Radiation Therapy for Small Cell Lung Cancer Guideline Endorsement

An interview with Dr. Megan E. Daly from the University of California, Davis on “Radiation Therapy for Small Cell Lung Cancer: ASCO Guideline Endorsement of an ASTRO Guideline.” An ASCO Expert Panel reviewed an ASTRO guideline on radiation therapy for SCLC and determined it was clear, thorough, and evidence based. ASCO endorsed the ASTRO guideline with a few discussion points, which Dr. Daly reviews in this podcast. Read the full guideline endorsement at www.asco.org/thoracic-cancer-guidelines. TRANSCRIPT PRESENTER: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. BRITTANY HARVEY: Hello, and welcome to the ASCO Guidelines Podcast Series brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content and offering enriching insight into the world of cancer care. You can find all the shows, including this one, at podcast.asco.org. My name is Brittany Harvey, and today, I'm interviewing Dr. Megan Daly from the University of California Davis, Co-Chair and lead author on "Radiation Therapy for Small Cell Lung Cancer: ASCO Guideline Endorsement of an ASTRO Guideline." Thank you for being here, Dr. Daly. DR. MEGAN DALY: Thank you. Glad to be here. BRITTANY HARVEY: First, I'd like to note that ASCO takes great care in the development of its guidelines and ensuring that the ASCO conflict of interest policy is followed for each guideline. The full conflict of interest information for this panel is available online with the publication of the guideline in the Journal of Clinical Oncology. Dr. Daly, do you have any relevant disclosures that are directly related to this guideline topic? DR. MEGAN DALY: I do not. BRITTANY HARVEY: Great. Thanks so much. So generally, can you give us an overview of what this guideline endorsement addresses and how the ASCO guideline endorsement process works? DR. MEGAN DALY: This guideline was designed to provide an endorsement of a very comprehensive guideline provided by the American Society of Radiation Oncology addressing the use of radiation therapy for small cell lung cancer. The guideline endorsement process involved us developing a team of physicians, both medical oncologists and radiation oncologists, to review and assess the ASTRO guideline and make recommendations and clarifications for the ASCO audience. So our guideline panel met several times by teleconference. We carefully reviewed the guidelines with assistance from the ASCO staff. We reviewed each individual recommendation within the ASTRO guideline, including the supporting evidence and the final recommendations, and provided clarifying comments, when necessary. The entire guideline panel had to vote and reach a consensus on each individual recommendation from the ASTRO guideline to form a final consensus. And ultimately in the case of this guideline, we largely agreed with the excellent ASTRO guideline that had already been produced. So this was largely a process of confirming and endorsing ASTRO's guideline product. We also, then, provided a written paper that provides some additional clarification in context for ASCO's audience. BRITTANY HARVEY: Great. So you just touched on some of the recommendations of the guidelines. So what were those key recommendations of this guideline? DR. MEGAN DALY: So this guideline was specifically addressing the use of radiation therapy for small cell lung cancer, both limited-stage and extensive-stage small cell lung cancer. So the key recommendations that came out of both the ASTRO guideline and ASCO's recommendation of ASTRO's guidelines were first that radiation therapy should be used for most patients with limited-stage small cell lung cancer, confirming standard practice, and that doses of 45 gray in twice daily fractionation remain the standard of care, but alternative schedules delivering 60 to 70 gray over a single fraction are also reasonable. The guideline also addressed that stereotactic radiation is an appropriate consideration for early-stage node-negative limited-stage small cell lung cancer. The guideline also addresses the use of prophylactic cranial irradiation and continues to recommend the use of prophylactic cranial irradiation for fit patients with limited-stage small cell lung cancer while recommending shared decision making for other patients, including those with extensive-stage disease or patients who might have contraindications to PCI for limited-stage small cell lung cancer. And finally, the guideline also addressed the use of consolidated thoracic radiation in extensive-stage small cell lung cancer, providing a recommendation that it be considered for well-selected patients with extensive-stage disease. BRITTANY HARVEY: OK, and then you mentioned earlier that there were select scenarios in which the panel offered clarifying comments. So in which sections did the ASCO expert panel decide to offer those clarifying comments? DR. MEGAN DALY: Our clarifying comments were largely simply to provide clarification in several of the recommendations. For example, in recommendation 1.2, where ASTRO recommends that it's important to maintain the dosage and timing of chemotherapy with radiation and that timing is more critical for accelerated dose intensive radiation, we clarified that dose intensive radiation would be referring to twice daily hyper-fractionated regimens. We also provided clarification that ultracentral tumors refer to those where a planning target volume is overlapping or touching the proximal bronchial tree, the esophagus, and trachea within the recommendation that those tumors, even when early stage might better be addressed by fractionated, rather than a stereotactic radiation. And finally, for recommendation 4.4, it states for patients with extensive-stage small cell with a response to chemotherapy and immunotherapy and residual disease in the thorax, thoracic radiation to 30 gray and 10 fractions within six to eight weeks can be considered. And we provided clarification that that would be six to eight weeks of completion of the chemotherapy and prior to maintenance immunotherapy. BRITTANY HARVEY: Great. Then it sounds like those notes will be key for the ASCO audience in interpreting and implementing these recommendations. So in your view, what is the importance of this guideline endorsement? And how will it affect ASCO members? DR. MEGAN DALY: So I believe this guideline endorsement and the initial ASTRO guideline are both very important in providing guidance to both radiation oncologists and medical oncologists who routinely treat small cell lung cancer patients in their practice. The small cell lung cancer space is constantly changing, and there have been some major developments in small cell lung cancer within the last 5 to 10 years, most notably surrounding the use of prophylactic cranial irradiation and extensive-stage disease. There's also a number of interesting ongoing clinical trials looking at the use of consolidated thoracic radiation in extensive-stage disease. And many practitioners have questions about how to use radiation in the landscape of changing systemic therapies, for example, the integration of immunotherapy into extensive-stage disease, as well as how to integrate newer irradiation technologies like stereotactic radiation into the treatment of small cell lung cancer. So I believe that this guideline endorsement, as well as the original guidelines, can provide valuable guidance to the ASCO community in how to treat these patients in their daily practice. BRITTANY HARVEY: Great. And then finally, how do these guideline recommendations impact patients with small cell lung cancer? DR. MEGAN DALY: Hopefully, these guideline recommendations will help patients with small cell lung cancer receive standard of care latest treatments incorporating radiation. And there's a number of areas where radiation has been shown to improve survival in small cell lung cancer. So we absolutely want to make sure that our patients are receiving the best possible care that incorporates all available treatment modalities and incorporates all the latest data. BRITTANY HARVEY: Great. Well, thank you so much for your work on this guideline endorsement, and thank you for taking the time to speak with me today, Dr. Daly. DR. MEGAN DALY: Yeah, Brittany, thank you so much. Glad to be here. BRITTANY HARVEY: And thank you to all of our listeners for tuning in to the ASCO Guidelines Podcast Series. To read the full guideline, go to www.asco.org/thoracic-cancer-guidelines. You can also find many of our guidelines and interactive resources in the free ASCO guidelines app available in iTunes or the Google Play store. If you have enjoyed what you've heard today, please rate and review the podcast and be sure to subscribe so you never miss an episode.