Small Cell Lung Cancer Guidelines 

Updated: Dec 23, 2016
  • Author: Winston W Tan, MD, FACP; more...
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Lung Cancer Screening

Guidelines on lung cancer screening have been issued by the following organizations:

  • American Cancer Society (ACS)
  • American College of Chest Physicians (ACCP)
  • American Association for Thoracic Surgery (AATS)
  • National Comprehensive Cancer Network (NCCN)
  • U.S. Preventive Services Task Force (USPSTF)

The guidelines are in agreement that annual screening with low-dose, computed tomography (LDCT) scanning should be offered to patients aged 55 to 74 years and who have at least a 30 pack-year smoking history and either continue to smoke or have quit within the past 15 years. [1, 2, 3, 4, 5]

The USPSTF extends the recommended age range to 80 years, while the NCCN notes the existence of uncertainty about the upper age limit for screening and advises that screening beyond age 74 years may be considered as long as the patient's functional status and comorbidity allow consideration for curative intent therapy. [4, 3]  

The American Association for Thoracic Surgery (AATS) extends the recommended age range to 79 years and also recommends annual screening starting at age 50 for patients who have a 20 pack-year smoking history and additional comorbid conditions that produce a cumulative risk for cancer of at least 5% over the next 5 years. Additionally, it recommends annual screening in long-term cancer survivors aged 55 to 79 years. [5]

The NCCN guidelines also recommend screening starting at age 50 in patients with at least a 20 pack-year smoking history and one or more of the following risk factors [3] :

  • Radon exposure (documented sustained and substantial)
  • Occupational exposure to lung carcinogens (eg, silica, cadmium, asbestos, arsenic, beryllium, chromium, diesel fumes, nickel, coal smoke, soot)
  • Cancer history (lung cancer, lymphomas, cancers of the head and neck, or smoking-related cancers)
  • Family history of lung cancer in first-degree relatives 
  • Chronic obstructive pulmonary disease or pulmonary fibrosis

The groups also agree that the shared decision making is required and should include a discussion of benefits and risks.

None of the guidelines recommend screening asymptomatic patients for lung cancer with chest radiograph (CXR) or sputum cytology.

See Small Cell Lung Cancer: Beating the Spread, a Critical Images slideshow, to help identify the key clinical and biologic characteristics of small cell lung cancer, the staging criteria, and the common sites of spread.

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ACCP Diagnosis and Management Guidelines

The American College of Chest Physicians (ACCP) updated its comprehensive set of lung cancer guidelines in 2013. The guideline set of more than 275 recommendations includes an executive summary of current recommendations for diagnosis and treatment, along with additional recommendations for screening, chemoprevention and treatment of tobacco use in patients with lung cancer. [6]

In 2015, the American Society of Clinical Oncology (ASCO) endorsed the ACCP guidelines, with the addition of minor qualifying statements.

Diagnosis of Pleural Abnormalities

The ACCP guidelines recommendations for diagnosis of pleural abnormalities include the following [6, 7] :

  • In patients suspected of having SCLC based on the radiographic and clinical findings, the diagnosis should be confirmed by the least invasive method (eg, sputum cytology, thoracentesis, fine needle aspiration (FNA), bronchoscopy including transbronchial needle aspiration), as dictated by the patient's presentation
  • For individuals who have a solitary extrathoracic site suspicious of a metastasis, tissue confirmation of the metastatic site should be obtained if FNA or biopsy of the site is feasible
  • In individuals in whom biopsy of a metastatic site would be technically difficult, diagnosis of the primary lung lesion should be obtained by the least invasive method
  • In patients suspected of having lung cancer who have an accessible pleural effusion, thoracentesis is recommended to diagnose the cause of the pleural effusion; ultrasound-guided thoracentesis is recommended for performing diagnostic thoracentesis
  • In patients suspected of having lung cancer who have an accessible pleural effusion, if pleural fluid cytology is negative, pleural biopsy (via image-guided pleural biopsy, medical or surgical thoracoscopy) is recommended as the next step

Diagnosis of Primary Tumor

The ACCP guidelines recommendations for diagnosis of primary tumor include the following [6, 7] :

  • If lung cancer is suspected and sputum cytology is negative for carcinoma, further testing should be performed
  • In patients who have a central lesion, bronchoscopy should be used to confirm the diagnosis; however, further testing should be performed if bronchoscopy results are non-diagnostic and suspicion of lung cancer remains
  • As an adjunct imaging modality when a tissue sample is required due to diagnostic uncertainty or poor surgical candidacy, radial endobronchial ultrasound can confirm in real time the ideal location of bronchoscopic sampling and increase the diagnostic yield over conventional bronchoscopy for peripheral nodules.
  • With peripheral lung lesions difficult to reach with conventional bronchoscopy, electromagnetic navigation guidance can be used if the equipment and the expertise are available; if electromagnetic navigation is not available, transthoracic needle aspiration (TTNA) is recommended
  • In patients who have a peripheral lesion, and who require tissue diagnosis before further management can be planned, TTNA is diagnostic option; however, further testing should be performed if TTNA results are nondiagnostic and suspicion of lung cancer remains
  • The possibility of an erroneous diagnosis of SCLC on a cytology specimen must be kept in mind if the clinical presentation or clinical course is not consistent with that of SCLC; in such a case, further testing should be performed to establish a definitive cell type
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Staging

The American Joint Commission for Cancer (AJCC) adopted the new tumor, node, metastasis (TNM) system in 2010. [8] In addition, the 2011 National Comprehensive Cancer Network (NCCN) clinical practice guideline for SCLC incorporated TNM staging into its diagnostic and therapeutic algorithms; the NCCN suggested that researchers begin to use the TNM staging system in an effort to more accurately assess prognoses and to more specifically personalize therapeutic options. This recommendation is also reflected in the current NCCN and European Society for Medical Oncology (ESMO) practice guidelines. [3, 9] However, the American College of Chest Physicians (ACCP) guidelines recommend use of both the TNM system and the Veterans Administration Lung Study Group (VALSG) system (limited-stage vs extensive-stage) to classify the tumor stage. [10]

SCLC consists of two stages: limited-stage and extensive-stage. Under the AJCC TNM staging system, limited-stage SCLC is defined as any T, any N, M0; the exception is T3-4, owing to multiple lung nodules that extend beyond a single radiation field. [8]

Extensive-stage disease describes tumors that extend beyond the ipsilateral hemithorax, such as those that reach the contralateral lung and/or contralateral lymph nodes or that find their way to distant organs (eg, bone marrow). The AJCC TNM staging system classifies extensive-stage disease as any T, any N, M1a/b, and T3-4, due to involvement of multiple lung nodules. [8]

The American College of Chest Physicians (ACCP) does not recommend positron emission tomography (PET) scanning in the routine staging of SCLC [10] , However, in a qualifying statement, ASCO recognizes that PET scanning is a widely used initial staging tool in patients with lung cancer, and recommends that when a PET scan is obtained for patientw with either limited-stage or extensive-stage disease, a bone scan may be omitted. [11]  The NCCN guidelines recommend combined PET–computed tomography scanning if limited-stage disease or metastasis is suspected. [3]

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Treatment for Limited-Stage SCLC

The American College of Chest Physician (ACCP) guidelines recommend that limited-stage small cell lung cancer (LS-SCLC) be treated with curative intent, based on an expected 20% to 25% 5-year survival. [6, 10] The ACCP guidelines recommendations for treatment of LS-SCLC also include the following:

  • Surgical resection is indicated for carefully selected stage I SCLC after a thorough distant and invasive mediastinal stage evaluation
  • Patients who have undergone surgical resection should be treated with platinum-based adjuvant chemotherapy
  • Accelerated hyper-fractionated radiation therapy (twice-daily treatment) should be administered early in the course of treatment, concurrently with chemotherapy consisting of four cycles of a platinum agent and etoposide

The ACCP and the National Comprehensive Cancer Network (NCCN) guidelines recommend prophylactic cranial irradiation in patients with limited-stage disease who have achieved a complete remission or in those with stage I disease who have undergone a complete resection, although the NCCN advises against its use in patients with poor performance status or impaired neurocognitive function. [6, 10, 3] The 2013 European Society for Medical Oncology (ESMO) practice guidelines recommends patients with T1, 2 N0, 1 M0 should be considered for prophylactic cranial irradiation (PCI) if they have responded to initial treatment using the same dose and fractionation as for patients with stage III SCLC. [9]

In addition, the NCCN clinical practice guidelines recommend sequential therapy be given for patients unable to tolerate concurrent chemoradiation. Chemotherapy is given first, followed by radiation therapy, because of the high rate of responsiveness to chemotherapy for SCLC. [3] .

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Treatment for Extensive-Stage SCLC

Guidelines from the American College of Chest Physicians (ACCP), the National Comprehensive Cancer Network (NCCN), and the European Society for Medical Oncology (ESMO) recommend that patients with extensive-stage disease be treated with combination chemotherapy alone. [4, 6, 10, 9]

The ACCP recommends combining palliative care with standard oncology care early in the treatment course. Conversations about the goals of care and end-of-life options should be initiated with all patients with extensive-stage SCLC. [12]

The ACCP and the NCCN guidelines recommend following treatment recommendations for SCLC in patients who have mixed histologic features of SCLC and non-SCLC. [6, 10, 3]

According to the NCCN guidelines, dose-dense or dose escalation chemotherapy regimens are not recommended outside of a randomized clinical trial. [3]

The ACCP recommends offering further chemotherapy to patients with relapsed or refractory SLCL. [6] However, except in the setting of a clinical trial, the ACCP does not recommend either of the following:

  • Maintenance treatment for patients with limited- or extensive-stage disease that has achieved a partial (PR) or complete remission (CR)
  • Dose-dense/intense initial/induction or maintenance treatment for limited- or extensive-stage disease
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Treatment of SCLC in the Elderly

The American College of Chest Physicians (ACCP) recommends that elderly patients with small-cell lung cancer (SCLC) who have a good performance status (PS) (ie, Eastern Cooperative Oncology Group [ECOG] PS 0 or 1) and intact organ function receive standard carboplatin-based chemotherapy. However, even patients who have poor prognostic factors (eg, poor PS, medically significant concomitant conditions) may still be considered for chemotherapy if appropriate precautions are taken to avoid excessive toxicity and further decline in PS. [6]

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Long-Term Monitoring

The National Comprehensive Cancer Network recommends that after recovery from primary therapy, patients should receive oncology follow-up visits on the following schedule [3] :

  • Years 1-2: Every 3–4 mo
  • Years 3-5: Every 6 mo
  • Subsequent years: Annuallly

At every visit, the patient should receive the following:

  • History and physical examination
  • Chest imaging (with workup for potential new primary if a new pulmonary nodule is detected)
  • Bloodwork as clinically indicated
  • Smoking cessation intervention, if necessary

PET/CT is not recommended for routine follow-up.

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