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Important Long-Term Considerations in Lung Cancer

Panelists: Gerald J. Berry, MD, Stanford University; David Spigel, MD, Sarah Cannon Research Institute; Heather Wakelee, MD, Stanford University; Anne S. Tsao, MD, MD Anderson Cancer Center
Published: Monday, Jun 26, 2017


Transcript:

David Spigel, MD:
When you’re designing a therapy for a patient, you tend to think, what will I give first and what could I give later as a second- or third-line option? You always want to use your best therapies first because you never know what will happen. You might think, “Oh, I’ll just use immunotherapy as my next line of therapy,” but we know that a lot of our patients—maybe 40%—never make it to that next line of therapy.

In nonsquamous non–small cell lung cancer, in the first-line setting these days, we tend to think about immunotherapy as an option. Is a patient a candidate for that? Can I give, for example, pembrolizumab alone as a first-line option knowing that chemotherapy would be a next line of therapy for that patient? For squamous non–small cell lung cancer, immunotherapy is still an option up front.

We don’t have the same kinds of options in terms of targeted options that we think about in our nonsquamous patients, like EGFR, ALK, and ROS inhibitors, so our options really come down to immunotherapy or chemotherapy first. And we may be finding out in the next year that chemotherapy and immunotherapy make sense in the first-line setting. The bottom line is that when you’re designing somebody’s first-line therapy, you always want to use the best therapy you have for the patient and not save therapies for later lines, because you may never get there.

Gerald J. Berry, MD: The indications for therapy and the determination of therapies for advanced lung cancer are obviously going to depend on stage. Whether it’s a combined therapy with radiation therapy or chemotherapy alone, whether you’re introducing the immunotherapies up front or they’re considered as a second-line therapy—all those decisions, I think, are based primarily on stage. They’re really based on the patient’s condition: can they tolerate one or more of these therapies?

And I think, importantly, they’re also going to be based on—in many cases, if not all cases—determinations in a multidisciplinary tumor board, where all the information is available and the input from all different specialties—surgical, radiologic, radiation oncology/pathology, medical oncology—can combine to provide the best therapeutic options for the patient.

Anne S. Tsao, MD: It’s actually very important to manage the side effects in our patients because it enables them to stay on treatments longer. If you don’t do that, then, very commonly, you encounter dose reductions or dose delays and that’s pretty suboptimal for the patients’ treatments. So, it’s important to bear that in mind and to educate the patients so that they know what to anticipate and so that they report these toxicities early enough where you can treat them quickly.

Heather Wakelee, MD: Quality of life has always been a really key component of cancer treatment. Whenever I’m talking with my patients, we talk about how everything that we’re doing is either going to be focusing on helping them live longer or helping them live better, ideally doing both at the same time. And so, as we have had more and more improvements in outcome, more people living longer, we are paying even more attention to side effects of treatment that could be debilitating and to working with patients to make sure that they’re able to enjoy life as much as possible.

Transcript Edited for Clarity
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Transcript:

David Spigel, MD:
When you’re designing a therapy for a patient, you tend to think, what will I give first and what could I give later as a second- or third-line option? You always want to use your best therapies first because you never know what will happen. You might think, “Oh, I’ll just use immunotherapy as my next line of therapy,” but we know that a lot of our patients—maybe 40%—never make it to that next line of therapy.

In nonsquamous non–small cell lung cancer, in the first-line setting these days, we tend to think about immunotherapy as an option. Is a patient a candidate for that? Can I give, for example, pembrolizumab alone as a first-line option knowing that chemotherapy would be a next line of therapy for that patient? For squamous non–small cell lung cancer, immunotherapy is still an option up front.

We don’t have the same kinds of options in terms of targeted options that we think about in our nonsquamous patients, like EGFR, ALK, and ROS inhibitors, so our options really come down to immunotherapy or chemotherapy first. And we may be finding out in the next year that chemotherapy and immunotherapy make sense in the first-line setting. The bottom line is that when you’re designing somebody’s first-line therapy, you always want to use the best therapy you have for the patient and not save therapies for later lines, because you may never get there.

Gerald J. Berry, MD: The indications for therapy and the determination of therapies for advanced lung cancer are obviously going to depend on stage. Whether it’s a combined therapy with radiation therapy or chemotherapy alone, whether you’re introducing the immunotherapies up front or they’re considered as a second-line therapy—all those decisions, I think, are based primarily on stage. They’re really based on the patient’s condition: can they tolerate one or more of these therapies?

And I think, importantly, they’re also going to be based on—in many cases, if not all cases—determinations in a multidisciplinary tumor board, where all the information is available and the input from all different specialties—surgical, radiologic, radiation oncology/pathology, medical oncology—can combine to provide the best therapeutic options for the patient.

Anne S. Tsao, MD: It’s actually very important to manage the side effects in our patients because it enables them to stay on treatments longer. If you don’t do that, then, very commonly, you encounter dose reductions or dose delays and that’s pretty suboptimal for the patients’ treatments. So, it’s important to bear that in mind and to educate the patients so that they know what to anticipate and so that they report these toxicities early enough where you can treat them quickly.

Heather Wakelee, MD: Quality of life has always been a really key component of cancer treatment. Whenever I’m talking with my patients, we talk about how everything that we’re doing is either going to be focusing on helping them live longer or helping them live better, ideally doing both at the same time. And so, as we have had more and more improvements in outcome, more people living longer, we are paying even more attention to side effects of treatment that could be debilitating and to working with patients to make sure that they’re able to enjoy life as much as possible.

Transcript Edited for Clarity
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