How do you decide when treating your advanced small-cell lung cancer (SCLC) is worthwhile and when it might be time to stop? Lyudmila Bazhenova, MD, professor of medicine and co-leader of thoracic oncology at the University of California, San Diego, addresses questions that can guide you through your thought process.
Why is the question of when to stop treatment especially important for people with advanced small-cell lung cancer?
SCLC has among (or the) lowest chances of survival of all cancers: Four out of five people with this disease will be diagnosed at a point where we cannot cure the disease. And even if you were diagnosed at a potentially curable stage, your chance of cure is 20%. So treatment goals in this population are different, and so are their lifestyle goals.
And to add to that, we really do not have a lot of good treatments for small-cell lung cancer. There are a lot of developments underway, so we are strongly hoping that this is going to change, but as of today, we don't have a lot of things to offer to people with this disease.
What kinds of treatments exist as options for people with advanced small-cell lung cancer?
In metastatic disease, we use the term "lines of therapy." The "first-line" treatment for SCLC is typically chemo-immunotherapy. Once it stops working or you can't tolerate it, we switch to the "second line."
Right now, we have several options for that. The option with the most efficacy is a drug called tarlatamab (Imdelltra), which works by physically bringing immune cells to the tumor cells with two "arms." One arm grabs the tumor cells, another grabs the immune cells, bringing them together. This is the most effective treatment we have, but it can also have serious side effects.
If you need options beyond that, there are more chemotherapy options. There are also many developments right now with a novel class of drugs for SCLC called antibody-drug conjugates. They are not yet approved, but they look very encouraging in trials. So we might see some shift in treatment sequencing if the current clinical trials on these are positive. But it's important to understand that there is currently no cure for metastatic small-cell lung cancer.
How do I decide if a treatment Is worth staying on?
In general, as long as the cancer is not growing, we consider treatment a success. We usually do CT scans every two months or so after you've done several rounds of treatments to look at how well the treatment is controlling the cancer.
We also take into account how you're tolerating it. We are not going to give you treatment that makes you miserable or keeps you in a hospital because of the side effects. My goal is to make you live longer, but if in the process I'm causing side effects that are not letting you enjoy your life, then we need to start discussions about it.
But there are exceptions. For example, your child may be getting married or having a baby in a few months, and in order to be there for that important event, you may be willing to bear side effects. We want to support you depending on what your goals are.
What are my options if I'm not tolerating my treatment well?
We usually first have a discussion about whether we should reduce your dose. We want to see if it's a dose-dependent toxicity or if you may be weak and not strong enough to tolerate the treatments we have.
In addition to dose reduction, if you're on one of the newer regimens with more than one type of drug, you could consider dropping one of the chemotherapies, or drop the chemotherapy and do immunotherapy by itself. You can also take breaks from treatment to see if you get some strength back.
These decisions are why we try to see people for a discussion before each treatment. And the goal of that visit is to ask: How are you tolerating the treatment? Do I need to reduce your treatment dose? What's your body telling us? How's your immune system? How are your red blood cells and platelets? What do your kidneys look like? What does your liver look like? We look at blood tests, and we also talk to you about how you're feeling and your goals.
How do you help someone decide if continuing treatment is worth It?
In an incurable setting, there are questions you can ask yourself: If I am to accept treatment, what are my gains and what are my losses? Am I going to live longer, and if so, how much longer? What are my side effects? Do I really want to go through the side effects based on the potential improvement in survival or symptoms?
What I usually see is that a lot of patients want to at least try treatment and see how it goes. Sometimes people hear about bad experiences from someone who didn't do well on a cancer treatment, and that influences their decision. But it's important to remember that not everybody is the same. Yes, there are some people who don't tolerate treatments, but there are some who do. And sometimes the only way to know if you're going to tolerate the treatment or not is to give it a try.
I think it's also important to ask your doctor what the chances are that your treatment will keep the cancer under control. For example, if there is a 100% chance of side effects, a 30% chance it's going to work, and a 70% chance it's not, you can look at those numbers and then decide if it makes sense that you should do that or not.
What happens after I decide to stop treatment?
A lot of people ask me if they will suffer or be in pain if they stop their treatments. But when we decide to stop cancer treatment, we don't stop taking care of you. We still make sure that your symptoms are well-managed. We use what we know about your individual cancer case to guide us. So if you have a tumor in the bone, for example, then we know pain is probably going to be your issue, and we address that. If you have tumors in the liver, then we think about how to address nausea.
We involve other teams, such as a palliative care team, which is made up of special doctors trained in managing symptoms. We also refer you to a hospice team. This is a group of health care professionals, including doctors, nurses, and advanced practitioners, whose job is to manage symptoms, and they can do this at your home. As an oncologist, I’m not able to visit people at home, but a hospice team can care for you in your own space.
Many people have a fear of the word hospice because they think that once it's mentioned, it means they're going to die soon. But I recommend hospice as early as possible; it gives you time to find a team you gel with and trust. They're going to be available during a difficult time. There is a lot of potential for you to tailor your hospice needs if you start involving them earlier rather than later.
Know this: By stopping treatment, you are not giving up. There are situations where treatment is causing harm and not extending your life. And in that situation, treatment is actually taking away from your time with your family because you have to be in an infusion center, you have nausea, you're sleepy all the time, etc. It can be a gift to you and others to be able to accept the fact that your survival is not going to be as long as you were hoping, and you can live accordingly. You can be intentional about making memories, spending time with family, and savoring the life you have.
