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Treatment Options for Relapsed Squamous NSCLC

Panelists:Edward S. Kim, MD, FACP, Carolinas HealthCare System; Benjamin Levy, MD, Mount Sinai Hospital; Paul K. Paik, MD, Memorial Sloan Kettering Cancer Center
Published: Wednesday, Apr 13, 2016


Transcript:

Benjamin Levy, MD:
Lastly in this discussion, we’ll talk about options for second-line therapy. [Let’s start with] cytotoxic options for a patient who has progressed either on an induction regimen followed by maintenance or just an induction regimen options on the table. Can we give these patients who have received carboplatin/nab-paclitaxel another taxane? I think there’s data that there is response rates with re-treatment of a different taxane. Are we moving more towards gemcitabine, Navelbine? We’re going to table the checkpoint inhibitors for now, but other options for these patients?

Paul K. Paik, MD: Well, they’re certainly more limited, I think, than lung adenocarcinoma which is the frustrating thing. And, in terms of cytotoxic, we again are limited by what we gave in the first-line setting. So, for someone who’s gotten a taxane doublet in the first-line setting, we’re left with a gemcitabine by itself, some data for gemcitabine/vinorelbine, some people give vinorelbine by itself. So it’s sort of what’s left and then you give it depending on the side effect profile and exactly what that patient looks like. But outside of that there’s not a lot. Platinum, taxane re-challenge can work certainly, from a study that we’re going to talk about in a little bit. On a subset analysis for docetaxel/ramucirumab, there was still a trend towards benefit for patients who had already gotten a taxane before. So certainly these are the options. They’re not very good options which is why, as Ed had said, approval of the first immune checkpoint inhibitor was met with such welcome and applause I think from the community.

Benjamin Levy, MD: Ed, do you?

Edward S. Kim, MD, FACP: Yeah, I think it’s something that an oncologist or a provider team dreads is it’s almost back to the third-line discussion of non-squamous where, okay, you’ve got vinorelbine, gemcitabine, irinotecan, or any of the TKIs. The data is very scant. It’s very loose. We hate that, especially as we brought up the pies earlier and you can subset people. You brought it up earlier that steroids are not required with nab-paclitaxel. That will be a favorable regimen used upfront unless some data just clearly change that with a doublet, because immunotherapies will become so valuable that we don’t want to do anything to try and compromise that. I don’t have any problem using a docetaxel with ramucirumab in those patients who can tolerate it. Erlotinib is certainly an option. After that it gets really dwindly as far as data. Single agent gemcitabine is there, but where’s vinorelbine anymore? Do we even use that drug anymore? It’s got more approvals than a lot of drugs right now.

Paul K. Paik, MD: Right.

Benjamin Levy, MD: Yeah, I think our options are a little bit restricted in this patient population. As you said, I think immunotherapy has completely changed the game where we’re having this conversation about chemotherapy options as third-line. I like you are not afraid to use docetaxel/ramucirumab in a second-line setting for a patient who may not be an immunotherapy candidate or even single agent gemcitabine. I have not used a lot of Navelbine in a long time which I guess is a good thing. I think the more we can talk about not using chemotherapy and using other alternative strategies that are creative like immunotherapy, that’s a very good thing.
                                                                                                                                                                                                                                                                                                               
Transcript Edited for Clarity
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Transcript:

Benjamin Levy, MD:
Lastly in this discussion, we’ll talk about options for second-line therapy. [Let’s start with] cytotoxic options for a patient who has progressed either on an induction regimen followed by maintenance or just an induction regimen options on the table. Can we give these patients who have received carboplatin/nab-paclitaxel another taxane? I think there’s data that there is response rates with re-treatment of a different taxane. Are we moving more towards gemcitabine, Navelbine? We’re going to table the checkpoint inhibitors for now, but other options for these patients?

Paul K. Paik, MD: Well, they’re certainly more limited, I think, than lung adenocarcinoma which is the frustrating thing. And, in terms of cytotoxic, we again are limited by what we gave in the first-line setting. So, for someone who’s gotten a taxane doublet in the first-line setting, we’re left with a gemcitabine by itself, some data for gemcitabine/vinorelbine, some people give vinorelbine by itself. So it’s sort of what’s left and then you give it depending on the side effect profile and exactly what that patient looks like. But outside of that there’s not a lot. Platinum, taxane re-challenge can work certainly, from a study that we’re going to talk about in a little bit. On a subset analysis for docetaxel/ramucirumab, there was still a trend towards benefit for patients who had already gotten a taxane before. So certainly these are the options. They’re not very good options which is why, as Ed had said, approval of the first immune checkpoint inhibitor was met with such welcome and applause I think from the community.

Benjamin Levy, MD: Ed, do you?

Edward S. Kim, MD, FACP: Yeah, I think it’s something that an oncologist or a provider team dreads is it’s almost back to the third-line discussion of non-squamous where, okay, you’ve got vinorelbine, gemcitabine, irinotecan, or any of the TKIs. The data is very scant. It’s very loose. We hate that, especially as we brought up the pies earlier and you can subset people. You brought it up earlier that steroids are not required with nab-paclitaxel. That will be a favorable regimen used upfront unless some data just clearly change that with a doublet, because immunotherapies will become so valuable that we don’t want to do anything to try and compromise that. I don’t have any problem using a docetaxel with ramucirumab in those patients who can tolerate it. Erlotinib is certainly an option. After that it gets really dwindly as far as data. Single agent gemcitabine is there, but where’s vinorelbine anymore? Do we even use that drug anymore? It’s got more approvals than a lot of drugs right now.

Paul K. Paik, MD: Right.

Benjamin Levy, MD: Yeah, I think our options are a little bit restricted in this patient population. As you said, I think immunotherapy has completely changed the game where we’re having this conversation about chemotherapy options as third-line. I like you are not afraid to use docetaxel/ramucirumab in a second-line setting for a patient who may not be an immunotherapy candidate or even single agent gemcitabine. I have not used a lot of Navelbine in a long time which I guess is a good thing. I think the more we can talk about not using chemotherapy and using other alternative strategies that are creative like immunotherapy, that’s a very good thing.
                                                                                                                                                                                                                                                                                                               
Transcript Edited for Clarity
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