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Initial Treatment Approach 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: Thursday, Jun 22, 2017


Transcript:

Heather Wakelee, MD:
When I’m meeting a patient who has just been diagnosed with metastatic lung cancer, I talk with them about the fact that there are really 3 different strategies for therapy. The standard remains chemotherapy, usually with a platinum doublet, but we’re also going to be thinking about whether or not the patient might be better served by molecularly targeted treatment or by immunotherapy. The decision between those 3 strategies really has to do with testing the tumor.

So, we need to learn about the PD-L1 level with a 22C3 assay test to figure out if immunotherapy with pembrolizumab versus chemotherapy might be better. We also need to get the molecular test results, especially thinking about the EGFR, ALK and ROS mutations, because if we find any of those driver mutations, going after them will be our first strategy. Those are really the key things that we’re thinking about.

And then, if we decide that the patient is going to be a candidate for 1 of those 3 treatments, we’re making sure that there’s no reason they shouldn’t get treated with it. So, if someone has a bad autoimmune disease—even if they do have a high PD-L1 expression level—we’re not going to recommend immunotherapy or there might be reasons that standard chemotherapy wouldn’t be appropriate. But excluding those folks—who are a rare percentage—we’re going to be focusing on chemotherapy, if there’s no reason to do anything else; immunotherapy, if there’s a high PD-L1 expression; or molecularly targeted therapy, if the patient’s tumor has a reasonable molecular target.

Anne S. Tsao, MD: When a patient has nonsquamous non–small cell lung cancer, for their frontline treatment, we have to do genetic profiling. So, if they have an EGFR mutation, they get an EGFR TKI as frontline therapy. If they have an ALK mutation, then they would get an appropriate ALK inhibitor—right now, it’s crizotinib, but it could potentially be ceritinib or alectinib. For our patients who don’t have a mutation—that is, a driver mutation that we’d put on a trial—you want to consider giving systemic chemotherapy or, if they have high PD-L1 expression over 50%, then we usually recommend doing immunotherapy with pembrolizumab.

David Spigel, MD: There are several goals of treatment in the first-line setting. Often, your patients have symptoms—they feel bad or are having trouble breathing—and one immediate goal is just to relieve those symptoms. Can you get the disease to respond, to shrink, so you can ease pain, improve breathing, and sometimes help the patient get out of the hospital? That’s a very important goal. We talk a lot about increasing survival. We do things to try to keep people alive longer, and that’s a very important goal. Although I always tell patients, if we’re unsuccessful in doing that, if we can at least keep them alive where they’re living well, where their symptoms aren’t advanced or they’ve regressed—hopefully, we can add life or days to their lives—at a minimum, if we can at least control symptoms and improve the quality of their life, I think that’s a very worthwhile goal.

These are all important things to discuss with patients up front, when sometimes they’re not sure why we’re even doing treatment—“I thought I heard lung cancer is not a treatable cancer.” And so, it’s important to express this message: “We can get you to feel better, we can make the time you have better for you, and we can extend your life.” Those are all important goals that are meaningful for patients and their families.

Transcript Edited for Clarity
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Transcript:

Heather Wakelee, MD:
When I’m meeting a patient who has just been diagnosed with metastatic lung cancer, I talk with them about the fact that there are really 3 different strategies for therapy. The standard remains chemotherapy, usually with a platinum doublet, but we’re also going to be thinking about whether or not the patient might be better served by molecularly targeted treatment or by immunotherapy. The decision between those 3 strategies really has to do with testing the tumor.

So, we need to learn about the PD-L1 level with a 22C3 assay test to figure out if immunotherapy with pembrolizumab versus chemotherapy might be better. We also need to get the molecular test results, especially thinking about the EGFR, ALK and ROS mutations, because if we find any of those driver mutations, going after them will be our first strategy. Those are really the key things that we’re thinking about.

And then, if we decide that the patient is going to be a candidate for 1 of those 3 treatments, we’re making sure that there’s no reason they shouldn’t get treated with it. So, if someone has a bad autoimmune disease—even if they do have a high PD-L1 expression level—we’re not going to recommend immunotherapy or there might be reasons that standard chemotherapy wouldn’t be appropriate. But excluding those folks—who are a rare percentage—we’re going to be focusing on chemotherapy, if there’s no reason to do anything else; immunotherapy, if there’s a high PD-L1 expression; or molecularly targeted therapy, if the patient’s tumor has a reasonable molecular target.

Anne S. Tsao, MD: When a patient has nonsquamous non–small cell lung cancer, for their frontline treatment, we have to do genetic profiling. So, if they have an EGFR mutation, they get an EGFR TKI as frontline therapy. If they have an ALK mutation, then they would get an appropriate ALK inhibitor—right now, it’s crizotinib, but it could potentially be ceritinib or alectinib. For our patients who don’t have a mutation—that is, a driver mutation that we’d put on a trial—you want to consider giving systemic chemotherapy or, if they have high PD-L1 expression over 50%, then we usually recommend doing immunotherapy with pembrolizumab.

David Spigel, MD: There are several goals of treatment in the first-line setting. Often, your patients have symptoms—they feel bad or are having trouble breathing—and one immediate goal is just to relieve those symptoms. Can you get the disease to respond, to shrink, so you can ease pain, improve breathing, and sometimes help the patient get out of the hospital? That’s a very important goal. We talk a lot about increasing survival. We do things to try to keep people alive longer, and that’s a very important goal. Although I always tell patients, if we’re unsuccessful in doing that, if we can at least keep them alive where they’re living well, where their symptoms aren’t advanced or they’ve regressed—hopefully, we can add life or days to their lives—at a minimum, if we can at least control symptoms and improve the quality of their life, I think that’s a very worthwhile goal.

These are all important things to discuss with patients up front, when sometimes they’re not sure why we’re even doing treatment—“I thought I heard lung cancer is not a treatable cancer.” And so, it’s important to express this message: “We can get you to feel better, we can make the time you have better for you, and we can extend your life.” Those are all important goals that are meaningful for patients and their families.

Transcript Edited for Clarity
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