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Imaging Schedule Following CRT in Locally Advanced NSCLC

Panelists: Mark A. Socinski, MD, Advent Health Cancer Institute; John V. Heymach, MD, PhD, MD Anderson Cancer Center; Leora Horn, MD, MSc, FRCPC, Vanderbilt University Medical Center; Mohammad Jahanzeb, MD, University of Miami Health System; Heather A. Wakelee, MD, Stanford University Medical Center; Jarushka Naidoo, MBBCh, Sidney Kimmel Cancer Center
Published: Monday, Mar 04, 2019



Transcript:

Mark A. Socinski, MD: So, Leora, we’ve talked about PACIFIC, we all agree that it’s changed the standard of care. How’s it changed your practice? I know patients need to be randomized within 6 weeks, that kind of changes how do you document lack of progression, all those sorts of issues that are now new since the results of the PACIFIC data?

Leora Horn, MD, MSc, FRCPC: So it’s amazing how often you have to argue with a company that this patient does need a CT [computed tomography] scan even though they had one 7 weeks ago. So we do a CT scan just the day or a few days before we’re starting them on durvalumab. So after they’ve done concurrent chemoradiation therapy, we’ll get a CT scan, bring them in, and assuming we do not see progression, we explain we’re not looking for a response because it’s early. We used to wait a few months before we did a scan that we’re going to get going with durvalumab. I think the other thing that has changed in practice is what do you do if you’re giving carbo/Taxol [carboplatin/paclitaxel]? Because a lot of patients were getting weekly carbo/Taxol followed by a consolidation, and that was not allowed in PACIFIC. So granted those are often the less fit patients who you couldn’t give cisplatin and etoposide, which has always been a preferred treatment. So there are a significant number of patients who we are giving weekly carbo/Taxol and potentially foregoing consolidation carbo/Taxol and starting those patients on durvalumab.

Mark A. Socinski, MD: I have a solution to that. I give it as induction.

Leora Horn, MD, MSc, FRCPC: Yes.

Mark A. Socinski, MD: Which 28% of the people on PACIFIC had induction therapy, so I think that’s a reasonable strategy. In the initial design of PACIFIC they were supposed to be randomized within 2 weeks of completing [chemoradiation]. But that got changed to 6 weeks because of the obvious accrual issues that were ongoing. There are some data from that analysis suggesting that starting it earlier is better. I have 2 questions: Do you believe that? And secondly, does that change your management strategy during chemoradiotherapy that you want to be more aggressive in managing esophagitis so they’re in better shape, they recover faster, and all those sorts of things? Or, what are your thoughts there?

Leora Horn, MD, MSc, FRCPC: I think it’s hard to manage not only the esophagitis but the fact that people are fairly beat up after 6 weeks of concurrent chemoradiation. So, we talk to people that there were data that potentially starting earlier is better. Who knows if it’s because of the radiation, and so you get more of that abscopal effect, or who knows if it was those patients who started early were just the better actors.

Mark A. Socinski, MD: Better patients.

Leora Horn, MD, MSc, FRCPC: So they were going to have a better prognosis regardless. We do try to start within 2 to 4 weeks. There’s also been patients who at 6 weeks aren’t quite ready, and a week or 2 later we’re starting durvalumab. So it can swing with both extremes. But I have found that most patients within 2 to 4 weeks we are able to start them on their durvalumab.

Mohammad Jahanzeb, MD: The only other thing to point out is the schedule, since the schedule is more inconvenient compared to other immunotherapy drugs. I’m actually curious to know what my colleagues think about Q4 [every 4 weeks] delivery; would you be comfortable with that?

Mark A. Socinski, MD: I haven’t done that; in my practice I haven’t had a lot of pushback about the every-2-week schedule. I know we are opening a trial of looking at durvalumab after SBRT [stereotactic body radiation therapy] in those stage I medically inoperable patients, and there the schedule is every 4.

Mohammad Jahanzeb, MD: It’s double dose every 4?

Mark A. Socinski, MD: Yes. So I do think that adds a convenience. But I haven’t gotten much pushback on the schedule.

Jarushka Naidoo, MBBCh: No.

Leora Horn, MD, MSc, FRCPC: We only see them once a month.

Jarushka Naidoo, MBBCh: Perhaps the Maryland patients are a little bit different. We have gotten a little bit of pushback about that. And we’ve opened a trial actually through the Big Ten [Cancer Research Consortium], or Hoosier Oncology Group, which looks at just 6 months of even NIVO [nivolumab], and NIVO/IPI [ipilimumab] where the NIVO is every Q4 weekly. And actually the schedule has been the reason why some people have preferred that.

John V. Heymach, MD, PhD: I think the traffic is worse in Maryland.

Transcript Edited for Clarity

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Transcript:

Mark A. Socinski, MD: So, Leora, we’ve talked about PACIFIC, we all agree that it’s changed the standard of care. How’s it changed your practice? I know patients need to be randomized within 6 weeks, that kind of changes how do you document lack of progression, all those sorts of issues that are now new since the results of the PACIFIC data?

Leora Horn, MD, MSc, FRCPC: So it’s amazing how often you have to argue with a company that this patient does need a CT [computed tomography] scan even though they had one 7 weeks ago. So we do a CT scan just the day or a few days before we’re starting them on durvalumab. So after they’ve done concurrent chemoradiation therapy, we’ll get a CT scan, bring them in, and assuming we do not see progression, we explain we’re not looking for a response because it’s early. We used to wait a few months before we did a scan that we’re going to get going with durvalumab. I think the other thing that has changed in practice is what do you do if you’re giving carbo/Taxol [carboplatin/paclitaxel]? Because a lot of patients were getting weekly carbo/Taxol followed by a consolidation, and that was not allowed in PACIFIC. So granted those are often the less fit patients who you couldn’t give cisplatin and etoposide, which has always been a preferred treatment. So there are a significant number of patients who we are giving weekly carbo/Taxol and potentially foregoing consolidation carbo/Taxol and starting those patients on durvalumab.

Mark A. Socinski, MD: I have a solution to that. I give it as induction.

Leora Horn, MD, MSc, FRCPC: Yes.

Mark A. Socinski, MD: Which 28% of the people on PACIFIC had induction therapy, so I think that’s a reasonable strategy. In the initial design of PACIFIC they were supposed to be randomized within 2 weeks of completing [chemoradiation]. But that got changed to 6 weeks because of the obvious accrual issues that were ongoing. There are some data from that analysis suggesting that starting it earlier is better. I have 2 questions: Do you believe that? And secondly, does that change your management strategy during chemoradiotherapy that you want to be more aggressive in managing esophagitis so they’re in better shape, they recover faster, and all those sorts of things? Or, what are your thoughts there?

Leora Horn, MD, MSc, FRCPC: I think it’s hard to manage not only the esophagitis but the fact that people are fairly beat up after 6 weeks of concurrent chemoradiation. So, we talk to people that there were data that potentially starting earlier is better. Who knows if it’s because of the radiation, and so you get more of that abscopal effect, or who knows if it was those patients who started early were just the better actors.

Mark A. Socinski, MD: Better patients.

Leora Horn, MD, MSc, FRCPC: So they were going to have a better prognosis regardless. We do try to start within 2 to 4 weeks. There’s also been patients who at 6 weeks aren’t quite ready, and a week or 2 later we’re starting durvalumab. So it can swing with both extremes. But I have found that most patients within 2 to 4 weeks we are able to start them on their durvalumab.

Mohammad Jahanzeb, MD: The only other thing to point out is the schedule, since the schedule is more inconvenient compared to other immunotherapy drugs. I’m actually curious to know what my colleagues think about Q4 [every 4 weeks] delivery; would you be comfortable with that?

Mark A. Socinski, MD: I haven’t done that; in my practice I haven’t had a lot of pushback about the every-2-week schedule. I know we are opening a trial of looking at durvalumab after SBRT [stereotactic body radiation therapy] in those stage I medically inoperable patients, and there the schedule is every 4.

Mohammad Jahanzeb, MD: It’s double dose every 4?

Mark A. Socinski, MD: Yes. So I do think that adds a convenience. But I haven’t gotten much pushback on the schedule.

Jarushka Naidoo, MBBCh: No.

Leora Horn, MD, MSc, FRCPC: We only see them once a month.

Jarushka Naidoo, MBBCh: Perhaps the Maryland patients are a little bit different. We have gotten a little bit of pushback about that. And we’ve opened a trial actually through the Big Ten [Cancer Research Consortium], or Hoosier Oncology Group, which looks at just 6 months of even NIVO [nivolumab], and NIVO/IPI [ipilimumab] where the NIVO is every Q4 weekly. And actually the schedule has been the reason why some people have preferred that.

John V. Heymach, MD, PhD: I think the traffic is worse in Maryland.

Transcript Edited for Clarity
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