From the Guidelines
Immunotherapy, specifically the addition of atezolizumab or durvalumab to platinum-based chemotherapy, is the recommended first-line treatment for metastatic small cell lung cancer (SCLC) due to its ability to improve overall survival compared to chemotherapy alone. The standard approach involves adding immune checkpoint inhibitors to platinum-based chemotherapy (carboplatin or cisplatin plus etoposide) for four to six cycles, followed by maintenance immunotherapy 1. For atezolizumab, the typical maintenance dose is 1200 mg IV every 3 weeks, while durvalumab is given at 1500 mg every 4 weeks. Maintenance therapy continues until disease progression or unacceptable toxicity, often for up to two years.
Key Points to Consider
- The combination of immunotherapy and chemotherapy has demonstrated improved overall survival compared to chemotherapy alone, with median survival extending by 2-3 months and some patients experiencing more durable responses 1.
- Immunotherapy works by blocking proteins like PD-L1 that cancer cells use to evade immune detection, thereby enhancing the body's natural ability to identify and attack cancer cells.
- Common side effects include fatigue, rash, colitis, pneumonitis, and endocrine abnormalities.
- Response rates remain modest (around 60-65% for combination therapy), and most patients eventually experience disease progression, highlighting the need for additional treatment options for this aggressive cancer type.
Treatment Algorithm
For patients with relapsed SCLC, the treatment approach depends on the chemotherapy-free interval, with options including single-agent chemotherapy or platinum-based chemotherapy, and consideration of maintenance immunotherapy 1.
Evidence-Based Recommendation
The recommendation to use immunotherapy in combination with chemotherapy for metastatic SCLC is based on high-quality evidence and is considered a strong recommendation, with benefits outweighing harms 1.
From the FDA Drug Label
TECENTRIQ is a programmed death-ligand 1 (PD-L1) blocking antibody indicated: Small Cell Lung Cancer (SCLC) in combination with carboplatin and etoposide, for the first-line treatment of adult patients with extensive-stage small cell lung cancer (ES-SCLC). (1.2)
The FDA drug label does not answer the question about immunotherapy for metastatic small cell lung cancer, as it only mentions the use of atezolizumab in combination with carboplatin and etoposide for the first-line treatment of adult patients with extensive-stage small cell lung cancer (ES-SCLC) 2.
From the Research
Immunotherapy for Metastatic Small Cell Lung Cancer
- Immunotherapy has shown promise in the treatment of metastatic small cell lung cancer (SCLC), with studies demonstrating improved overall survival and progression-free survival in patients with extensive-stage disease 3, 4.
- The combination of immunotherapy with chemotherapy, such as platinum-etoposide, has been shown to be effective in treating SCLC, with durvalumab plus platinum-etoposide significantly improving overall survival compared to platinum-etoposide alone 4.
- Other immunotherapy agents, such as atezolizumab and pembrolizumab, have also been studied in combination with chemotherapy, with mixed results 5.
- The safety profile of immunotherapy combinations in SCLC has been similar to the known safety profiles of the individual agents, with no new adverse events observed 4, 5.
- Predictive biomarkers of response to immunotherapy in SCLC are still being identified, and the role of immunotherapy in patients with limited-stage SCLC is being explored 5.
- In patients with platinum-sensitive extensive-stage SCLC, retreatment with platinum and etoposide is a preferred treatment option, although the use of immune checkpoint inhibitors is discouraged if there is progression on a drug in this class 6.
- Ongoing research is focused on developing new immunotherapy combinations and identifying biomarkers to improve treatment outcomes for patients with SCLC 3, 6, 5.