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What is Small-Cell Lung Cancer When cells of the lung start growing rapidly in an uncontrolled manner, the condition is called lung cancer. Cancer can affect any part of the lung and it's the leading cause of cancer deaths in both women and men in the United States, Canada, and China. Two main types of lung cancer exist: small-cell lung cancer (SCLC, also called oat cell cancer) and non– small-cell lung cancer (NSCLC). Small-cell lung cancer accounts for approximately 20%-25% of all cases of lung cancer. Small-cell lung cancer differs from non–small-cell lung cancer in the following ways: Small-cell lung cancer grows rapidly. Small-cell lung cancer spreads quickly. Small-cell lung cancer responds well to chemotherapy (using medications to kill cancer cells) and radiation therapy (using high-dose X-rays or other high-energy rays to kill cancer cells). Small-cell lung cancer is frequently associated with distinct paraneoplastic syndromes (a collection of symptoms that result from substances produced by the tumor). Small-Cell Lung Cancer Causes: The predominant cause of both small-cell lung cancer and non–small-cell lung cancer is tobacco smoking. However, small-cell lung cancer is more strongly linked to smoking than non–small-cell lung cancer. Even secondhand tobacco smoke is a risk factor for lung cancer. Those living with a smoker have a 30% increase in their risk of lung cancer compared to people who are not exposed to secondhand smoke. All types of lung cancer occur with increased frequency in people who mine uranium, but small-cell lung cancer is most common. The prevalence is increased further in persons who smoke. Exposure to radon (an inert gas that develops from the decay of uranium) has been reported to cause small-cell lung cancer. Exposure to asbestos greatly increases the risk of lung cancer. A combination of asbestos exposure and cigarette smoking increases the risk even further. Symptoms of Small-Cell Lung Cancer: Persons with small-cell lung cancer typically have had symptoms for a relatively short time (eight to 12 weeks) before they visit their doctor. The symptoms can result from local growth of the tumor, spread to nearby areas, distant spread, paraneoplastic syndromes, or a combination thereof. Symptoms due to local growth of the tumor include the following: Cough Coughing up blood Shortness of breath Chest pain worsened by deep breathing Symptoms due to spread of the cancer to nearby areas include the following: Hoarse voice, resulting from compression of the nerve that supplies the vocal cords Shortness of breath, resulting from compression of the nerve that supplies the muscles of the diaphragm or the lungs filling with fluid and stridor (sound produced by turbulent flow of air through a narrowed part of the respiratory tract) resulting from compression of the trachea (windpipe) and larger bronchi (airways of the lung) Difficulty swallowing, resulting from compression of the esophagus (food pipe) Swelling of the face and hands, resulting from compression of the superior vena cava (vein that returns deoxygenated blood from the upper body) Symptoms due to distant cancer spread depend on the site of spread and include the following: Spread to the brain can cause headache, blurring of vision, nausea, vomiting, weakness of any limb, mental changes, and seizures. Spread to the vertebral column can cause back pain. Spread to the spinal cord can cause paralysis and loss of bowel or bladder function. Spread to the bone can cause bone pain. Spread to the liver can cause pain in the right upper part of the abdomen. Symptoms due to paraneoplastic syndromes include the following: Symptoms may or may not be characteristic of a specific organ system. Nonspecific symptoms include fatigue, loss of appetite, and weight gain or loss. Severe muscle weakness. Trouble with balance or walking. Changes in mental status. Changes in skin color, texture, and facial features. Medical Treatment: The most effective treatment for small-cell lung cancer is chemotherapy (using medications to kill cancer cells), either alone or in combination with radiation therapy (using high-dose X-rays or other high-energy rays to kill cancer cells). Medications Chemotherapy: Chemotherapy uses powerful drugs to kill cancer cells. These medications may be taken by mouth (orally), but they are usually injected into a vein (IV). Chemotherapy is a systemic treatment because the drugs enter the bloodstream, travel throughout the body, and kill cancer cells wherever they are. However, some normal cells are also killed. This is responsible for some of the side effects of chemotherapy. Chemotherapy is usually given at intervals to ensure that the bone marrow has recovered before the next dose of chemotherapy is given. Extensive research and clinical trials have identified different chemotherapy medications for the treatment of small-cell lung cancer. Response rates with these medications have been found to be at least 80% in previously untreated patients. Some drugs are used alone, while some are used in combination with others for greater effectiveness. An oncologist (cancer specialist) recommends chemotherapy specific to the patient’s condition. Chemotherapy medications used for the treatment of small-cell lung cancer include the following: Etoposide (Toposar, VePesid). It slows or stops the growth of cancer cells in the body by causing breakage in the DNA (genetic material) strand. It may be given as an IV injection or as a pill. Cyclophosphamide (Cytoxan, Neosar) interferes with the growth of normal cells and cancer cells. It slows the growth of cancer cells and their spread in the body. It may be given as an IV injection or as a pill. Doxorubicin (Adriamycin, Rubex) causes destruction of DNA, which slows or stops the growth and spread of cancer cells in the body. It is an IV medication. Vincristine (Oncovin) is a plant-based compound. It causes cell death by interfering with the way genetic material (DNA) multiplies in the cell. It is only available as an IV medication. Topotecan (Hycamtin) interferes with the growth of cancer cells by inhibiting the duplication of DNA. It can be given through an IV or as a pill. Cisplatin (Platinol) causes breakage in the DNA (genetic material) strand and interferes with cell growth. It is an IV medication. Carboplatin (Paraplatin) is similar to cisplatin. It also causes breakage in the DNA (genetic material) strand and interferes with cell growth. Its effectiveness is similar to cisplatin, but it is better tolerated with less side effects. Irinotecan (Camptosar) acts in a similar manner as topotecan to decrease cancer cell growth by causing damage to cancer cell DNA. It is an IV medication. Commonly used chemotherapy regimens in small-cell lung cancer include the following: CAV (cyclophosphamide, doxorubicin [Adriamycin], and vincristine) PE (cisplatin and etoposide) CAVE (cyclophosphamide, doxorubicin [Adriamycin], vincristine, and etoposide) EC (etoposide and carboplatin) Topotecan alone Etoposide alone Cisplatin and irinotecan Treatment of limited-stage small-cell lung cancer: Currently, cisplatin, etoposide, vincristine, doxorubicin, and cyclophosphamide are the most commonly used medications for the treatment of persons with small-cell lung cancer. Standard treatment of small-cell lung cancer involves combination chemotherapy with a cisplatin- containing regimen. Treatment cycles are repeated every three weeks. People receive treatment for four to six cycles. The combination of cisplatin and etoposide (PE) is the most widely used regimen in both limited- and extensive-stage small-cell lung cancer. Some doctors start radiotherapy to the chest as early as possible, while others may give it with the fourth cycle of chemotherapy. Radiation and chemotherapy: Sequential-radiation treatment may be given, followed by chemotherapy. However, in comparative studies, the earlier the radiation is started concurrently with chemotherapy (as early as the first cycle of chemotherapy), the better the outcome. If the patient has limited disease, and has had a complete remission, of the cancer, radiation therapy may be given to the patient’s brain to reduce the risk of small-cell lung cancer spreading to the brain. This is called prophylactic cranial irradiation (PCI). It is usually given after the patient has completed the full chemotherapy, and radiotherapy (to the thorax). The radiation doses are low, and the treatment duration is short, so the side effects of this therapy are minimal. Treatment of extensive-stage small-cell lung cancer (small-cell lung cancer that remains incurable with current treatment options) : Persons with extensive-stage small-cell lung cancer are treated with combination chemotherapy. Currently, the combination of cisplatin or carboplatin and etoposide (PE) is the most widely used regimen. Radiation therapy may be used for relief of the following symptoms: Bone pain Compression of the food pipe (esophagus), windpipe, spinal cord, or superior vena cava caused by tumors Obstructive pneumonia caused by the tumor Treatment of relapse of small-cell lung cancer: Persons who have a relapse of small-cell lung cancer have an extremely poor prognosis. If the disease does not respond to treatment or progresses after initial treatment (called "refractory disease") or if the disease relapses within six months of completion of therapy, the person has little chance of responding to additional chemotherapy. The most common drug used in this setting is topotecan. Persons whose cancer does not progress for more than six months may be given additional chemotherapy, including re-treatment with their original chemotherapy regimen. Persons with relapsed or refractory small-cell lung cancer may enroll in a clinical trial. For information about ongoing clinical trials, visit the National Cancer Institute's Clinical Trials. Other drugs may be given to prevent and treat adverse effects of radiation, chemotherapy, or the cancer itself, such as nausea or vomiting. Pain medications are also important to relieve pain due to cancer or its treatment. Surgery for Small Cell Lung Cancer: Surgery plays little, if any, role in the management of small-cell lung cancer because almost all cancers have spread by the time they are discovered. The exceptions are the relatively small number of people (less than 5%) whose cancer is discovered at a very early stage of the disease, when the cancer is confined to the lung without any spread to the lymph nodes. However, surgery alone is not considered curative, so chemotherapy is also given. Other Therapy Radiation therapy: Radiation therapy is the use of high-dose X-rays or other high-energy rays to kill cancer cells. Radiation can be given from outside the body using a machine (external radiation therapy), or it can be given with the help of radiation-producing materials that are implanted inside the body (brachytherapy). Radiation therapy can be curative (kills all cancer cells), prophylactic (reduces the risk of cancer spreading to the area to which it is given), or palliative (helps reduce suffering). Next Steps Follow-up Patients who are receiving chemotherapy require close monitoring for side effects and response to therapy. A blood workup, including CBC (complete blood count), is needed prior to each cycle of chemotherapy to ensure that the bone marrow has recovered before the next dose of chemotherapy is given. Kidney function is monitored, especially if the patient is taking cisplatin, as it can damage the kidneys. Also, carboplatin's dosage is based upon kidney function. The patient will undergo a CT scan to assess their response to treatment Other tests are performed to monitor liver function and electrolytes -- especially sodium and magnesium levels -- due to the effects of the cancer and its treatment. Palliative and terminal care: Because small-cell lung cancer is diagnosed in most people when it is not curable, palliative care becomes important. The goal of palliative and terminal care is to manage pain and discomfort and enhance quality of life. Palliative care not only focuses on comfort but also addresses the concerns of the patient’s family and loved ones. Caregivers may include family and friends in addition to doctors, nurses, and other health care professionals. Palliative and terminal care is often given in a hospital, hospice, or nursing home; however, it can also be provided at home.
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