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<p>Small cell lung cancer (SCLC) is a highly aggressive neuroendocrine tumor. Although patient survival has been significantly improved by immune checkpoint inhibitors combined with chemotherapy, three major unmet needs remain in SCLC management. First, while prophylactic cranial irradiation (PCI) can reduce the risk of brain metastases, its neurotoxicity limits its use, particularly in elderly patients or those with neurological deficits. Whole-brain radiotherapy (WBRT) remains the primary approach for brain metastases, and hippocampal-avoidance WBRT (HA-WBRT) combined with neuroprotective agents can significantly reduce cognitive risks. Stereotactic radiosurgery (SRS) has shown survival benefits and less cognitive damage for patients with up to 10 brain metastatic lesions. Emerging therapies, such as antibody-drug conjugates targeting B7-H3/DLL3 (I-Dxd, ZL-1310) and bispecific antibody tarlatamab, have demonstrated intracranial response rates of 62.5%-71%. Regardless of whether the brain metastases had previously undergone radiation therapy, the novel drugs showed consistent activity, indicating promising improvements in the prognosis of brain metastases. Second, the rapid progression and severe treatment-related toxicity of SCLC greatly affect patients’ physical and mental well-being. Therefore, quality of life (QoL) should be prioritised. Strategies to improve QoL include early palliative care, proactive symptom management, application of HA-WBRT or SRS to preserve neurocognitive function, and novel agents such as tarlatamab to alleviate symptoms including cough and dyspnoea. Third, real-world evidence (RWE), which complements clinical trial data by reflecting treatment efficacy and safety in routine clinical practice, is gaining increasing recognition but faces challenges due to data heterogeneity, bias, and lack of methodological standardization. Future directions involve developing new drugs with high blood-brain barrier penetration, such as radioligand therapy, conducting prospective studies to optimize HA and SRS applications, establishing high-quality RWE databases to support personalized treatments, exploring molecular subtypes (SCLC-A/N/P/I) and leveraging AI technologies to advance precision radiotherapy. SCLC management needs to be patient-centered, integrating precise treatment of brain metastases, QoL improvement, and the application of RWE to achieve a balance between survival benefits and QoL.</p>

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Addressing Unmet Needs in the Management of Small Cell Lung Cancer: Treatment of Brain Metastases, Quality of Life, and the Role of Real-World Evidence

  • 期刊论文

  • 出版模式：

    开放获取

  • 发表日期：

    2026年5月9日

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  • Yunfei Dai,
  • Jing Fei

摘要

Small cell lung cancer (SCLC) is a highly aggressive neuroendocrine tumor. Although patient survival has been significantly improved by immune checkpoint inhibitors combined with chemotherapy, three major unmet needs remain in SCLC management. First, while prophylactic cranial irradiation (PCI) can reduce the risk of brain metastases, its neurotoxicity limits its use, particularly in elderly patients or those with neurological deficits. Whole-brain radiotherapy (WBRT) remains the primary approach for brain metastases, and hippocampal-avoidance WBRT (HA-WBRT) combined with neuroprotective agents can significantly reduce cognitive risks. Stereotactic radiosurgery (SRS) has shown survival benefits and less cognitive damage for patients with up to 10 brain metastatic lesions. Emerging therapies, such as antibody-drug conjugates targeting B7-H3/DLL3 (I-Dxd, ZL-1310) and bispecific antibody tarlatamab, have demonstrated intracranial response rates of 62.5%-71%. Regardless of whether the brain metastases had previously undergone radiation therapy, the novel drugs showed consistent activity, indicating promising improvements in the prognosis of brain metastases. Second, the rapid progression and severe treatment-related toxicity of SCLC greatly affect patients’ physical and mental well-being. Therefore, quality of life (QoL) should be prioritised. Strategies to improve QoL include early palliative care, proactive symptom management, application of HA-WBRT or SRS to preserve neurocognitive function, and novel agents such as tarlatamab to alleviate symptoms including cough and dyspnoea. Third, real-world evidence (RWE), which complements clinical trial data by reflecting treatment efficacy and safety in routine clinical practice, is gaining increasing recognition but faces challenges due to data heterogeneity, bias, and lack of methodological standardization. Future directions involve developing new drugs with high blood-brain barrier penetration, such as radioligand therapy, conducting prospective studies to optimize HA and SRS applications, establishing high-quality RWE databases to support personalized treatments, exploring molecular subtypes (SCLC-A/N/P/I) and leveraging AI technologies to advance precision radiotherapy. SCLC management needs to be patient-centered, integrating precise treatment of brain metastases, QoL improvement, and the application of RWE to achieve a balance between survival benefits and QoL.