The typical patient with small cell lung cancer has a history of smoking, but may be a current or former smoker of either gender and is usually in their sixth to seventh decade of life. Patients may have symptoms, signs, and/or laboratory test abnormalities caused directly by the primary tumor, those related to spread of tumor within the chest cavity or to distant sites like other organs, and those related to paraneoplastic syndromes.^2-3 Paraneoplastic syndromes are group of rare disorders that are triggered by an abnormal immune system response to a cancerous tumor.⁴ Patients may present with symptoms of shortness of breath, cough, or chest pain due to disease in the chest. For patients with disease outside the chest, symptoms depend on the location of spread such as bone pain with bone metastases or headaches and dizziness in patients with central nervous system (CNS) disease involving  the brain. Constitutional symptoms may include weakness, loss of appetite, weight loss or fever.^3-5 These parameters alone do not help to clearly distinguish small cell lung cancer from non-small cell lung cancer.

Biopsy

Before starting on treatment, it is important to have a biopsy to confirm the diagnosis of small cell lung cancer. A biopsy is when a piece of tissue is taken and examined under a microscope. The type of biopsy performed depends on the location of the tumor.

Many different methods may be used to obtain a biopsy, including:

A bronchoscopy: a patient is put to sleep with anesthesia and a very thin tube is inserted through the mouth or nose and pushed into the lungs. This procedure may be used to sample the lung tissue and/or a lymph node within the chest. An ultrasound may be used in an endobronchial ultrasound (EBUS) to assist in the procedure.

CT or ultrasound-guided biopsy: a needle guided by a CT scan or ultrasound is passed through the skin to obtain a piece of tissue.

A thoracentesis: in some patients presenting with fluid in the chest, a needle may be placed into the chest, and fluid is removed. The fluid is sent for evaluation of cancer cells.

Surgery: rarely, it is necessary to operate to obtain tissue to make a cancer diagnosis.

Although it is not common, if there is not enough tissue in the original biopsy, a second biopsy may be required.

The biopsy specimen will be sent to a pathologist, a physician who specializes in looking at tissue samples. The pathologist will make the diagnosis and will determine what kind of cancer it is. Small cell lung cancer may occur alone or combined with other tumors. (Figure 1)

Figure 1. Microscopic image of a small cell lung cancer taken with a microscope
(The cancer cells are the small purple cells in the top half of the picture)

Radiology Tests

Once a diagnosis is established, radiograph imaging studies will be performed to determine the location of cancer within the body. The purpose of the testing is to stage the cancer, determine if treatment will be curative or if a cure is not possible. Some of these tests may have been done prior to the biopsy and may not need to be repeated.

CT (CAT) scan of the chest, abdomen, and pelvis: this test has the purpose of looking for cancer that may be in the lungs, lymph nodes, liver, adrenal glands, bones, and other organs. (Figure 2)

Figure 2.  CT scan of the chest and abdomen with a cancer in the left lung.

Magnetic resonance imaging (MRI) of the brain: this test is done because small cell lung cancer may spread to the brain. Some patients cannot have an MRI scan and a CT scan with intravenous (IV) contrast of the brain may be done instead.

Bone scan: this test is done because small cell lung cancer may spread to the bones. If a patient is having a PET scan a bone scan is generally not necessary.

Positron Emission Tomography (PET) scan: because small cell lung cancer may spread anywhere in the body, this test is done to look at the entire body, except for the brain. PET scans measure increased levels of sugar (or glucose) that is being metabolized by the tumor as well some normal organs that may not have any active cancerexten (including the brain, heart, liver, and kidneys). (Figure 3)

Figure 3.  Positron Emission Tomography (PET) scan which shows involvement of cancer in the left lung.

Blood Tests

Before starting treatment for lung cancer, blood tests are needed to evaluate how different organs in the body are working. The results may impact what treatment is prescribed. These tests are described below and are commonly performed in most patients with a cancer diagnosis and may be repeated regularly during or after treatment.

Kidney tests: creatinine and blood urea nitrogen (BUN)

Liver tests: alanine transaminase (ALT), aspartate aminotransferase (AST), alkaline phosphatase, and bilirubin

Bone marrow tests: complete blood count

Electrolytes: sodium, potassium chloride, phosphate and magnesium

Staging

Stage is an indication of the size and location of the cancer. Approximately 60-70% of patients are diagnosed with small cell lung cancer will have extensive stage (or Stage IV) disease at presentation. This means that the tumor has spread outside of the chest. Although there is a shift in recommendations for the staging of small cell lung cancer most patients are still diagnosed using the traditional staging system of limited-stage disease and extensive-stage disease.⁶ Patients with limited-stage disease have cancer confined to the lung that can be treated with a combination of chemotherapy and radiation therapy and the goal of therapy is generally cure. Patients with extensive-stage disease have cancer that has spread within or beyond the lung and the cancer may not be cured with either systemic therapy or radiation therapy. Regardless of stage, patients with small cell lung cancer often experience an initial response to treatment.

The Tumor-Node-Metastasis (TNM) staging system is a newer system also used to stage small lung cancer. Using this system, small cell lung cancer may be staged as one of four stages, Stage I, II, III which are similar to limited-stage disease and Stage IV which is the same as extensive-stage disease. Staging is imperative to know prior to embarking on treatment.

Surgery

Surgery is reserved for patients with small tumors confined to the lung and that have not spread to lymph nodes. Prior to surgery, lymph node sampling is performed via one of two methods:

Endobronchial ultrasound biopsy (EBUS) as mentioned above is a procedure where a tube is inserted through the mouth or nose into the airway and an ultrasound device is used to help identify lymph nodes that will be biopsied. This has become the preferred method to sample lymph nodes in patients with suspected cancers.

Mediastinoscopy is used in cases where lymph nodes  cannot be accessed via EBUS. This is a minor surgery where a small incision is made at the bottom of the neck and a camera is placed into the chest to identify lymph nodes to biopsy.

If surgery is performed to remove the tumor from the lung, chemotherapy is recommended once the patient has recovered from surgery to treat microscopic disease, which are residual cancer cells that may be present but are not able to be seen with any imaging or the naked eye. If lymph nodes are found to be involved at the time of surgery, it will be necessary to have both chemotherapy and radiation after surgery.

Due to the extensive and infiltrative nature of small cell lung cancer, surgery has not traditionally been a part of small cell lung cancer management. In less than 5% of cases, small cell lung cancer is diagnosed in very early stages (stage I-IIA; T1-2, N0, M0) and surgery may be considered for  those who have undergone sampling of the mediastinal (mid-chest) lymph nodes to prove that these are not involved.⁷ More commonly, limited-stage small-cell lung cancers are stage IIB or beyond (T1-2, N1, M0). After completing investigations demonstrating no distant metastases (i.e., spread to the other lung or to other organs), these cases are typically treated with both chemotherapy and chest radiation given concurrently.

Combination of Chemotherapy and Radiation Therapy

Combined chemotherapy and radiation therapy is recommended for most patients with limited-stage small cell lung cancer. While a medical oncologist will oversee the chemotherapy, a radiation oncologist will oversee the radiation therapy during treatment.

If the patient is a current smoker, smoking cessation is very important prior to starting on therapy. Several studies have suggested that patients who stop smoking  prior to initiation of therapy have higher chances of cure and living longer compared to patients who continue to smoke.⁸ Patients can ask their doctors for resources to help them quit smoking. Additional information is available by calling 1-800-QUIT-NOW, reviewing www.smokefree.gov or Chapter 13: How to Quit Smoking Confidently and Successfully.

Chemotherapy

Chemotherapy is an important component of treatment for patients with small cell lung cancer, whether given after surgery (i.e., adjuvant therapy), concurrently with radiation, or in extensive-stage disease (discussed below).⁷

The most common chemotherapy regimen for the treatment of small cell lung cancer in the United States is a combination of a platinum agent , either cisplatin or carboplatin, plus etoposide.⁹ Your medical oncologist will choose between cisplatin or carboplatin by considering your other medical conditions and the different side effect profiles of each drug. Chemotherapy is given daily for 3 days in a row and repeated 3 weeks later. In between each cycle, the body recovers from the side effects of chemotherapy and gets ready for the next treatment. Each 3-week period is called a “cycle” and most commonly, a total of 4 cycles are given. Altogether, this means that chemotherapy treatment is given over a total of 12 weeks (3 weeks per cycle x 4 cycles). Concurrent chemotherapy and radiation for limited stage small cell lung cancer does not always require both to be started on exactly the same day. Often to prevent delays to treatment start, patients may receive 1-2 cycles of chemotherapy alone before radiation is added.

Chemotherapy is given intravenously through a needle that is inserted into the veins. Some patients may have an IV inserted into the vein that can be removed each day at the end of treatment while other patients may require a peripherally inserted catheter (PICC) or an implanted port that are placed in the vein and remains in the vein throughout the entire treatment.

The platinum and etoposide are both given on the first day and may take anywhere from 4-6 hours because additional fluids and medications are given prior to chemotherapy. Additional fluids are given prior to platinum-based chemotherapy due to the tendency of these agents to damage the kidneys without proper pre-hydration with fluids. These drugs can also cause nausea and vomiting, but pre-medications given before each treatment help to prevent these symptoms. Etoposide is given on its own on the second and third days, and takes about two hours to administer.

Most people do not feel anything unusual while receiving chemotherapy. However, patients may start to notice side effects 2-4 days after chemotherapy is administered.

Chemotherapy Side Effects

Most patients do not have significant side effects from chemotherapy because of the many supportive therapies available. However, important side effects to remember include:

Increased risk of infection: this is one of the most serious side effects of chemotherapy. Any patient with a fever (temperature higher than 100.4ºF), during chemotherapy needs to seek immediate medical attention.

Some patients may not have a fever and instead develop flu-like symptoms, cough, shortness of breath, pain with urination, diarrhea, or ear pain among other symptoms. You should seek medical attention if you have these symptoms as you may have an infection.

The increased risk of infection is because chemotherapy kills white blood cells, which normally are responsible for defending the body against infections. However, white blood cells grow back between each cycle. As a matter of precaution, it is important for patients to wash their hands regularly, avoid large crowds and sick people, and eat foods that come from trusted sources.

Fatigue: Both chemotherapy and radiation therapy may cause fatigue. This is normally the worst the first few days after chemotherapy and usually improves during the second and third week of each cycle. Fatigue can accumulate with each cycle of chemotherapy and radiation therapy. Fatigue will typically improve once all therapy is completed.

Nausea and Vomiting: As described above, nausea and vomiting have become less common with the modern day use of potent anti-nausea medications. Medications are typically given in a preventative fashion and as needed. Pre-medications are given routinely before chemotherapy is administered regardless of whether or not patients have nausea/vomiting in order to prevent the development of any nausea/vomiting.  In addition, patients are given medications to take home and use as needed should they require. These may include aprepitant or fosaprepitant which are given with chemotherapy as well as ondansetron, granisetron, dexamethasone, promethazine, prochlorperazine, metoclopramide and/or lorazepam which may be given with therapy or to take at home.

Hair Loss: Hair loss typically occurs within 3-4 weeks of starting chemotherapy. Hair often starts to grow back about one month after completing chemotherapy, but may be delayed in patients who are treated with radiation to the brain.

Other Side Effects: Other side effects of therapy include mouth sores, loss of appetite, diarrhea, easy bruising and bleeding (due to decreased hemoglobin and/or platelets), dehydration and damage to the kidneys, ringing in the ears (i.e., tinnitus) or numbness and tingling in the fingers and toes (i.e., peripheral neuropathy). All chemotherapy side effects should be discussed with a medical oncologist. See Chapter 8: Supportive Care.

Radiation Therapy

The techniques of radiation therapy for the treatment of limited stage small cell lung cancer are similar to what is done for Stage IIIA to IIIB non-small cell lung cancer—radiation therapy given concurrently with 4 to 6 cycles of chemotherapy. The same team approach is used in consultation, simulation, treatment planning, patient education, treatment delivery, and quality assurance. See Chapter 5: Radiation Therapy for Non-Small Cell Lung Cancer for additional technical details.

Unlike non-small cell lung cancers, limited-stage small cell lung cancers are best treated with radiation twice a day using a lower dose per treatment, at least 6 hours apart, based on a famous clinical trial that showed patients with limited stage small cell lung cancer did better with twice a day treatments (4500 cGy in 150 cGy fractions given twice a day over 30 treatments in 3 weeks). The trial compared this twice daily method to the same dose of once a day radiation that nobody uses (4500 cGy in 180 cGy fractions given once a day over 25 treatments).¹⁰ Treating a patient twice a day is harder on the patient due to increasing the daily treatment time and increases the acute side effects. Therefore in practice, many radiation oncologists will treat patients to total doses of 6000 to 7000 cGy in 180 to 200 cGy fractions.¹¹ A recent clinical trial showed that median survival was about the same for patients given 7000 cGy (30.5 months) given over seven weeks (35 once daily treatments) compared to twice daily treatment to 4500 cGy (28.7 months), supporting the use of higher dose once daily radiation treatments for patients with limited stage small cell lung cancer.¹²

As mentioned in the section on surgery, due to the extensive nature of small cell lung cancer and the fact that spread to the lymph nodes in the middle of the chest is so common, SBRT (stereotactic body radiation therapy) is not typically offered, but is a viable option for Stage I-IIA patients who are either too frail for surgery or who refuse surgery.¹³

Radiation Side Effects

Side effects of chest radiation in small cell lung cancer is similar to chest radiation in non-small cell lung cancer.

Acute side effects occur when a patient is receiving lung radiation therapy with or without chemotherapy. These include redness and irritation of the skin overlying the radiation treatment portals; inflammation of the esophagus (esophagitis) causing heartburn or a feeling that something is stuck in the throat; irritation of the lung causing a dry cough; inflammation of the sac surrounding the heart causing chest pain (pericarditis); electric shock sensations in the low back or legs when bending the neck (Lhermitte sign); and generalized fatigue. These acute side effects typically resolve 2 weeks after completing chest radiation therapy.

Subacute side effects occur 1 to 6 months after completing radiation therapy. These side effects are less frequent and may include radiation pneumonitis, which is inflammation of the lung that causes chest pain, fever, and cough.¹⁴ As mentioned above in the section on treatment planning, radiation pneumonitis occurs infrequently, especially when the V20 (volume of both lungs receiving ≥ 20 Gy or 2000 cGy) is no more than 35%. Your radiation oncologist, dosimetrist, and physicist work hard to ensure that the least amount of radiation possible goes to normal lung without sacrificing coverage of the lung tumor. Treatment of radiation pneumonitis includes corticosteroids such as prednisone or dexamethasone.

Long term side effects of lung radiation therapy include pulmonary fibrosis (permanent scarring of the radiated lung tissue), esophageal fibrosis and stricture (scarring and narrowing of the esophagus that causes difficulty swallowing and treated with esophageal dilation), constrictive pericarditis (shrinkage of the sac surrounding the heart, that may require surgical removal), and damage to the heart muscle and blood vessels that may increase the risk of heart failure and heart attack. These long-term side effects are uncommon because modern radiation therapy techniques have resulted in better sparing of normal tissues and organs. Excerpted from Chapter 5: Radiation Therapy for Non-Small Cell Lung Cancer.

Prophylactic Cranial Irradiation

Because the risk of brain metastases in small cell lung cancer is so high, MRI of the brain with contrast is part of the staging workup for limited stage small cell lung cancer. About 20% of small cell lung cancer patients will already have brain metastases when they are diagnosed.¹⁵ Prophylactic cranial irradiation (PCI) is giving radiation therapy to the entire brain (also called whole brain radiation therapy, WBRT) for patients without brain metastases on MRI to lower the risk of developing brain metastases (59% without PCI to 33% with PCI over 3 years in patients with limited stage small cell lung cancer).¹⁶ The standard dose has been 2500 cGy given in 250 cGy fractions over 10 treatments. PCI includes the entire brain (like whole brain radiation) but also includes the spinal cord down to the level of the C2 vertebra. PCI is currently recommended for all patients with limited stage small cell lung cancer who have a good response to chemotherapy and radiation. Nevertheless, your radiation oncologist should thoroughly discuss the benefits and risks of whole brain radiation with you before making a decision on this (see the section on palliative radiation to the brain in Chapter 5: Radiation Therapy for Non-Small Cell Lung Cancer). If you choose not to receive PCI, then an MRI of the brain should be done every 3 to 4 months to monitor you closely.

Follow Up

After therapy is completed, patients are followed regularly to make sure they recover from side effects and also for surveillance to monitor for signs of disease recurrence.

The majority of side effects usually start to improve about four weeks after completing chemotherapy with more energy and increased appetite. However, prophylactic cranial irradiation, which starts about a month after chemotherapy is complete, may delay recovery. Late side effects from radiation to the chest may occur such as inflammation of the lungs (pneumonitis) or difficulty swallowing from narrowing of the esophagus, both of which can be effectively treated. For this reason, it is important to tell the doctors about any new symptoms that occur after treatment has ended.

Regular visits are recommended with the medical oncologist every one to two months initially, and then less frequently if the patient is feeling well. Your radiation oncologist will want to see you one to three months after completing your treatment and subsequently at longer intervals in coordination with your medical oncologist. At every visit the doctor will review symptoms and perform a physical examination. A CT scan of the chest and blood work may be done every three to four months initially, every four to six months later, and annually after three years. An MRI (preferred) or CT of the brain will be done every three to four months during the first year, then every six months. Regular follow-up and routine CT/MRI scans are part of surveillance, which is scheduled monitoring for early signs of disease recurrence.

Prognosis

The intention of treatment for limited stage small cell lung cancer is to cure the cancer. It is expected that 70-90% of patients who receive therapy will have a response with the cancer showing shrinkage. However even after completing treatment, there is a high risk of recurrence and only 25-30% of patients are alive at five years. For patients who do not wish to receive treatment or are unable to receive treatment, the expected survival is lower.

Patients with extensive stage small cell lung cancer have cancer that has spread either within or beyond the lungs. For the first time in three decades we have seen progress in the treatment of patients with extensive stage disease with a combination of chemotherapy and immunotherapy. Radiation therapy may be used for consolidation or for symptom control during or after chemotherapy. Surgery is generally not recommended.

Chemotherapy

Similar to patients with limited stage disease chemotherapy consists of a platinum doublet cisplatin or carboplatin with etoposide in combination with immunotherapy for patients in North America and Europe. Treatment is given over 3 days with platinum and etoposide given on the first day along with the atezolizumab and then etoposide alone on day 2 and 3 for four cycles, with each treatment being 21 days apart. After four cycles the atezolizumab is continued as a maintenance therapy for as long as the treatment remains effective. Treatment is given through a vein using either a needle inserted into the arm or a PICC or PORT as described above.  Treatment is generally given as an outpatient and may take 4-6 hours the first day and then about two hours on day two and three. Prior to treatment on the first day blood work is done to make sure it is safe to give chemotherapy and you will likely meet with your medical oncologist or a member of the healthcare team. In between each cycle the body recovers from the side effects of chemotherapy and immunotherapy and gets ready for the next treatment. Chemotherapy for extensive stage disease is usually given for 4 cycles with immunotherapy, followed by maintenance immunotherapy every 3 weeks with imaging performed every 2-3 cycles.

Immunotherapy

Immune checkpoint inhibitors have been approved for the treatment of multiple different tumor types including patients with small cell lung cancer. These agents work very differently from chemotherapy acting on proteins expressed on cancer cells and T cells that normally prevent the body from recognizing cancer cells as foreign. When these proteins are blocked the T cells are activated and able to kill cancer cells. Currently, atezolizumab is approved in combination with chemotherapy as a first-line option for patients with small cell lung cancer.¹⁷ Durvalumab has also shown promise in combination with platinum-based chemotherapy but is not yet approved. Nivolumab and Pembrolizumab are also approved in the third-line setting for patients who have progressed on platinum-based chemotherapy as well as a second-line chemotherapy regimen. Not all patients are candidates for treatment with immunotherapy. These agents are generally not recommended for patients with a history of autoimmune disease, organ transplant or certain paraneoplastic syndromes.^18-19

Chest Radiation

The combination of chemotherapy and radiation therapy is not typically given to patients with extensive stage small cell lung cancer. However, radiation may be given to help relieve symptoms, such as pain, shortness of breath, difficulty swallowing, and/or blockage of a bronchus, while a patient waits to get started with chemotherapy. Small cell lung cancer is the most common cause (75 to 80%) of superior vena cava (SVC) syndrome, a condition caused by a large tumor compressing the superior vena cava causing swelling of the face, neck, and upper arms; shortness of breath; and coughing.²⁰ Chest radiation in extensive stage small cell lung cancer is given on a case by case basis, and when given, can sometimes be given after a few courses of chemotherapy to treat any tumor that is left. Despite the fact that chest radiation is not used routinely in extensive stage small cell lung cancer, clinical studies analyzing the benefits of chest radiation in extensive stage small cell lung cancer patients have been promising and have suggested that patients may live longer if chest radiation is added to chemotherapy.²¹

Prophylactic Cranial Irradiation (PCI)

MRI of the brain with contrast is also part of the staging workup for extensive stage small cell lung cancer. Prophylactic cranial irradiation (PCI, 2500 cGy given in 250 cGy fractions over 10 treatments as in limited stage small cell lung cancer) was a standard treatment for extensive stage small cell lung cancer patients without brain metastases on MRI to lower the risk of developing brain metastases (40.4% to 14.6% over 1 year in extensive stage), as mentioned in Lung Cancer Choices, 4^th Edition.²² However, another clinical trial in extensive stage small cell lung cancer patients who responded well to chemotherapy, showed no increased survival in patients getting PCI.²³ Because of the side effects to the brain and the limited survival benefit, patients with extensive stage small cell lung cancer can choose to omit PCI. Whether or not PCI is given, you should get an MRI (preferred) or CT of the brain every three to four months to monitor for appearance of any brain metastases. It must be emphasized that PCI is still recommended for patients with limited stage small cell lung cancer.

Management of Metastases with Radiation

When patients with small cell lung cancer actually develop brain metastases, whole brain radiation (WBRT) is the recommended radiation treatment method, for a total dose of 3000 cGy given in 300 cGy fractions over 10 treatments. If patients have a good performance status and have an estimated survival of 6 months or more, some patients can be treated with a longer fractionation dose of 3750 cGy in 250 cGy fractions over 15 treatments. Memantine, a drug FDA approved to treat Alzheimer’s dementia, has been shown to reduce the rate of decline in memory, executive function, and processing speed in patients receiving WBRT.²⁴ Ask your radiation oncologist about a prescription for memantine if you are going to receive PCI or WBRT.

Even when only 1 to 3 masses are detected on MRI, it is understood that in small cell lung cancer, there may be many additional masses that are too small to be detected on MRI. Because of this, focused treatments such as surgical removal or stereotactic radiosurgery (SRS) are not routine, as it is felt that the entire brain is at risk. Nevertheless, up front SRS for brain metastases in small cell lung cancer has been studied and shows promise as an alternative to whole brain radiation.²⁵

In patients that develop brain metastases after PCI, repeat WBRT can be given safely but with more cognitive side effects. As an alternative to repeat WBRT, SRS can also be done with potentially less side effects provided there are a limited number of metastases.²⁶

Small cell lung cancer can also spread to the liver, adrenal glands, bones (including vertebra). In these cases, radiation therapy (either conventional radiation or SBRT) can be used to treat these sites to relieve pain and prevent fracture (in cases of bone metastases). (SRS and SBRT are discussed in detail in Chapter 5: Radiation Therapy for Non-Small Cell Lung Cancer in the section “Palliative Radiation Therapy for Sites of Metastases in Stage IV Non-Small Cell Lung Cancer”.

Prognosis

Patients with extensive stage small cell lung cancer are generally not cured with chemotherapy or radiation therapy. The purpose of treatment is to improve quality of life and symptoms as well as prolong survival. Approximately 60-70% of patients will respond to chemotherapy the first time with their cancer shrinking or disappearing. Unfortunately, responses may not last for long and additional chemotherapy or radiation may be needed. For patients who get treated, less than 5% of patients are alive at 5 years. Life expectancy is usually less than 2-3 months and often only a few weeks for patients who choose not to have any treatment.

Clinical Trials

Given the limited number of drugs currently approved for small cell lung cancer, not due to lack of studies but due to lack of success, clinical trials remain critical to advance therapy for this disease.

A clinical trial is a research program designed to evaluate whether a new drug is effective in the treatment of a particular disease. Some trials may compare a new treatment to the current standard of care or add a treatment to the standard of care. Some people may not wish to participate in a clinical trial for fear of not receiving adequate treatment for their disease, however this is not the case in clinical trials involving cancer patients.

Patients may speak with their doctor about a clinical trial, ask questions, and make a decision if the trial is a reasonable choice for their disease. Sometimes a patient may not be able to participate in a trial because of other comorbid illnesses and the doctor would know if this was the case.

Patient participation in a clinical trial is critical to advancing the care for patients with lung cancer. See Chapter 7: Clinical Trials and Emerging Therapies for Lung Cancer

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