Treatment choices by stage for small cell lung cancer

As mentioned in "How is small cell lung cancer staged?", for practical reasons small cell lung cancer (SCLC) is usually staged as either limited or extensive. In most cases, SCLC has already spread by the time it is found (even if that spread is not seen on x-rays and other imaging tests), so it usually cannot be treated by surgery alone. If you are healthy enough, you will probably get chemotherapy (chemo), regardless of the stage of your disease.

If you smoke, one of the most important things you can do to be ready for treatment is to try to quit. Studies have shown that patients who stop smoking after a diagnosis of lung cancer tend to have better outcomes than those who don't.

Stage I SCLC

If you only have a single small tumor in your lung with no evidence of cancer in lymph nodes or elsewhere, your doctors may recommend surgery to remove the tumor and the nearby lymph nodes. This is only an option if you are in fairly good health and able to tolerate removing all or part of a lung. You will be checked for signs of cancer spread to the lymph nodes in the chest with mediastinoscopy or other tests before this is considered. Very few patients with SCLC are treated this way.

Surgery is generally followed by chemo (see the "Chemotherapy" section for more details on commonly used drugs). Radiation to the chest is usually advised as well if cancer is found in the lymph nodes that were removed. The radiation is often given at the same time as the chemo. Although this increases the side effects of treatment, it appears to be more effective than giving one treatment after the other. You may not be given radiation therapy if you already have severe lung disease (in addition to your cancer) or other serious health problems.

Limited stage SCLC

For most cases of limited stage SCLC, surgery is not an option because the tumor is too large, or has spread to nearby lymph nodes or other places in the lung. If you are in good health, the standard treatment is chemo plus radiation (given at the same time). People given these treatments together live longer and have a better chance of cure, but this treatment combination is hard to take.

If you have lung problems or other major health problems, chemotherapy may be given alone.

If no preventive measures are taken, about half of people with SCLC will have cancer spread (metastasis) to their brain. For this reason, if your cancer has responded well to initial treatment, you may be given radiation therapy to the head (prophylactic cranial irradiation, or PCI) to try to prevent spread to the brain. The radiation is usually given in lower doses than that for treatment of known metastases. Still, some patients given PCI may have side effects, such as those described in the "Radiation therapy" section.

Most people treated with chemotherapy (with or without radiation) for their limited stage SCLC will have their tumors shrink significantly. In about half of these people, the cancer will shrink to the point where it can no longer be seen on imaging tests. Unfortunately, the cancer will still return at some point in most people.

Clinical trials of new chemotherapy drugs and combinations, as well as other new treatments, are being done to improve on current treatment results. Because these cancers are hard to cure, a clinical trial may be a good option for some people. If you think you might be interested in taking part in a clinical trial, talk to your doctor.

Extensive stage SCLC

If you have extensive SCLC and are in fairly good health, chemotherapy can often treat your symptoms and also help you live longer. (See the "Chemotherapy" section for more details on commonly used drugs.) About 3 out of 4 people will have their cancer shrink significantly with chemotherapy. Unfortunately, the cancer will still return at some point in almost all people with extensive stage SCLC.

If the cancer responds well to chemo, radiation treatments to the brain may also be considered to prevent future problems (prophylactic cranial irradiation).

Because these cancers are hard to treat, clinical trials of new chemotherapy drugs and combinations, as well as other new treatments, may be a good option for some people. If you think you might be interested in taking part in a clinical trial, talk to your doctor.

Radiation therapy is sometimes used to help shrink tumors and control symptoms in a specific part of the body, such as if cancer growth within the lungs is causing shortness of breath or bleeding. Other types of treatment, such as laser surgery, can also sometimes be helpful in these situations. Radiation therapy can also be used to relieve symptoms if the cancer has spread to the bones or brain.

If your general health is poor, you may not be able to withstand the side effects of chemotherapy or benefit from it. In this case, your doctor may select a treatment plan based on your individual medical situation. If you are too ill to have chemotherapy, the best plan may be to have supportive care. This would include treatment of any pain, breathing problems, or other symptoms you might have.

Cancer that progresses or recurs after treatment

If the cancer continues to grow during treatment or comes back, any further treatment will depend on the extent of the cancer, what treatments have been used, and a person's health and desire for further treatment. It is always important to understand the goal of any further treatment before it starts – if it is to try to cure the cancer, to slow its growth, or to help relieve symptoms – as well as the likelihood of benefits and risks.

If a cancer continues to grow during chemotherapy, another type of chemotherapy may be tried, although it may be less likely to be effective. For cancers that come back after initial treatment is finished, the choice of chemotherapy drugs may depend on how long the cancer was in remission (see the "Chemotherapy for small-cell lung cancer" section).

At some point, it may become clear that standard treatments are no longer controlling the cancer. If you want to continue anti-cancer treatment, you might think about taking part in a clinical trial of newer lung cancer treatments. Although these are not always the best option for every person, they may benefit you as well as future patients.

Even if your cancer can't be cured, you should be as free of symptoms as possible. If curative treatment is not an option, treatment aimed at specific sites can often relieve symptoms and may even slow the spread of the disease. Symptoms caused by cancer in the lung airways – such as shortness of breath or coughing up blood – can often be treated effectively with radiation therapy, laser therapy, or other local treatments if needed. Radiation therapy can be used to help control cancer spread in the brain or relieve pain if cancer has spread to the bones.

Many people with lung cancer are concerned about pain. If the cancer grows near certain nerves it can sometimes cause pain, but this can almost always be treated effectively with pain medicines. Sometimes radiation therapy or other treatments will help as well. It is important that you talk to your doctor and take advantage of these treatments.

Deciding on the right time to stop treatment aimed at curing the cancer and focus on care that relieves symptoms is never easy. Good communication with doctors, nurses, family, friends, and clergy can often help people facing this situation.