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Editor's Note
December 6, 2018

Moving Beyond Limited and Extensive Staging of Small Cell Lung Cancer

Author Affiliations
  • 1Swedish Cancer Institute, Seattle, Washington
JAMA Oncol. Published online December 6, 2018. doi:10.1001/jamaoncol.2018.5187

Small cell lung cancer (SCLC) is traditionally classified into limited-stage SCLC (LS-SCLC) and extensive-stage SCLC according to whether disease is confined to one hemithorax or not. Approximately 10% of patients present with stage II and 4% with stage I SCLC under the American Joint Committee on Cancer staging system.1 Surgery remains a leading approach for patients with node-negative SCLC, among whom long-term survival was in the 50% range in retrospective series,2 exceeding expected results for a broader population with LS-SCLC.

In this issue of JAMA Oncology, Salem et al3 report outcomes for a subset of patients with stage I to II vs stage III LS-SCLC in the Concurrent Once-Daily vs Twice-Daily Radiotherapy Trial (CONVERT) of chemoradiotherapy with cisplatin and etoposide administered concurrently with chest radiotherapy. Among the 509 of 543 patients (93.7%) with LS-SCLC and TNM staging results available, 86 (16.9%) had stage I to II SCLC, among whom most (82 [95.3%]) had stage II disease. Overall survival was significantly superior in this subgroup compared with those with stage III SCLC (median overall survival, 50 vs 25 months; hazard ratio, 0.60; 95% CI, 0.44-0.83; P = .001), as were other efficacy measures, with no differences in outcomes observed between the 2 radiotherapy schedules for these patients.

In the study by Salem et al,3 patients with stage I to II SCLC had a significantly better prognosis than those with stage III SCLC despite the fact that these populations are typically aggregated into the LS-SCLC group. These results imply that we may do our patients a disservice by dispensing with clinically relevant staging information that can lead to a more refined assessment of prognosis and optimal treatment. The better outcomes in smaller-volume and earlier-stage SCLC may be attributable to greater efficacy of the same chemoradiotherapy for low-volume compared with higher-volume disease, more favorable underlying biology of these earlier-stage cancers, or a combination of these factors. These findings should also lead us to question whether the particularly favorable results among patients who have undergone surgery for stage I SCLC are attributable to the unique contribution of resection or selection bias of a distinct biological mechanism of node-negative SCLC that confers candidacy for surgery.

Although most future practice-changing advances are likely to emerge from identification of molecular and immunologic features of different subgroups of patients with SCLC, we cannot overlook opportunities to refine management based on obvious issues, such as more precise staging, particularly when they are accompanied by distinctions in prognosis and potentially tumor biology.

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Article Information

Published Online: December 6, 2018. doi:10.1001/jamaoncol.2018.5187

Corresponding Author: Howard (Jack) West, MD, Swedish Cancer Institute, 1221 Madison St, Ste 200, Seattle, WA 98104 (howard.west@swedish.org).

Conflict of Interest Disclosures: None reported.

Goldstraw  P, Chansky  K, Crowley  J,  et al; International Association for the Study of Lung Cancer Staging and Prognostic Factors Committee, Advisory Boards, and Participating Institutions; International Association for the Study of Lung Cancer Staging and Prognostic Factors Committee Advisory Boards and Participating Institutions.  The IASLC Lung Cancer Staging Project: proposals for revision of the TNM stage groupings in the forthcoming (eighth) edition of the TNM classification for lung cancer.  J Thorac Oncol. 2016;11(1):39-51. doi:10.1016/j.jtho.2015.09.009PubMedGoogle ScholarCrossref
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(2):215-219. doi:10.1097/JTO.0b013e3181cd3208PubMedGoogle ScholarCrossref
Salem  A, Mistry  H, Hatton  M,  et al.  Association of chemoradiotherapy with outcomes among patients with stage I to II vs stage III small cell lung cancer: secondary analysis of a randomized clinical trial  [published online December 6, 2018].  JAMA Oncol. doi:10.1001/jamaoncol.2018.5335Google Scholar