Controversies in oncology: surgery for small cell lung cancer? It’s time to rethink the case

Small cell lung cancer (SCLC) is a devastating disease, which owns the poorest prognosis of all different types of lung cancer. There has been only modest progress in its treatment over the last decades, and 5-year survival rates still are as low as 5%–7%.1 Main reasons for these disappointing results are the early and rapid spread of the tumour and the high recurrence rate after initial response to chemotherapy. Both these features of SCLC have at the same time been used as strong arguments against the use of surgery as part of any treatment algorithm. However, over the last two decades, we have seen major improvements in diagnosis, precision of staging and development of more sophisticated multimodality-based treatment strategies, which have changed the therapeutic standards in many fields of oncology. It therefore seems to be timely and appropriate to also rediscuss the treatment algorithm for SCLC, especially with regard to a potential contribution of surgery for limited-stage SCLC.Although surgery was in fact the treatment of choice in patients who were diagnosed at an early limited-stage of SCLC, many decades ago, chemotherapy and radiation therapy soon became the only accepted treatment modalities, mainly based on the findings of three randomised studies which, seen from today’s perspective, did all not fulfil modern quality requirements.In 1973, the medical research council trial2 compared surgery and radiotherapy for the primary treatment of SCLC. Patients treated in the surgery group had a significantly inferior mean survival (199 vs 300 days, p=0.04) compared with the radiotherapy group. However, the study …