracic RT, anlotinib might have DCR, PFS, and OS benefits compared with placebo. In those without previous thoracic RT patients, anlotinib might have DCR and PFS benefits compared with placebo. The safety was similar between anlotinib and placebo groups.

Trends and variations in the treatment of stage I-III small cell lung cancer from 2008 to 2019: A nationwide population-based study from the Netherlands

OBJECTIVES

Recent treatment patterns for small cell lung cancer (SCLC) in the Netherlands were unknown. This nationwide population-based study describes trends and variations in the treatment of stage I-III SCLC in the Netherlands over the period 2008-2019.

MATERIALS AND METHODS

Patients were selected from the population-based Netherlands Cancer Registry. Treatments were studied stratified for clinical stage. In stage II-III, factors associated with the use of concurrent (cCRT) versus sequential chemoradiation (sCRT) and accelerated versus conventionally fractionated radiotherapy in the context of cCRT were identified.

RESULTS

In stage I (N = 535), 29% of the patients underwent surgery in 2008-2009 which increased to 44% in 2018-2019. Combined use of chemotherapy and radiotherapy decreased in stage I from 47% to 15%, remained constant (64%) in stage II (N = 472), and increased from 57% (2008) to 70% (2019) in stage III (N = 5,571). Use of cCRT versus sCRT in stage II-III increased over time (odds ratio (OR) _{2008-2011 vs 2016-2019}: 0.53 (95%-confidence interval (95%CI): 0.41-0.69)) and was strongly associated with lower age, WHO performance status 0, and diagnosis in a hospital with in-house radiotherapy. Forty-six percent of patients with stage III received cCRT in 2019. Until 2012, concurrent radiotherapy was mainly conventionally fractionated, thereafter a hyperfractionated accelerated scheme was administered more frequently (57%). Accelerated radiotherapy was strongly associated with geographic region (OR_{south vs north}: 4.13 (95%CI: 3.00-5.70)), WHO performance (OR_{1 vs 0}: 0.50 (95%CI: 0.35-0.71)), and radiotherapy facilities treating ≥ 16 vs < 16 SCLC patients annually (OR: 3.01 (95%CI: 2.38-3.79)).

CONCLUSIONS

The use of surgery increased in stage I. In stages II and III, the use of cCRT versus sCRT increased over time, and since 2012 most radiotherapy in cCRT was accelerated. Treatment regimens and radiotherapy fractionation schemes varied between patient groups, regions and hospitals. Possible unwarranted treatment variation should be countered.

Sequential Versus Concurrent Thoracic Radiotherapy in Combination With Cisplatin and Etoposide for N3 Limited-Stage Small-Cell Lung Cancer

At present, concurrent chemoradiotherapy (CRT) is considered the standard treatment of limited-stage small cell lung cancer (LS-SCLC). However, LS-SCLC is highly heterogeneous in the T stage, N stage, and prognosis. Increasing evidence has shown that individual treatment should be considered when treating LS-SCLC patients. The aim of the present study was to explore the optimal combination model of thoracic radiotherapy (TRT) and chemotherapy in N3 LS-SCLC. We retrospectively analyzed 93 N3 LS-SCLC patients treated in the Department of Oncology of Binzhou Medical University Hospital (Shandong, China) between March 2010 and October 2015. A total of 52 (52/93; 55.9%) patients received sequential CRT, and 41 (41/93; 44.1%) patients received concurrent CRT. All patients received 4-6 cycles of chemotherapy and TRT (50-60 Gy). The median follow-up time was 25.4 months (range was 6-65 months).The overall response rate was 88.5% in the sequential CRT group (9.6% complete response rate and 78.8% partial response rate) and 90.2% in the concurrent CRT group (14.6% complete response rate and 75.6% partial response rate). The PFS and OS were 15.4 months and 19.1 months in sequential CRT group, and 16.9 months and 20.5 months in concurrent CRT group. There was no significant difference in treatment response rate, PFS, and OS between sequential and concurrent CRT patients. The most common treatment-related toxicities were nausea/vomiting, neutropenia, and esophagitis. In conclusion, when concurrent CRT is performed in N3 LS-SCLC patients, tolerance to treatment should be fully considered. In our study, sequential CRT and concurrent CRT showed the same efficacy, and sequential CRT demonstrated better tolerance. However, these results require confirmation in future follow-up studies.

Multidisciplinary treatment of lung cancer in older patients: A review

Lung cancer is the leading cause of cancer death worldwide. Older patients represent approximately half of the patient population and optimal management of these patients is challenging. In early-stagenon-small cell lung cancer (NSCLC), lobectomy should be considered in fit older patients. For unfit patients, stereotactic body radiotherapy (SBRT) represents a good alternative. While data on the benefit and risk of concurrent chemo-radiotherapy (cCRT) in older patients with locally advanced NSCLC is conflicting, age alone should not preclude cCRT. Multidisciplinary collaboration is essential for appropriate patient selection. In limited disease small cell lung cancer (SCLC), older patients appear to benefit similarly from standard treatment compared to their younger counterparts, however, with a higher risk of toxicity. Appropriately selected older patients with lung cancer seem to derive as much benefit from active oncological treatment as their younger counterparts. Geriatric screening tests and comprehensive geriatric assessments (CGA) can be helpful when choosing between treatment strategies. Older patients are at risk for under-treatment; this should be avoided by proper selection and multidisciplinary management. This review outlines the management of lung cancer in older patients.

The expression of S100B protein in serum of patients with brain metastases from small-cell lung cancer and its clinical significance

The objective of the present study was to investigate the expression of S100B protein in serum of patients with brain metastases from small cell lung cancer (SCLC), and its clinical significance. A total of 138 patients with SCLC were selected from June 2013 to December 2015. Simultaneously, 138 healthy adult volunteers (healthy controls) were selected in the medical examination center of People's Hospital of Rizhao. Among the 138 patients with SCLC, 48 had liver metastases and 44 had brain metastases. Of the remaining 46 patients, 20 were initially diagnosed with SCLC and 26 underwent surgery and postoperative chemotherapy. The levels of serum S100B in patients and healthy controls were measured by ELISA, and analyzed by SPSS 20.0 statistical software. The serum S100B protein levels in patients with SCLC were significantly higher than those in healthy controls (p<0.05). Among the subgroups of patients with SCLC, the levels of serum S100B in patients with brain metastases were significantly higher than in the other subgroups (p<0.05). No significant differences were found between the other subgroups, except for the brain metastases group. We found that serum S100B protein expression levels were significantly reduced in patients with brain metastases after cobalt-60 radiotherapy (p<0.05). During follow-up, we found that higher expression of S100B protein was usually associated with poorer prognosis, higher mortality rate at 1 year, and lower survival rate. In conclusion, S100B protein can serve as a serological marker for brain metastases from SCLC, which provides important theoretical support for early detection of brain metastases.

Multidisciplinary decision-making regarding chemotherapy for lung cancer patients-An age-based comparison

Optimising decision-making in elderly patients is becoming increasingly urgent. We analysed treatment decisions and course of therapy for patients with lung cancer in different age categories: <65, 65-75, and 75 years and older. About 349 patients with lung cancer (median age 67.8 years), discussed at the multidisciplinary team meeting in the Diakonessenhuis Utrecht, the Netherlands, were reviewed. Multidisciplinary decision-making and subsequent clinical course were extracted from medical files. We found that 39% of eligible patients older than 75 years of age started treatment with chemotherapy compared to 80% of the younger patients (<65 and 65-75). When patients did receive chemotherapy, primary and secondary treatment adaptations were effectuated in 58%: for patients aged <65 in 49%, for patients aged 65-75 and >75 years in 66%. For 44% of all patients treated with chemotherapy, unplanned hospital admissions were required: in 42% for the patients <65, in 52% for those aged 65-75 and in 27% for >75 years. The decision-making process and course of treatment for lung cancer vary per age category. In particular, patients between 65 and 75 years of age might be more frail than initially thought. Age and frailty are important characteristics that need more attention.

Lung Cancer in the Older Patient

Cancers of the lung and bronchus are the leading cause of cancer deaths in men and women in the United States, and two-thirds of new lung cancer cases are diagnosed in patients over age 65. There are few dedicated clinical trials in the elderly, leading to both undertreatment and overtreatment biases. Even fit older adults experience age-related decline in physiologic reserve, and additional issues of polypharmacy, geriatric syndromes, and inadequate social support are not uncommon, leading to disparities in treatment and survival. This review discusses the challenges in balancing benefits and harms in management of lung cancer in elderly patients.

The Younger Patients Have More Better Prognosis in Limited Disease Small Cell Lung Cancer

BACKGROUND

Factors associated with the prognosis of patients with small cell lung cancer (SCLC) is relatively unknown, than of those with non-small cell lung cancer. This study was undertaken to identify the prognostic factors of SCLC.

METHODS

The medical records of 333 patients diagnosed with SCLC at tertiary hospital from January 1, 2008, to December 31, 2012 were retrospectively reviewed. Patients were categorized by age (≤65 years vs. >65 years) and by extent of disease (limited disease [LD] vs extensive disease [ED]). Overall survival and progression free survival rates were determined. Factors associated with prognosis were calculated using Cox's proportional hazard regression model.

RESULTS

Most baseline characteristics were similar in the LD and ED groups. Eastern Cooperative Oncology Group (ECOG) performance status (PS), first chemotherapy regimen, and prophylactic cranial irradiation (PCI) differed significantly in patients with LD and ED. Mean ECOG PS was significantly lower (p<0.001), first-line chemotherapy with etoposide-cisplatin was more frequent than with etoposide-carboplatin (p<0.001), and PCI was performed more frequently (p=0.019) in LD-SCLC than in ED-SCLC. Prognosis in the LD group was better in younger (≤65 years) than in older (>65 years) patients, but prognosis in the ED group was unrelated to age.

CONCLUSION

This study showed that overall survival (OS) was significantly improved in younger than in older patients with LD-SCLC. Univariate and multivariate analyses showed that age, PCI and the sum of cycles were significant predictors of OS in patients with LD-SCLC. However, prognosis in the ED group was unrelated to age.