Lung cancer is one of the commonest malignancies worldwide and the incidence continues to increase. Small cell lung cancer accounts for approximately 15% of all lung cancer cases although incidence of this subtype appears to be falling. It is an aggressive malignancy but responds well to chemotherapy and radiotherapy. The prognosis for untreated small cell lung cancer is less than 3 months. Small cell lung carcinoma is considered to be either limited-stage (LS) or extensive-stage (ES) on the basis of anatomical staging. In spite of high initial response rates in both limited- and extensive-stage patients, the relapse rate is high and overall median survival in LS and ES is 18 months and 9 months respectively. Standard chemotherapy regimens for small cell lung cancer patients with good performance status are platinum based, the commonest being cisplatin/etoposide. However, many patients present with a poor performance status (ECOG performance status of 2 or more and Karnofsky performance status of 60 or less) and these patients are at higher risk of toxicity from chemotherapy. Furthermore, the lung cancer population is largely elderly, 40% of patients being over 75 years. Whilst age is not an independent poor prognostic factor in itself, 90% of older patients have co-morbidity and may be at increased risk of toxicity due to functional organ impairment. Most clinical trials do not include patients with poor performance status and also the elderly (more than 70 years of age) tend to be under-represented, therefore not really reporting on the elderly. This review summarizes the evidence for treating small cell lung carcinoma patients with a poor performance in order to guide clinical decision-making. Treatment decisions should reflect not only the prognostic groups but take into account performance status and co-morbidities as well. It is important to differentiate between poor performance due to comorbidities and that due to the aggressive nature of small cell carcinoma. In the latter case a patient may have been previously fit and well and compromise on treatment based solely on poor performance may not be desirable, as the performance may improve dramatically if patient responds well to treatment.