Radiation Therapy for Small Cell Lung Cancer
Publication Date: March 1, 2020
Last Updated: March 14, 2022
Recommendations
Thoracic RT for limited-stage SCLC
For patients with LS-SCLC who can tolerate definitive therapy, thoracic RT is recommended. (Strong, High)
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For patients with LS-SCLC receiving chemotherapy and RT, thoracic RT should begin with cycle 1 or 2 of chemotherapy. (Strong, Moderate)
- Implementation Remark: It is important to maintain the dosage and timing of chemotherapy with RT based on trial data. Timing is more critical for accelerated dose-intensive RT.
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For postoperative patients with LS-SCLC and R1 or R2 resection, postoperative RT is conditionally recommended. (Conditional, Expert Opinion)
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For postoperative patients with LS-SCLC that is clinically node negative and pathologically N2-positive, mediastinal RT is conditionally recommended. (Conditional, Expert Opinion)
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For patients with LS-SCLC, twice-daily RT in 150 cGy fractions to 4500 cGy is recommended. (Strong, High)
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For patients with LS-SCLC, daily RT in 200 cGy fractions to 6000-7000 cGy is conditionally recommended as an acceptable alternative to twice-daily RT. (Conditional, Moderate)
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For patients with LS-SCLC, involved field RT is recommended as the standard of care (defined as fluorodeoxyglucose avid on PET, enlarged on CT, and/or biopsy-positive). (Strong, Moderate)
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For tumors that experience shrinkage with chemotherapy in patients with LS-SCLC, treating all involved nodal stations (at time of diagnosis) and postchemotherapy lung parenchymal tumor is recommended. (Strong, Moderate)
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For patients with LS-SCLC, highly conformal techniques are recommended to minimize normal tissue dose. (Strong, Low)
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SBRT in stage I or II node negative SCLC
For patients with stage I or II node negative LS-SCLC who are medically inoperable, either SBRT or conventional fractionation is recommended. (Strong, Moderate)
Implementation Remarks:
- Ideally the node negative status should be confirmed by invasive nodal staging.
- Ultracentral tumors may be more appropriately treated with conventional fractionation schema.
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For patients with stage I or II node negative LS-SCLC receiving SBRT, chemotherapy should be delivered to patients in whom it is medically tolerated. (Strong, Moderate)
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Prophylactic cranial RT
For patients with SCLC who respond to initial therapy, restaging with brain MRI to guide decision-making regarding PCI is recommended. (Strong, Low)
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For patients with stage I SCLC, PCI is conditionally not recommended. (Conditional, Low)
- Implementation Remark: In lieu of PCI, surveillance using brain MRI with contrast can serve as an alternative.
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For patients with stage II-III LS-SCLC who are less than 70 years of age with good performance status (ECOG 0-2) and respond to thoracic chemoradiation, PCI is recommended. (Strong, High)
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For patients with LS-SCLC who have limited performance status, older age, and/or significant comorbidities, shared decision-making on PCI (considering patient- and disease-specific characteristics) is recommended. (Strong, Low)
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For patients with LS-SCLC receiving PCI, 2500 cGy in 10 fractions is recommended. (Strong, Moderate)
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For patients with ES-SCLC who respond to chemotherapy, consultation with a radiation oncologist to enhance shared decision-making on PCI versus MRI surveillance (considering patient- and disease-specific characteristics) is recommended. (Strong, Moderate)
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For patients with ES-SCLC who elect PCI, 2500 cGy in 10 fractions or 2000 cGy in 5 fractions is recommended. (Strong, Moderate)
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Thoracic consolidation for ES-SCLC
For patients with ES-SCLC with a response to chemotherapy alone but residual tumor in the thorax, thoracic RT is recommended. (Strong, High)
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For patients with ES-SCLC with a response to chemotherapy alone, thoracic RT to a dose of 3000 cGy in 10 fractions is conditionally recommended. (Conditional, Moderate)
- Implementation Remark: In patients expected to have a prolonged survival, higher doses may be appropriate.
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For patients with ES-SCLC who will receive thoracic RT, the treatment should be given after completion of chemotherapy alone. (Strong, High)
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For patients with ES-SCLC with a response to chemotherapy and immunotherapy and residual disease in the thorax, thoracic RT to 3000 cGy in 10 fractions within 6-8 weeks is conditionally recommended. (Conditional, Expert Opinion)
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Recommendation Grading
Overview
Title
Radiation Therapy for Small Cell Lung Cancer
Authoring Organization
American Society for Radiation Oncology
Publication Month/Year
March 1, 2020
Last Updated Month/Year
September 3, 2024
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Target Patient Population
Patients with small cell lung cancer either limited stage or extensive stage
Inclusion Criteria
Female, Male, Adolescent, Adult, Older adult
Health Care Settings
Ambulatory, Hospice, Hospital, Long term care, Outpatient, Radiology services
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Management, Treatment
Diseases/Conditions (MeSH)
D018787 - Radiation Oncology, D011827 - Radiation, D055752 - Small Cell Lung Carcinoma, D018288 - Carcinoma, Small Cell
Keywords
lung cancer, radiation therapy, Adjuvant Radiation Therapy, small cell lung cancer
Source Citation
Supplemental Methodology Resources
Methodology
Number of Source Documents
111
Literature Search Start Date
July 1, 1998
Literature Search End Date
December 31, 2018
Description of External Review Process
While the guideline is undergoing consensus voting, peer reviewers are identified who have an active clinical and/or research interest in the topic of the guideline. They are drawn from multiple sources, including the ASTRO membership and partner or collaborating organizations, and are selected to provide a variety of perspectives and areas of expertise. The task force chair(s), GLSC, and, where applicable, other committees and panels propose official ASTRO reviewers. Partner, collaborating, and potential endorsing societies are also encouraged to nominate reviewers on their behalf since this is their primary opportunity to recommend changes to the guideline. Like task force members, reviewers must disclose all industry relationships and personal interests and their disclosures are evaluated using a stringent COI review process. Once consensus on the draft guideline is achieved by the task force, the document undergoes review simultaneously by the invited peer reviewers, the GLSC (including in-depth review by 2-3 members for content, process and consistency with other ASTRO clinical documents), and ASTRO staff and legal counsel. The resulting comments are adjudicated by the task force and the guideline revised as appropriate.
Description of Public Comment Process
Following peer review, guidelines are posted on ASTRO’s website for 4-6 weeks for public comment. Announcements are made via emails and postings on the ASTRO website inviting comments from ASTRO members and committees; patient support and advocacy groups; and other potential stakeholders.
Specialties Involved
Internal Medicine General, Oncology, Pulmonology, Radiology, Radiation Oncology, Oncology
Description of Systematic Review
The task force also assesses and refines the preliminary KQs using the Patients, Interventions, Comparators, Outcomes, Timing, and Setting (PICOTS) framework, which guides a systematic approach to evidence review for guidelines. Focused questions make the project more manageable and lead to specific recommendations and conclusions that support patient care. Once the KQs are finalized, writing assignments are determined, including leads for each KQ.
List of Questions
See full text
Description of Study Criteria
See full text.
Description of Search Strategy
Drawing on the PICOTS for the KQs, a search protocol is developed, which details the search strategies and inclusion and exclusion criteria. The literature is derived from research involving human subjects, published in English, and indexed in MEDLINE. Hand searches of other sources, particularly recent review articles and trial data, may confirm or supplement the electronic searches. Studies published after the end date of the literature search are not used to develop the recommendations but may be discussed in a future directions/ emerging data section.
Description of Study Selection
The literature search results go through a series of reviews to synthesize the evidence based on the pre-defined inclusion and exclusion criteria to determine their relevance to the identified KQs and scope of the guideline. An independent literature review team dual-screens first the titles and then the abstracts of the articles included from title screening. The studies included after the second round are reviewed and further refined by the task force. Study characteristics from the final group of selected articles is abstracted into detailed evidence tables, which summarize the primary evidence base for the guideline and are used to inform the recommendations. The evidence tables are published as a supplement to the document.
Description of Evidence Analysis Methods
To ensure high standards in developing ASTRO’s guidelines, a rigorous, transparent, reproducible, and unbiased review of the evidence is paramount. Through a series of conference calls, small work groups synthesize and summarize the evidence for each KQ to determine the quality of the evidence. These discussions inform the development of draft recommendations, which include assigning the recommendation strength and
overall quality of evidence ratings, as defined in Table 1. It is important that guideline recommendations be clear and actionable statements that align with the PICOTS framework, denoting in most instances the patient group, intervention, comparator, and outcome. Implementation remarks are included sparingly to enhance the reader’s interpretation and understanding of a recommendation or to append information like timing, setting, or dosing details to the recommendation.
Description of Evidence Grading
High: We are very confident that the true effect lies close to that of the estimate of the effect.
Moderate: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate.
Very Low: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate.
In 2018, ASTRO’s guideline methodology was modified to incorporate an expert opinion strength of recommendation category and to quantify the number and type of studies that determine the quality of evidence.
Expert opinion recommendations are used where guidance is considered essential due to factors such as high prevalence, mortality, or morbidity but either relevant data do not exist, the available evidence does not reflect current technology/practice, or there is substantial variation in practice or controversy
Description of Recommendation Grading
General agreement on the recommendations is achieved during task force discussions throughout the writing process. Formal consensus is then evaluated using a modified Delphi approach.
Strong:
Definition:
Benefits clearly outweigh risks and burden, or risks and burden clearly outweigh benefits.
All or almost all informed people would make the recommended choice for or against an intervention.
Overall Quality of Evidence Grade:
Any (usually high or moderate)
Recommendation Wording:
“Recommendation/Should”
Conditional:
Definition:
Benefits are finely balanced with risks and burden or appreciable uncertainty exists about the magnitude of benefits and risks.
Most informed people would choose the recommended course of action, but a substantial number would not.
There is a strong role for patient preferences and shared-decision making.
Overall Quality of Evidence Grade
Any (usually moderate to very low)
Recommended Wording
“Conditionally Recommend”
Description of Funding Source
ASTRO provides funding for Guideline Development.
Company/Author Disclosures
ASTRO has detailed policies and procedures related to disclosure and management of industry relationships to avoid actual, potential, or perceived conflicts of interest. Based on the scope of the guideline, ASTRO staff initially identify categories of affected companies – commercial entities whose business and products may be influenced, positively or negatively, by the guideline recommendations. This list is reviewed during the proposal approval process and further refined by the selected task force chairs. All task force members are required to disclose industry relationships and personal interests that were active within the 12 months before initiation of the project. Disclosures go through a rigorous review process with final approval by ASTRO’s Conflict of Interest Review Committee. A majority of task force members (>50%), including the chairs, do not have relationships with affected companies and certain types of relationships are not permitted at all. For the purposes of full transparency, task force members’ comprehensive disclosure information is published in the guideline.
Percentage of Authors Reporting COI
100