Updated January 2014
Until lung cancer symptoms are controlled by antineoplastic therapy, appropriate symptomatic treatment is essential not only for patient comfort but these measures may enhance the fidelity of the combined modality program by minimizing protocol violations.
Neutropenia and fever associated with chemotherapy and thoracic irradiation occurs in 10-20% of patients and is a major factor in the 1-2% probability of treatment related mortality. There is evidence from randomized trials that prophylactic antibiotics with co-trimoxazole (one double strength tablet bid) or ciprofloxacin (500 mg bid) reduces the risk of neutropenic fever and sepsis during induction therapy for patients with SCLC. Patients with bronchial obstruction and atelectasis are particularly at risk and prophylactic antibiotics should be considered during the neutrophil nadir. If a patient has an episode of neutropenia and fever, prophylactic antibiotic may be justified for subsequent chemotherapy cycles.
Esophagitis is common during the final phase of thoracic irradiation and during the week after completion of radiotherapy. Supportive care should include diet modification, analgesics and oral mucaine. When esophagitis appears to be aggravated by gastroesophageal reflux, gastric acid suppression may be helpful (H2 blockers or omeprazole). Severe radiation esophagitis may require hospitalization with intravenous supportive care. Dehydration must be avoided to minimize renal impairment and maintain optimal chemotherapy delivery.
According to the BCCA guidelines for use of cytokine support, patients receiving treatment with curative intent can be considered for G-CSF. However, chemotherapy supported with G-CSF plus concurrent thoracic irradiation has been associated with unexpectedly severe hematologic toxicity and should be avoided (Bunn 1995). Similarly erythropoietin support during chemoradiation has been linked with a high risk of vascular events (35%) and poorer survival.
Clinicians must assess the psychosocial needs of lung cancer patients and use the expertise of their health care colleagues specializing in this area. Inadequate psychological support of the patient can undermine the best treatment plan. Smoking cessation after successful treatment of SCLC is associated with fewer smoking-related second primary cancers. These patients must be actively encouraged and assisted to stop smoking.
References:
1. De Jongh CA, Wade JC, Finley RS, et al. Trimethoprim/sulfamethoxazole versus placebo: a double-blind comparison of infection prophylaxis in patients with small cell carcinoma of the lung. J Clin Oncol 1983;1:302.
2. Tjan-Heijnen V, Manegold C, Buchholz D, et al. Reduction of chemotherapy-induced febrile leukopenia by ciprofloxacin and roxithromycin in small cell lung cancer (SCLC) patients: an EORTC phase III study. Proc Amer Soc Clin Oncol 18;469a, 1999, (abst. 1808)
3. Bunn PA, Crowley J, Kelly K, et al. Chemoradiotherapy with or without granulocyte-macrophage colony-stimulating factor in the treatment of limited-stage small-cell lung cancer: a prospective phase III randomized study of the Southwest Oncology Group. J Clin Oncol 13:1632-1641, 1995.
