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ASCO Endorses CHEST Guideline on Treatment of Small Cell Lung Cancer

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As reported in the Journal of Clinical Oncology, ASCO has endorsed the current American College of Chest Physicians (CHEST) guideline on treatment of small cell lung cancer, released in 2013.

After review of evidence from an updated literature search covering 2011 to March 2015, an ASCO endorsement panel determined that there was no definitive evidence warranting substantive modification of CHEST treatment recommendations. However, the panel added qualifying statements for recommendations in several areas. The endorsement panel was co-chaired by Giuseppe Giaccone, MD, PhD, of Georgetown University, and Charles M. Rudin, MD, PhD, of Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College.

The CHEST guideline sought to address the following questions:

  1. What is the ability of positron-emission tomography (PET) imaging to determine stage of cancer?
  2. In patients with limited-stage disease, how do the parameters of thoracic radiotherapy affect survival?
  3. In patients with extensive-stage disease, what is survival after treatment with chemotherapy, including novel and targeted agents?
  4. In elderly patients, what are survival and toxicity after treatment with chemotherapy or radiation therapy? 

Key recommendations are reproduced below. On the CHEST evidence-grading system, retained in the endorsement, 1 = strong recommendation, 2 = weak recommendation, and A, B, and C = high-, medium-, and low-quality evidence. ASCO qualifying statements and remarks appear in italics.

Key Recommendations

  • In patients with proven or suspected small cell lung cancer, a staging evaluation is recommended consisting of medical history and physical examination, complete blood cell count (CBC) and comprehensive chemistry panel with renal and hepatic function tests, computed tomography (CT) of the chest and abdomen with IV contrast or CT scan of the chest extending through the liver and adrenal glands, magnetic resonance imaging (MRI) or CT of the brain, and bone scan (grade 1B).
    Qualifying statement: If PET is obtained, then bone scan may be omitted. CBC should include differential.
  • In patients with clinically limited-stage small cell lung cancer, PET imaging is suggested (grade 2C).
    Remark: If PET is obtained, then bone scan may be omitted.
    Qualifying statement: PET scan use is also applicable to extensive-stage small cell lung cancer.
  • It is recommended that both the Veterans Administration system (limited-stage vs extensive-stage) and the American Joint Committee on Cancer/International Union Against Cancer seventh edition system (TNM) should be used to classify the tumor stage (grade 1B).
  • In patients with clinical stage I small cell lung cancer who are being considered for curative-intent surgical resection, invasive mediastinal staging and extrathoracic imaging (head MRI/CT and PET or abdominal CT plus bone scan) are recommended (grade 1B).
  • In patients with clinical stage I small cell lung cancer, after a thorough evaluation for distant metastases and invasive mediastinal stage evaluation, surgical resection is suggested over nonsurgical treatment (grade 2C).
  • In patients with stage I small cell lung cancer who have undergone curative-intent surgical resection, platinum-based adjuvant chemotherapy is recommended (grade 1C).
  • In patients with limited-stage small cell lung cancer, early chemoradiotherapy, with accelerated hyperfractionated radiation therapy (twice-daily treatment) concurrently with platinum-based chemotherapy, is recommended (grade 1B).
    Qualifying statement: Comparison of accelerated hyperfractionated radiotherapy with an extended course of daily radiation therapy at standard fractionation is currently being investigated.
  • In patients with limited-stage or extensive-stage small cell lung cancer who achieve a complete or partial response to initial therapy, prophylactic cranial irradiation (PCI) is recommended (grade 1B).
    Remark: The regimen of 25 Gy in 10 daily fractions has the greatest supporting data for safety and efficacy.
    Qualifying statement: The panel notes that a recent Japanese study failed to demonstrate a survival advantage with PCI in patients with extensive-stage small cell lung cancer. On publication of the mature data from this study, the recommendation for PCI in extensive-stage small cell lung cancer might be subject to revision.
  • In patients with extensive-stage small cell lung cancer who have completed chemotherapy and achieved a complete response outside the chest and a complete or partial response in the chest, a course of consolidative thoracic radiotherapy is suggested (grade 2C).
    Qualifying statement: Further evaluation of this question is required before a treatment recommendation can be made.
  • In patients with either limited-stage or extensive-stage small cell lung cancer, four to six cycles of platinum-based chemotherapy with either cisplatin or carboplatin plus either etoposide or irinotecan are recommended over other chemotherapy regimens (grade 1A).
    Qualifying statement: Clinical trials in the United States and Europe have not demonstrated a benefit for the irinotecan regimen over that based on etoposide. In limited-stage disease, four cycles is preferred.
  • In patients with relapsed or refractory small cell lung cancer, administration of second-line, single-agent chemotherapy is recommended (grade 1B).
    Remark: Reinitiation of the previously administered first-line chemotherapy regimen is recommended in patients who experience relapse 6 months from completion of initial chemotherapy. Enrollment onto a clinical trial is encouraged.
    Qualifying statement: Single-agent topotecan has approval of the US Food and Drug Administration (FDA) in this context
    .
  • In elderly patients with limited-stage small cell lung cancer and a good performance status (Eastern Cooperative Oncology Group performance status of 0 to 2), treatment with platinum-based chemotherapy plus thoracic radiotherapy is suggested, with close attention to management of treatment-related toxicity (grade 2B).
  • In elderly patients with extensive-stage small cell lung cancer and a good performance status, treatment with carboplatin-based chemotherapy is suggested (grade 2A).
  • In elderly patients with small cell lung cancer and a poor performance status, treatment with chemotherapy is suggested if the poor performance status is due to small cell lung cancer (grade 2C).

More information is available at www.asco.org/endorsements/sclc and www.asco.org/guidelineswiki. Patient information is available at www.cancer.net. The CHEST guideline is available at www.chestnet.org.

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.


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