Efficacy of Second and Subsequent Lines of Chemotherapy in Patients with Small Cell Lung Cancer-a Retrospective Single Institution Analysis

INTRODUCTION

Lung cancer is still the leading cause of death in patients with cancer [1]. It accounts for over 1100 000 deaths worldwide every year. In Germany, the incidence is about 33 000; 39 500 patients died of lung cancer in 2004 [2]. Of these cases, 15%–20% are diagnosed with small cell lung cancer (SCLC). The frequency of SCLC has been slightly decreasing over the last 20 years [1, 3]. In extensive disease (ED) SCLC without treatment, median survival is about 6–8 weeks after establishment of diagnosis [3]. With chemotherapy, median survival reaches 9–11 months. In limited disease (LD) SCLC, median survival without treatment is 15–17 weeks. With combined radiochemotherapy, 22–27 months are reached. SCLC is characterized by response rates (RR) usually being much higher than in non-SCLC. Unfortunately the disease relapses in a substantial number of patients with LD SCLC within a few months. In ED SCLC, disease recurrence occurs in virtually all patients. These patients usually present with symptoms at time of relapse. RR is important, as responding patients often achieve impressing symptom palliation. This is crucial in the treatment of ED SCLC. Therefore, second and subsequent lines of chemotherapy are important milestones in the treatment of LD and ED SCLC—beyond first-line chemotherapy and radiation therapy. Reinduction therapy can be applied in cases with response on first-line therapy. To date there are no comprehensive data on the role of reinduction versus second-line therapy.

Abstract

PURPOSE

The aim of this retrospective study is to present data on efficacy and toxicity of second and subsequent lines of chemotherapy in an unselected contemporary patient population with small cell lung cancer (SCLC) in limited disease (LD) and extensive disease (ED) stage.

PATIENTS AND METHODS

From June 2004 to June 2008, our electronic database including all in-patient and out-patient contacts was searched for patients with newly diagnosed SCLC. We identified 397 cases. Data were collected on patient characteristics, chemotherapy, side effects, response on treatment and survival. Time to progression (TTP) was assessed for every line of chemotherapy.

RESULTS

155 patients had LD SCLC. Response rate (RR) reached 76%. Thoracic radiation therapy was administered in 72%, Prophylactic cranial irradiation in 33%. TTP was 7.5 months. 51% received 2nd line treatment. In two thirds of these cases, the primary regimen was given as re-induction therapy. TTP in this group was 11.5 months, RR 36% and median survival 30 months. In patients with true second line therapy, RR was 8% and median survival median reached only 16 months.

ED SCLC was seen in 242 cases. RR was 69%. All patients relapsed with a median TTP of 3.5 months. 50% were given second line treatment. Median survival reached 13 months in this group versus 7 months in patients receiving first line therapy only. Response on first line therapy and performance status at start of second line treatment were the two most important predictive markers for survival.

CONCLUSION

Second line treatment should be given to all patients with recurrent SCLC in good performance status. Third line therapy is reasonable in patients with good PS and sensitive tumor on first line therapy.

Keywords

small cell lung cancer, treatment, recurrent disease