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NSCLC Immunotherapy: Transformation of Upfront Therapy

Panelists: Everett Vokes, MD, University of Chicago Medicine and Biological Sciences; Roy Herbst, MD, PhD, Yale Cancer Center; Fred Hirsch, MD, PhD, University of Colorado School of Medicine; Suresh Ramalingam, MD, Winship Cancer Institute Emory University; Naiyer Rizvi, MD, Columbia University Medical Center
Published: Thursday, Sep 28, 2017



Transcript:

Everett Vokes, MD: Hello, and thank you for joining this OncLive® Peer Exchange® titled “Immuno-Oncology in Advanced Lung Cancer.” We continue to see extraordinary progress in the treatment of advanced non–small cell lung cancer, with paradigm-changing research being completed at an astounding rate. In this OncLive® Peer Exchange® discussion, I am joined by some of the world’s leading experts in the use of immune-oncology agents for patients with lung cancer. Together, we will discuss the latest data from The European Society for Medical Oncology (ESMO) 2017 Congress, and explore the nuances of using checkpoint inhibitors in your patients with advanced disease.

I am Everett Vokes, John E. Ultmann professor of medicine, chair in the Department of Medicine, and physician-in-chief at University of Chicago Medicine and Biological Sciences.
Participating today on our distinguished panel are: Dr Roy Herbst, professor of medicine and chief of medical oncology at the Yale Cancer Center in New Haven, Connecticut; Dr Fred Hirsch, professor of medicine and pathology at the University of Colorado School of Medicine in Denver, Colorado, and the CEO of IASLC (International Association for the Study of Lung Cancer); Dr Suresh Ramalingam, professor of hematology and oncology and director of the Division of Medical Oncology at the Winship Cancer Institute at Emory University, in Atlanta, Georgia; and Dr Naiyer Rizvi, professor of medicine and director of Thoracic Oncology at Columbia University Medical Center in New York, New York.

Thank you very much for joining us. We’ll turn to our first segment, which will cover immunotherapy in non–small cell lung cancer and the transformation of upfront management. And here, we’re going to talk very much about the historical perspective—how treatment for non–small cell lung cancer has evolved over the past15, 20 years (from the beginnings where chemotherapy was questionable). Chemotherapy, then, got established—first-line, second-line. And eventually, targeted therapies came along. And now, immunotherapies are coming along. So, as we look at patients who don’t have driver mutations and those who have squamous cell histology, but also others, how do we now look at their treatment? And, how have things changed over the last 5 years?

Suresh Ramalingam, MD: Now we have immunotherapy in the first-line space. Before that (going back about a year on the clock), we had patients with non-squamous histology undergo molecular testing. And if they had a driver mutation (EGFR, ALK, or ROS1), they got targeted therapy. If they did not have a driver mutation, they got platinum-based chemotherapy with or without bevacizumab (for non-squamous disease). In squamous histology, we used platinum-based chemotherapy. Molecular testing in squamous disease was only for those rare patients who were never-smokers (where there’s a possibility of EGFR mutations). For a vast majority of these patients given platinum-based chemotherapy, the targeted option, there, was necitumumab. It’s still approved in the frontline setting, in combination with chemotherapy, for advanced squamous cell disease. This has been the treatment paradigm and, then, patients went on to second-line chemotherapy. Two years ago, we had second-line immunotherapy. Now, of course, we’re going to talk about how immunotherapy is integrated into the first-line setting.

Everett Vokes, MD: Very good. And for that, it is always based on the data that have come out. We should, as we move forward, talk about that a little bit. Is there anything you want to add to that, Naiyer?

Naiyer Rizvi, MD: I think that with chemotherapy, in the era of chemotherapy or even targeted therapy for a patient who had advanced lung cancer, it was really hard to offer them a lot of hope. I think that you had a really finite benefit from these therapies. Everyone developed resistance. I remember the first patient I treated with the PD-1 antibody, nivolumab. He had been multiply pretreated. He showed up in clinic with a painful adrenal mass. It was so painful that, after he got his nivolumab infusion, he had to go to the emergency department for an intravenous pain medication. He woke up and he was pain-free. And now, it’s 8 years later and he still has no evidence of disease. That’s why I think we’re so excited about incorporating immunotherapy into our treatment.

Everett Vokes, MD: I think that’s very correct, and those are stories we never talked about when we were giving chemotherapy. I, very similarly, remember the first patient where I stopped pembrolizumab after 2 years (because that’s how it was written). The drug was still investigational and, of course, you have all the fears of doing that. And yet, it is now, again, 2 or 3 years later and that patient is doing well. So, it’s transformative.

Transcript Edited for Clarity 

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Transcript:

Everett Vokes, MD: Hello, and thank you for joining this OncLive® Peer Exchange® titled “Immuno-Oncology in Advanced Lung Cancer.” We continue to see extraordinary progress in the treatment of advanced non–small cell lung cancer, with paradigm-changing research being completed at an astounding rate. In this OncLive® Peer Exchange® discussion, I am joined by some of the world’s leading experts in the use of immune-oncology agents for patients with lung cancer. Together, we will discuss the latest data from The European Society for Medical Oncology (ESMO) 2017 Congress, and explore the nuances of using checkpoint inhibitors in your patients with advanced disease.

I am Everett Vokes, John E. Ultmann professor of medicine, chair in the Department of Medicine, and physician-in-chief at University of Chicago Medicine and Biological Sciences.
Participating today on our distinguished panel are: Dr Roy Herbst, professor of medicine and chief of medical oncology at the Yale Cancer Center in New Haven, Connecticut; Dr Fred Hirsch, professor of medicine and pathology at the University of Colorado School of Medicine in Denver, Colorado, and the CEO of IASLC (International Association for the Study of Lung Cancer); Dr Suresh Ramalingam, professor of hematology and oncology and director of the Division of Medical Oncology at the Winship Cancer Institute at Emory University, in Atlanta, Georgia; and Dr Naiyer Rizvi, professor of medicine and director of Thoracic Oncology at Columbia University Medical Center in New York, New York.

Thank you very much for joining us. We’ll turn to our first segment, which will cover immunotherapy in non–small cell lung cancer and the transformation of upfront management. And here, we’re going to talk very much about the historical perspective—how treatment for non–small cell lung cancer has evolved over the past15, 20 years (from the beginnings where chemotherapy was questionable). Chemotherapy, then, got established—first-line, second-line. And eventually, targeted therapies came along. And now, immunotherapies are coming along. So, as we look at patients who don’t have driver mutations and those who have squamous cell histology, but also others, how do we now look at their treatment? And, how have things changed over the last 5 years?

Suresh Ramalingam, MD: Now we have immunotherapy in the first-line space. Before that (going back about a year on the clock), we had patients with non-squamous histology undergo molecular testing. And if they had a driver mutation (EGFR, ALK, or ROS1), they got targeted therapy. If they did not have a driver mutation, they got platinum-based chemotherapy with or without bevacizumab (for non-squamous disease). In squamous histology, we used platinum-based chemotherapy. Molecular testing in squamous disease was only for those rare patients who were never-smokers (where there’s a possibility of EGFR mutations). For a vast majority of these patients given platinum-based chemotherapy, the targeted option, there, was necitumumab. It’s still approved in the frontline setting, in combination with chemotherapy, for advanced squamous cell disease. This has been the treatment paradigm and, then, patients went on to second-line chemotherapy. Two years ago, we had second-line immunotherapy. Now, of course, we’re going to talk about how immunotherapy is integrated into the first-line setting.

Everett Vokes, MD: Very good. And for that, it is always based on the data that have come out. We should, as we move forward, talk about that a little bit. Is there anything you want to add to that, Naiyer?

Naiyer Rizvi, MD: I think that with chemotherapy, in the era of chemotherapy or even targeted therapy for a patient who had advanced lung cancer, it was really hard to offer them a lot of hope. I think that you had a really finite benefit from these therapies. Everyone developed resistance. I remember the first patient I treated with the PD-1 antibody, nivolumab. He had been multiply pretreated. He showed up in clinic with a painful adrenal mass. It was so painful that, after he got his nivolumab infusion, he had to go to the emergency department for an intravenous pain medication. He woke up and he was pain-free. And now, it’s 8 years later and he still has no evidence of disease. That’s why I think we’re so excited about incorporating immunotherapy into our treatment.

Everett Vokes, MD: I think that’s very correct, and those are stories we never talked about when we were giving chemotherapy. I, very similarly, remember the first patient where I stopped pembrolizumab after 2 years (because that’s how it was written). The drug was still investigational and, of course, you have all the fears of doing that. And yet, it is now, again, 2 or 3 years later and that patient is doing well. So, it’s transformative.

Transcript Edited for Clarity 
View Conference Coverage
Online CME Activities
TitleExpiration DateCME Credits
Community Practice Connections™: 18th Annual International Lung Cancer Congress®Oct 31, 20181.5
Clinical Interchange™: Translating Research to Inform Changing Paradigms: Assessment of Emerging Immuno-Oncology Strategies and Combinations across Lung, Head and Neck, and Bladder CancersOct 31, 20182.0
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