1L Treatment: Induction and Maintenance

Platinum-based chemotherapy has been the longtime standard of care for 1L induction treatment.1 Treatment recommendations may also include radiotherapy depending on staging. Despite high response rates to platinum-based induction, nearly all patients will relapse.

The approval of IOs in 1L induction and maintenance treatment has improved patient outcomes—robust clinical and real-world evidence shows that ES-SCLC patients who received maintenance therapy achieved longer survival outcomes than those who did not.2,3

Recently, the first combination 1L maintenance regimen, consisting of an alkylating agent plus IO, was approved for ES-SCLC. Clinical trial results indicated a significant improvement in survival outcomes compared with those who were treated with maintenance IO alone.4

Only ~40% of SCLC patients who receive 1L treatment will go on to receive 2L treatment, and less than 40% of those patients will receive 3L treatment.5

Using your best options as early as possible may give patients the opportunity for the best possible outcomes.

LIMITED STAGE: CHEMOTHERAPY AND RADIOTHERAPY

  • The role of concomitant chemotherapy with radiotherapy is well established in the management of LS disease1

Initial Treatment Options for LS-SCLC1,6

COMBINATION CHEMOTHERAPY

Use in
LS-SCLC		 Recommended first-line therapy is platinum plus etoposide (platinum doublet) for eligible patients7,a
  • For patients who respond with at least disease control after systemic therapy and concurrent radiotherapy:
  • Continue with immunotherapy alone until:
    • Disease progression
    • Unacceptable toxicity
    • A maximum of 24 months
 Recommended first-line therapy is platinum plus etoposide (platinum doublet) for eligible patients7,a
  • For patients who respond with at least disease control after systemic therapy and concurrent radiotherapy:
  • Continue with immunotherapy alone until:
    • Disease progression
    • Unacceptable toxicity
    • A maximum of 24 months

RADIOTHERAPY

Use in
LS-SCLC		 Given concurrently or sequentially to combination chemotherapy7,a

PROPHYLACTIC CRANIAL IRRADIATION (PCI)b

Use in
LS-SCLC		 Offered to patients who respond to initial concurrent chemoradiotherapy (CRT) and have a performance status of 0‑11
Evidence supporting PCI is not as clear in patients1:
  • With a performance status of 2 after CRT
  • >70 years of age
  • With pre-existing neurological conditions

aSee the NCCN Clinical Practice Guidelines In Oncology (NCCN Guidelines®) for SCLC for detailed recommendations.

bCurrent randomized trials are evaluating whether brain MRI surveillance alone is non-inferior to MRI surveillance plus PCI on overall survival.7

After consolidation therapy for LS-SCLC, patients may receive maintenance immunotherapy for up to 24 months.7 At which time, follow-up visits may become less frequent. It is important to monitor for early signs of relapse.

EXTENSIVE STAGE: CHEMOTHERAPY AND IMMUNOTHERAPY

  • Chemotherapy in combination with immunotherapy is an option for eligible patients with ES-SCLC4,7

Initial Treatment Options for ES-SCLC1,4,8,9

COMBINATION CHEMOTHERAPY + IMMUNOTHERAPY

Use in
ES-SCLC		 Systemic therapy:
  • Platinum agent plus etoposide plus immunotherapy7,a
About chemotherapy:
  • Standard duration: 4‑6 cycles
  • For patients who respond with at least disease control:
  • Maintenance treatment with alkylating agent plus immunotherapy or continue with immunotherapy alone until4,7:
    • Disease progression
    • Unacceptable toxicity
 Systemic therapy:
  • Platinum agent plus etoposide plus immunotherapy7,a
About chemotherapy:
  • Standard duration: 4‑6 cycles
  • For patients who respond with at least disease control:
    • Maintenance treatment with alkylating agent plus immunotherapy or continue with immunotherapy alone until4,7:
      • Disease progression
      • Unacceptable toxicity

RADIOTHERAPY

Use in
ES-SCLC		 If patients respond to initial treatment, radiation to the chest may be given
  • Typically reserved for palliation, including painful bone metastases

PROPHYLACTIC CRANIAL IRRADIATION (PCI)b

Use in
ES-SCLC		 Controversial in this context:
Recent randomized phase 3 data suggest limited or no patient benefit9

PFS=progression-free survival.

aSee the NCCN Guidelines® for SCLC for detailed recommendations.

bCurrent randomized trials are assessing brain MRI surveillance alone compared to brain MRI surveillance plus PCI for patients with late-stage SCLC and early-stage SCLC.7

As with any medical therapy, it is essential to weigh the risks and benefits of available treatments for SCLC.1 After relapse, you should choose the appropriate treatment option for your patient.1,7

Discover FDA-approved
treatments for SCLC

►

ASSESSMENT, SURVEILLANCE, AND SECOND-LINE TREATMENT

Response Assessment Is an Important Aspect of Patient Management7

LS-SCLC

ES-SCLC

After adjuvant chemotherapy alone or chemotherapy with concurrent RT for patients with LS-SCLC, response assessment using CT with contrast of the chest/abdomen/pelvis, and brain MRI or brain CT with contrast, should occur only after completion of therapy; repeating CT scans during therapy is not recommended in the absence of new symptoms7

For systemic therapy alone or sequential systemic therapy followed by RT in patients with LS-SCLC, response assessment using CT with contrast of the chest/abdomen/pelvis should occur after every 2 cycles of systemic therapy, and again at completion of therapy7

During systemic therapy for patients with ES-SCLC, response assessment using CT with contrast of the chest/abdomen/pelvis should occur after every 2 to 3 cycles of systemic therapy7
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Frequency of follow-up depends on7:

  • Disease stage
  • Response to treatment (partial or complete, stable disease)

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Since relapse is highly likely1,10:

  • Schedule time for routine monitoring
  • Offer salvage treatment if appropriate

RT=radiotherapy.

FREQUENCY OF FOLLOW-UP VISITS IS DEPENDENT ON DISEASE STAGE

For Complete Response/Partial Response/Stable Disease7

LIMITED STAGE

After completion of initial therapy

  • Every 3 months during years 1-2
  • Every 6 months during year 3
  • Then annually

EXTENSIVE STAGE

After completion of initial
or subsequent therapy

  • Every 2 months during year 1
  • Every 3-4 months during years 2-3
  • Every 6 months during years 4-5
  • Then annually
  • NCCN Guidelines recommend follow-up visits. At each such visit:
    • A history, physical exam, and CT scans of the chest ± abdomen/pelvis are recommended7
    • Brain MRI (preferred) or CT is typically performed every 3-4 months during year 1 and every 6 months during year 27
  • Patient follow-up should also include the management of the multiple comorbidities often associated with the disease, including cardiac and respiratory comorbidities1
    • This may provide better symptom control, and possibly, better patient outcomes1

SCLC has poor prognosis due to high relapse rates.
 It is important to evaluate optimal therapy.1,7

NCCN=National Comprehensive Cancer Network® (NCCN®).

    REFERENCES:
  1. Rudin CM, Brambilla E, Faivre-Finn C, Sage J. Small-cell lung cancer. Nat Rev Dis Primers. 2021;7(1):3. doi:10.1038/s41572-020-00235-0
  2. Reck M, Mok TSK, Mansfield A, et al. Brief report: exploratory analysis of maintenance therapy in patients with extensive-stage SCLC treated first line with atezolizumab plus carboplatin and etoposide. J Thorac Oncol. 2022;17(9):1122-1129. doi:10.1016/j.jtho.2022.05.016
  3. Shaw J, Pundole X, Balasubramanian A, et al. Recent treatment patterns and real-world survival following first-line anti-PD-L1 treatment for extensive-stage small cell lung cancer. Oncologist. 2024;29(12):1079-1089. doi:10.1093/oncolo/oyae234
  4. Paz-Ares L, Borghaei H, Liu SV, et al. Efficacy and safety of first-line maintenance therapy with lurbinectedin plus atezolizumab in extensive-stage small-cell lung cancer (IMforte): a randomised, multicentre, open-label, phase 3 trial. Lancet. 2025;405(10495):2129-2143. https://doi.org/10.1016/S0140-6736(25)01011-6.
  5. Cramer-van der Welle CM, Schramel FMNH, van Leeuwen AS, Groen HJM, van de Garde EMW; Santeon SCLC Study Group. Real-world treatment patterns and outcomes of patients with extensive disease small cell lung cancer. Eur J Cancer Care (Engl). 2020;29(5):e13250. doi:10.1111/ecc.13250
  6. Faivre-Finn C, Snee M, Ashcroft L, et al. Concurrent once-daily versus twice-daily chemoradiotherapy in patients with limited-stage small-cell lung cancer (CONVERT): an open-label, phase 3, randomised, superiority trial. Lancet Oncol. 2017;18(8):1116-1125. doi:10.23937/2378-3419/1410111
  7. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Small Cell Lung Cancer V.2.2026. © National Comprehensive Cancer Network, Inc. 2025. All rights reserved. Accessed September 18, 2025. To view the most recent and complete version of the guideline, go online to NCCN.org. NCCN makes no warranties of any kind whatsoever regarding their content, use or application and disclaims any responsibility for their application or use in any way.
  8. Slotman BJ, van Tinteren H, Praag JO, et al. Use of thoracic radiotherapy for extensive stage small-cell lung cancer: a phase 3 randomised controlled trial. Lancet. 2015;385(9962):36-42.
  9. Takahashi T, Yamanaka T, Seto T, et al. Prophylactic cranial irradiation versus observation in patients with extensive-disease small-cell lung cancer: a multicentre, randomised, open-label, phase 3 trial. Lancet Oncol. 2017;18(5):663-671.
  10. Alvarado-Luna G, Morales-Espinosa D. Treatment for small cell lung cancer, where are we now? – a review. Transl Lung Cancer Res. 2016;5(1):26-38.

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Relapse and 2L Treatment