Do you routinely recommend prophylactic cranial irradiation for stage I small-cell lung cancers treated with lobectomy and adjuvant chemotherapy?

PCI was 'associated' with better long-term survival even in stage 1, and age and size factors do not seem to matter. However, as the information gets divided, fewer patients fall into each cohort.

A recent study published in the JCO, analyzing over 1,000 patients in the NCDB, found that thoracic radiotherapy had no positive effect on survival unless N-2 nodes were involved. However, the addition of chemotherapy to surgery and brain treatment for the group receiving chemotherapy and surgery provided a benefit.

The challenge with PCI is its effectiveness. Within the field, the SRS proponents aim to eliminate any form of whole-brain treatment. The adverse effect on cognition with 250 cGy times 10 is negligible. Though some focus on 'late effects...

All physicians have their personal biases, especially evident in discussions about PCI, but it's crucial not to let these biases obscure our judgment in understanding and treating cases where different approaches might be warranted.

In the context of stage I SCLC treated with resection and adjuvant chemotherapy, the current ASTRO guidelines conditionally do NOT recommend PCI for these patients (while recommending it for stages II and III). Following these guidelines, anyone not routinely recommending PCI for these patients is operating within the standard of care.

Simone et al., PMID 32222430

Personally, I discuss the pros and cons of PCI with early-stage patients and treat those who wish it. However, I remain skeptical. The other side of the ...

Great question. While we attempt to determine the benefit of PCI in the modern MRI era for limited-stage SCLC (MAVERICK trial), for a patient in this scenario, I would present the choice of PCI or undergoing surveillance MRI every three months. However, pending the results of MAVERICK, the current standard of care remains PCI even for stage I SCLC.

Update: Based on the results of MAVERICK, routine MRI surveillance appears to be the new standard of care, without any impact on survival (preliminary) and reduced adverse events with the addition of whole brain. As data matures, we will get a better understanding of both late adverse events and any impact on overall survival but as of now it seems the new standard is observation.

My disclaimer: I ...