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Future Directions in Lung Cancer Management

Insights From: Suresh Ramalingam, MD, Winship Cancer Institute of Emory University
Published: Friday, Sep 06, 2019



Transcript: 

Suresh Ramalingam, MD: With all these exciting advances, personalized therapy for lung cancer is now a reality. In non–small cell lung cancer for patients with nonsquamous histology, using molecular testing for every patient to identify optimal treatments is the standard of care. If patients have a targetable driver mutation, then targeted therapy is the frontline treatment. If not, then we use PD-L1 [programmed death-ligand 1] expression to decide optimal immunotherapy [I/O]. In small cell lung cancer, we have seen the approval of atezolizumab with chemotherapy in the frontline space, and that’s become a new standard of care. The CASPIAN study will help us understand where durvalumab plus chemotherapy fits in the frontline treatment of small cell lung cancer.

As these studies read out and as advances are made, we look at what are the next wave of studies that will help us improve outcomes for patients with lung cancer. One specific setting we’re excited about is the early stage non–small cell lung cancer where there are neoadjuvant and adjuvant studies with immune checkpoint inhibitors. It’s likely that we will see data from the adjuvant therapy trials first.

These are patients who are treated with surgery for early stage lung cancer, particularly stage I, II, or IIIa disease, and then they get standard adjuvant therapy in the form of platinum-based chemotherapy and subsequently are randomized to checkpoint inhibition or not. There are several trials ongoing and some of them have been completed, so we look forward to seeing the results to see if using immune checkpoint inhibition in early stage disease will result in improved cure rates for non–small cell lung cancer.

In stage III patients who are not candidates for surgery but are treated with chemotherapy plus radiation, we’ve already seen the use of consolidation durvalumab as part of the PACIFIC regimen, resulting in improved overall survival. Now there are ongoing studies to move durvalumab to the concurrent phase of chemotherapy and radiation to see if that will result in added benefits. There are also studies with pembrolizumab, and ipilimumab plus nivolumab, in this setting. So even the stage III disease is seeing finally that we have turned the corner and there are better outcomes for patients.

In small cell lung cancer, the key questions are going to be what effective second-line therapies are there when patients progress on chemotherapy plus checkpoint inhibition. Lurbinectedin is a drug that has demonstrated promising activity in the salvage therapy setting. We hope to see the results of the phase III trial to see whether we will have an effective salvage therapy option when patients progress on a chemotherapy or chemotherapy plus I/O strategy. There are also studies in the limited stage small cell lung cancer setting where I/O agents are being integrated with chemotherapy and radiation to improve the cure rate. So clearly, there are a plethora of exciting studies that build upon the advances made, so we can take the treatment of lung cancer to the next level and hopefully provide longer and better outcomes for our patients.

Transcript Edited for Clarity
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Transcript: 

Suresh Ramalingam, MD: With all these exciting advances, personalized therapy for lung cancer is now a reality. In non–small cell lung cancer for patients with nonsquamous histology, using molecular testing for every patient to identify optimal treatments is the standard of care. If patients have a targetable driver mutation, then targeted therapy is the frontline treatment. If not, then we use PD-L1 [programmed death-ligand 1] expression to decide optimal immunotherapy [I/O]. In small cell lung cancer, we have seen the approval of atezolizumab with chemotherapy in the frontline space, and that’s become a new standard of care. The CASPIAN study will help us understand where durvalumab plus chemotherapy fits in the frontline treatment of small cell lung cancer.

As these studies read out and as advances are made, we look at what are the next wave of studies that will help us improve outcomes for patients with lung cancer. One specific setting we’re excited about is the early stage non–small cell lung cancer where there are neoadjuvant and adjuvant studies with immune checkpoint inhibitors. It’s likely that we will see data from the adjuvant therapy trials first.

These are patients who are treated with surgery for early stage lung cancer, particularly stage I, II, or IIIa disease, and then they get standard adjuvant therapy in the form of platinum-based chemotherapy and subsequently are randomized to checkpoint inhibition or not. There are several trials ongoing and some of them have been completed, so we look forward to seeing the results to see if using immune checkpoint inhibition in early stage disease will result in improved cure rates for non–small cell lung cancer.

In stage III patients who are not candidates for surgery but are treated with chemotherapy plus radiation, we’ve already seen the use of consolidation durvalumab as part of the PACIFIC regimen, resulting in improved overall survival. Now there are ongoing studies to move durvalumab to the concurrent phase of chemotherapy and radiation to see if that will result in added benefits. There are also studies with pembrolizumab, and ipilimumab plus nivolumab, in this setting. So even the stage III disease is seeing finally that we have turned the corner and there are better outcomes for patients.

In small cell lung cancer, the key questions are going to be what effective second-line therapies are there when patients progress on chemotherapy plus checkpoint inhibition. Lurbinectedin is a drug that has demonstrated promising activity in the salvage therapy setting. We hope to see the results of the phase III trial to see whether we will have an effective salvage therapy option when patients progress on a chemotherapy or chemotherapy plus I/O strategy. There are also studies in the limited stage small cell lung cancer setting where I/O agents are being integrated with chemotherapy and radiation to improve the cure rate. So clearly, there are a plethora of exciting studies that build upon the advances made, so we can take the treatment of lung cancer to the next level and hopefully provide longer and better outcomes for our patients.

Transcript Edited for Clarity
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