An evidence-based practice guideline was developed to identify the optimal
combination chemotherapy regimen, schedule of administration, and
duration of therapy for the first-line treatment of adults with limited-stage
small-cell lung cancer. The guideline is based on a systematic search and review of literature published between 1985 and December 2002. Three reviewers selected studies for inclusion in the guideline according to pre-defined criteria. Fifty randomized controlled trials, five in abstract form, were included in the review, and feedback on a draft version of the guideline was obtained from medical oncologists in the province of Ontario, Canada. The most commonly used regimens in clinical trials are
cyclophosphamide-
doxorubicin(
Adriamycin)-
vincristine, and
etoposide-
cisplatin. No combination chemotherapeutic regimen has been conclusively shown to be superior to either of these regimens. Most studies comparing chemoradiation regimens used sequential rather than concurrent thoracic
radiotherapy. When treating for cure with chemoradiation, there is evidence from one randomized controlled trial to support the use of
etoposide-
cisplatin over an
anthracycline-containing regimen. There is conflicting evidence concerning a survival advantage for a regimen that alternates
cyclophosphamide-
doxorubicin-
vincristine with
etoposide-
cisplatin compared with either regimen alone. If bolus
etoposide-
cisplatin is the treatment of choice, evidence from one randomized trial suggests that the optimal sequence of administration is
cisplatin followed by
etoposide. The use of
maintenance chemotherapy is not indicated. There is insufficient evidence to support the routine use of dose-intensive regimens outside a clinical trial, to determine the optimal duration of
chemotherapy, or to support the routine substitution of
carboplatin for
cisplatin in
combination chemotherapy regimens in this patient population.
RECOMMENDATIONS: