International consensus guidelines recommend concurrent chemo-radiotherapy +/- prophylactic cranial irradiation (PCI) for patients with limited-stage small cell lung cancer (LS SCLC), and palliative chemotherapy +/- PCI for patients with extensive-stage disease (ES SCLC). The feasibility and application of guideline recommended treatment in the real world population is unknown. The primary aims were: (i) determine the proportion of patients receiving clinical guideline (CG) vs. modified (M) treatment; and (ii) compare survival outcomes between groups.
A retrospective review of prospectively collated data for patients treated in South Western Sydney between 2006 and 2014 was performed. Baseline clinico-pathological data, treatment modalities and outcome data were captured. The proportion of patients receiving CG vs. M treatment was recorded. The two groups were compared with regards to overall survival (OS) using the Kaplan-Meier method. Multivariate analysis was performed to identify potential confounders.
256 patients were identified: 102 with LS SCLC; 154 with ES SCLC. Mean age was 68 years. In the LS SCLC cohort, 34% of patients received CG treatment. Presentation at a multi-disciplinary team meeting was high (83%). Median OS for CG vs. M treatment was 25 months vs. 13 months (HR 1.95, p= 0.009). Main reasons for M treatment were poor baseline ECOG performance status (PS), co-morbidities and patient choice. On multivariate analysis, poor ECOG PS and higher Charlston Comorbidity Index score were independent predictors for worse OS. For the ES SCLC cohort, 64% of patients received CG treatment. The median OS for CG vs. M treatment was 7.5 months vs. 3 months (HR 1.62, p = 0.004).
It is challenging to deliver guideline recommended treatment in routine clinical practice. The key barriers to this are patient co-morbidities and ECOG PS. Future advances in systemic therapy and radiation techniques may make treatment more tolerable and deliverable in this group.