Isabel Preeshagul, DO, is a thoracic medical oncologist at Memorial Sloan Kettering Cancer Center in Montvale, New Jersey, and the chair of the Patient Education and Engagement Committee for the Lung Cancer Research Foundation.
Small-cell lung cancer is a rare form of cancer that affects the lungs. There are two main types of SCLC:
Small-cell carcinoma, which is sometimes called oat cell carcinoma. It grows quickly and is the most common type of SCLC
Combined small-cell carcinoma. The combined version of SCLC has components of both the more common form of lung cancer (non-small-cell lung cancer), such as squamous cell or adenocarcinoma, and SCLC.
The cancer develops because cigarette smoke contains thousands of chemicals that damage the DNA of the lung's cells. DNA is what tells cells how and when to grow. Smoke also creates inflammation in the lungs, which damages the tissues and makes it difficult for the body to repair itself. When cells are damaged and stay damaged, mutations that cause cancer can more easily arise.
SCLC can be cured if it is caught early, but unfortunately, this rarely happens. About 60% to 70% of all SCLC is diagnosed when it has already moved to the extensive stage and has metastasized to other parts of the body. This is why it's important to get diagnosed as early as possible and start a treatment plan right away. Today, there are more treatments for SCLC than ever before, and doctors and researchers are hopeful that they will be able to cure more people.
To get more insight into this rare disease, we spoke to Isabel Preeshagul, DO, a thoracic medical oncologist at Memorial Sloan Kettering Cancer Center in Montvale, New Jersey, and chair of the Lung Cancer Research Foundation's Patient Education and Engagement Committee.
How do most patients get diagnosed with SCLC?
Lung cancer screening has not taken off nearly as fast as screenings for other cancers, like colonoscopies for colon cancer, PAP smears for cervical cancer, and mammograms for breast cancer. So by the time we see people, they often have extensive-stage cancer. About 25% of people have no symptoms at all. A lot of times, what happens with patients with small-cell lung cancer is that it comes on very fast, and it comes on very hot, and patients tend to be very symptomatic very quickly. They come in with a cough that keeps getting worse or progresses to where they are coughing up blood. They may have chest pain or trouble breathing. They may also start losing a lot of weight fast and be tired.
Patients will go in to see their primary care doctor, who will do imaging of the chest. If something shows on the scans, then we do a biopsy to confirm the disease. Once we find the cancer, we stage it, doing more imaging to see if the cancer has spread.
When we have all the facts, that's when we give the patient and their loved ones this life-changing diagnosis. We want to be able to tell them, 'We're treating you with the intention to cure you,' or 'We're treating this like a chronic disease. It's treatable, but not curable.' Whatever you say, it's difficult because you're telling somebody that they have the C-word, so it's not something that I take lightly by any means.
I focus on making sure that the patient feels empowered. You really want to make sure that they feel like they're part of the team, and that any choices that are made are done with shared and informed decision-making. It's never just the doctor or someone else dictating what the plan is, and that's it. You have to lay out the options and discuss what their goals are. We have to approach somebody with cancer regardless of stage as a whole person – emotionally, spiritually. What are their priorities? That's really important.
What are the current ways of managing symptoms and treating small-cell lung cancer?
It really depends on the staging. There are two stages in small-cell lung cancer:
Limited stage. We treat cancer in this stage with intention to cure by giving chemotherapy, usually cisplatin, and radiation at the same time.
Extensive stage. This stage is treatable but not curable. It is typically treated with chemotherapy and immunotherapy from the start. Patients will receive platinum-based chemotherapy, like cisplatin or carboplatin plus etoposide, paired with immunotherapy such as atezolizumab (Tecentriq) or durvalumab (Imfinzi).
In both cases, we're thinking about managing symptoms before they happen. There's obviously drug-related complications that happen – side effects, toxicity – some of which are predictable and some of which are not. We try to explain all the things that could potentially happen and how we would manage them. We walk through all the potential toxicities and the schedule of when they will occur. Sometimes people will be afraid to start treatment. That's when I follow up and ask them what their concerns are. Can you tell me where that's coming from? And sometimes it's, 'Well, I'm afraid I'm going to feel nauseous.' I try to walk them through what we do to offset that, or manage that, or anticipate that, so they're not feeling those things.
Outside of that, there's obviously the financial toxicity and the insurance changes that happen. You know, all of a sudden a patient now has New Jersey-only insurance, but they are seeing somebody in New York City, and now they have to change treatment plans and institutions sometimes. So that happens, and we want to make sure we're prepared and ready to help the patient with all of these things.
When you prepare the patient for what to expect, it's easier for them to stick with their treatments. If we do things like tell a patient about a potential side effect but give them medication to help them deal with it, they are more likely to agree to get treatment.
What are challenges that patients have had while living with SCLC?
Small-cell lung cancer treatment challenges are more than just dealing with medication side effects like nausea. There are also financial issues, logistics issues, and even insurance issues. That's why I like to ask up front: 'What's your support system like? What are your financial struggles? Do you have food insecurity? Is there housing insecurity?'
These are things that we need to think about because cancer treatment is a commitment that you can't do alone. So I always ask, 'What's your social support? Who can you call if you're not feeling well at midnight and you need to go to the ER? Who's there for you?' And people sometimes laugh about that. They're like, 'I have friends.' Sometimes the answer is literally nobody, in which case, those are the people that I bring back really frequently. I say, 'Listen, let's touch base really often. Let me be that person for you.'
We often bring in other expertise. For example, we often involve our social workers who can look into philanthropic funding or for other kinds of support resources we have to get patients through. Right now, I am very invested in developing patient navigation at Memorial Sloan Kettering that will function as a home base for patients and make their process easier.
How do you track the progression of the disease?
There are guidelines for scanning folks at certain intervals, which we do follow as best we can. But cancer grows between scans. It's not going to only grow right before a scan, so we have to teach patients to listen to their bodies. I have a very low threshold to scan someone sooner if they call me with new symptoms – new pain, weight loss, new cough, new shortness of breath, dizziness, falls. But I also make sure that patients know that I want to hear from them as soon as any of those things happen. I don't want them to wait until three months have passed between visits and they've been suffering the whole time. Even one day is too long. I couldn't tell you how many times people are like, 'Oh, I don't want to call you over the weekend,' or 'I heard you were on vacation so I figured I would just wait until our appointment.'
I always tell my patients who I'm only seeing in certain intervals, 'I need you to be my eyes. I need you to be my ears.' If someone tells you, 'please don't bother the doctor,' that's all the more reason to please bother the doctor. You're never a bother. It's my job to be here for you, and that job is much harder for me to do if you wait until you're really, really sick to come see me. A lot of times, I can turn things around very quickly if you let me know immediately when something comes up. If I'm hearing about things at the 11 o'clock hour, it can be really hard to pull you back from the edge.
So much is happening with SCLC research. What are you most excited about for future patient treatments?
We're at the beginning of an era of personalized medicines and treatments for small-cell lung cancer. There are many clinical trials out there for those in limited stage and extensive stage, and we're using them to treat people earlier, putting the most promising patients on study right away to try to move the needle.
This is happening because small-cell lung cancer is finally getting the spotlight that it so well deserves. There have been American Society of Clinical Oncology presentations about advances in small-cell recently that are happening now that we haven't seen in the previous 20 years. There are new studies and drugs coming out that are improving survival and improving overall outcomes for these patients. This space that has been really the orphan child for way too long is appropriately exploding, and I am really excited to see these developments. I have been implementing them, too, and I've seen the benefits for my patients. I'm really happy my patients with lung cancer are living longer and believe the trend will only accelerate.
