Small cell lung cancer

Surgery is not usually considered for patients with small cell lung cancer, an aggressive form of lung cancer. This is because of the results of two randomised trials (the first is from my own institution The Royal Brompton Hospital) published in the 1970's and 1980's, before CT scans were in use and before PET/CT scans were available demonstrated no benefit compared to medical therapy.(1,2)

Research that I conducted (this side of the millenium!) reported that the results of surgery for small cell lung cancer in today's era was in fact excellent with published results from my institution (The Royal Brompton Hospital) demonstrating survival rates that were very much (four to five fold) higher than conventional medical therapy.(3) The clinical community were (rightly) initially skeptical about such excellent outcomes, until the results were replicated in large North American studies.(4)

Clinicians then (correctly) pointed out that the outstanding results of surgery could be explained by surgeons "choosing" patients with an earlier stage of disease to operate on, again this was refuted by evidence from North America revealing that stage for stage, outcome of patients undergoing surgery was superior in terms of overall survival compared to medical therapy alone.(5)

Finally, the only remaining explanation might be that surgeons might be choosing patients who were physically fitter, and this will not be resolved unless we conduct a new randomised trial. 

In the absence of such a trial, I believe that the weight of evidence is strongly in support of surgery for small cell lung cancer, as part of multi-modality treatment. So much so that it was a recommendation that we made in the 2010 British Guidelines for the Radical Management of Lung Cancer.(6)

When we analysed the results across the United Kingdom, we found that the survival of patients undergoing surgery for small cell lung cancer was lower but not very much different from patients undergoing surgery for conventional non-small cell lung cancer and we concluded based on the results that if we offered surgery for non-small cell lung cancer, then we should also offer surgery for small cell lung cancer.(7)

Please contact me if you would like to discuss surgical options for small cell lung cancer.

References

1. Fox W, Scadding JG. Medical Research Council comparative trial of surgery and radiotherapy for primary treatment of small-celled or oat-celled carcinoma of bronchus. Ten-year follow-up. Lancet 1973;2:63-5.
2. Lad T, Piantadosi S, Thomas P, Payne D, Ruckdeschel J, Giaccone G. A prospective randomized trial to determine the benefit of surgical resection of residual disease following response of small cell lung cancer to combination chemotherapy. Chest 1994;106:320S-3S.
3. Lim E, Belcher E, Yap YK, Nicholson AG, Goldstraw P. The role of surgery in the treatment of limited disease small cell lung cancer: time to reevaluate. J Thorac Oncol 2008;3:1267-71.
4. Yu JB, Decker RH, Detterbeck FC, Wilson LD. Surveillance epidemiology and end results evaluation of the role of surgery for stage I small cell lung cancer. J Thorac Oncol 2010;5:215-9.
5. Schreiber D, Rineer J, Weedon J, et al. Survival outcomes with the use of surgery in limited-stage small cell lung cancer: should its role be re-evaluated? Cancer 2010;116:1350-7.
6. Lim E, Baldwin D, Beckles M, et al. Guidelines on the radical management of patients with lung cancer. Thorax 2010;65 Suppl 3:iii1-27.
7. Luchtenborg M, Riaz SP, Lim E, et al. Survival of patients with small cell lung cancer undergoing lung resection in England, 1998-2009. Thorax 2014;69:269-73.