Improving Overall Survival In Extensive Stage Small Cell Lung Cancer - Episode 1

Presentation of a 73-Year-Old Woman With Stage IV SCLC

Jyoti D. Patel, MD:Hi, I’m Jyoti Patel, the director of thoracic oncology at Northwestern University Feinberg School of Medicine.

The patient is a 73-year-old woman who presented with some cough and shortness of breath. She went to her physician and was found to have some dullness in her right lower lobe. She expressed that she also had some weight loss and some dyspnea on exertion. At that juncture, a chest x-ray was done, showing a right lower lobe mass. A subsequent CT [computed tomography] scan demonstrated that she had mediastinal adenopathy, a right lower lobe mass, and some areas in her liver that were suspicious for disease.

She was otherwise pretty healthy. She had been working until a couple of years ago and was enjoying retirement. She was active with her family. She had a 50-pack-a-year smoking history and quit about 6 years ago. She was on some high blood pressure medicines but had very few other comorbidities.

At that juncture, she returned to her physician. A decision was made that she should get a PET [positron emission tomography] scan to look for other sites of disease. A PET scan confirmed that she had liver involvement. She ultimately underwent an IR [interventional radiology] biopsy, and that IR biopsy of her liver showed that she unfortunately had small cell lung cancer.

At that juncture, her physician sent her to me, a medical oncologist, for further opinion. She’d gotten an MRI [magnetic resonance imaging] of her brain on a previous appointment and was coming back to clinic to talk about her treatment options.

When we met, we talked about her social structures in life. She was married and was very involved with her daughter, who is expecting a baby in the next several months. This will be her first grandchild, and she’s thrilled about that. It was important for her to remain independent for as long as she could and to be able to see the birth of this grandchild.

Given that she had disease in her liver, she was felt to have T3N3M1 disease. That’s stage IVB disease. In small cell lung cancer, we often break the disease down into 2 easier stages based on the VA [Veterans Administration] staging system that’s in greater accordance with treatment approach. And so she had extensive-stage disease. Her performance status [PS] was intact. She had had some weight loss and some shortness of breath, so she was still PS1.

Given her extensive involvement, we had a discussion about treatment options. At that juncture, we elected to do treatment with carboplatin and etoposide as a backbone and added therapy with durvalumab. She received the durvalumab with chemotherapy for 4 cycles. A CT scan after 2 cycles demonstrated significant response. She then had completed 4 cycles and was about to start maintenance durvalumab.

She came to us to talk about how she was doing. She had improvement in her dyspnea on exertion, and her weight had increased pretty nicely. She was back to being active. She did have some fatigue after her chemotherapy cycles that, at the time of durvalumab, had improved pretty significantly. She was excited to begin durvalumab every 4 weeks, with CT scans every 3 to 4 months, depending on how far she’d been.

Our plan was to start durvalumab and to do a CT scan at 3 months and then at 6 months, unless she had new symptoms or unless she was found to have changes in her chemistry. We were able to treat her for 6 months with durvalumab.

This is a 73-year-old woman with a couple of comorbidities, like high blood pressure, who was found to have extensive-stage small cell lung cancer. Our approach to extensive-stage small cell lung cancer has changed dramatically in the relatively recent past. For years, the backbone of therapy for patients was carboplatin or cisplatin with etoposide, and the goal of therapy was to get tumor shrinkage early on and relief in symptoms. Generally, we treated patients for 4 to 6 cycles. Two-thirds to three-quarters of patients had improvement in disease, but unfortunately, this was a cancer for which rapid relapse often happened. Depending on when that relapse happened, second-line therapies had varied benefit.

Really, we’ve been using this backbone of treatment for decades with few improvements. The improvements that have occurred are primarily a result of better staging. So we have PET scans to perhaps find really limited stage II disease and extensive-stage disease with improvements in supportive care and improvements in radiation.

Transcript edited for clarity.


Case: A 73-Year-Old Female With Stage IV SCLC

Initial presentation

  • A 73-year—old woman presented with shortness of breath, productive cough, chest pain, fatigue, anorexia and an 18-lb weight loss.
  • PMH: HTN
  • SH: Elementary school teacher; 50 pack year smoking history; quit 6 years ago; married with 2 children and her first grandchild on the way.
  • PE: Dullness to percussion, decreased breath sounds, BMI 17

Clinical workup

  • Imaging:
    • Chest x-ray showed a hilar mass and a 5.4cm right lower lobe mass
    • Chest/abdomen/pelvic CT scan revealed mediastinal adenopathy, right lower lung lobe mass, suspicious liver lesions
    • PET scan showed activity in the left upper lobe mass and supraclavicular nodal areas and liver lesions
    • No metastases to brain on MRI
  • IR biopsy of liver revealed small cell lung cancer
  • Staging: T3N3M1 - IVb
  • ECOG PS 1

Treatment

  • Concurrent durvalumab with carboplatin/etoposide; has completed 4 cycles
  • Developed constipation and nausea after second cycle (constipation successfully treated with increased oral hydration and docusate; nausea treated with ondansetron)
  • Repeated chest/abdomen/pelvis CT with contrast after every 2 cycles demonstrated significant response. After 4 cycles patient started maintenance durvalumab for 6 months
  • Continued durvalumab every 4 weeks, with CT scans at 3 and 6 months