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Immunotherapy in Lung Cancer

Panelists: Mark A. Socinski, MD, AdventHealth Cancer Institute; Paul K. Paik, MD, Memorial Sloan Kettering Cancer Center; Kristin Higgins, MD, Emory Healthcare; Corey J. Langer, MD, Hospital of the University of Pennsylvania; Heather A. Wakelee, MD, Stanford University Medical Center; Ticiana A. Leal, MD, University of Wisconsin School of Medicine and Public Health
Published: Wednesday, Aug 07, 2019



Transcript: 

Mark A. Socinski, MD: Well, guys, this has been an extremely robust discussion. It has been very informative. What I want to do in the few minutes that we have before we have to end our discussion is go around and get some final thoughts. Paul, for the audience, can you provide some parting wisdom for them about the management of lung cancer in the current era?

Paul K. Paik, MD I think it is quite impressive how quickly things have changed. Certainly, since I began looking at lung cancer as a Fellow, but even as an attending within the past few years, it is impressive just how quickly the field has shifted. The first immunotherapy, nivolumab, was approved for squamous cell back in 2015, and now there is this wave of monotherapy and combination therapy trials in the early stage space, which has given us a lot of gains and things to chase after. As much as we have done some measured criticizing of things, that’s against that backdrop of the enormous amount of progress that we’ve made in this very short period of time. So I remain sort of over-the-moon optimistic about where we’re going, particularly as we work hand-in-hand with our surgeons and radiation oncologists. It’s another era now, where we’re working much more closely with our colleagues who have really pushed things forward. That’s another reason why I’m pretty optimistic.

Mark A. Socinski, MD: Heather?

Heather A. Wakelee, MD: I share Paul’s enthusiasm, and I’m going to put a plug in to make sure that we’re remembering to do the testing up front for our patients and not get too swept up in the immunotherapy enthusiasm that we don’t provide the right care for our patients who do have the driver mutations. As that list keeps growing, the key driver mutations where we can act differently for our patients if we know about them, I’m just going to mention that. And don’t jump as soon as you get that PD-L1 [programmed death-ligand 1] level. Get that mutation testing result back, and then we can carefully craft the best treatment for each of our patients. But, yes, there is so much happening. It’s really exciting.

Mark A. Socinski, MD: Paul made me remember that when I think Corey and I started in lung cancer, we used to argue as to whether lung cancer was even treatable.

Corey J. Langer, MD: We had debates of that sort.

Mark A. Socinski, MD: Yes, and I can show you editorials written in the early 1990s, some of them by current lung cancer thought leaders. And we had this rash of trials against best supportive care. And so, that’s what I remember. And to your point, the progress seen is exponential in our understanding. Ticiana?

Ticiana A. Leal, MD: I’ll echo what the panelists have said so far. I would add really understanding better how to manage immune-related adverse events. I think we’re extrapolating the data and how to manage that from what we’ve seen in other diseases. But really, how do we manage immune-mediated pneumonitis? What is the best way to approach immune-related myocarditis? These are severe toxicities that are becoming increasingly common because we’re treating more patients. So certainly, I think there needs to be more efforts in that, in educating patients and making sure that we really focus on how to optimize that management.

Mark A. Socinski, MD: Kristin?

Kristin Higgins, MD: I would say multidisciplinary care is best, and we can do more when we work together.

Corey J. Langer, MD: And I echo what everybody else has said. By the way, that was firmly debated exactly 25 years ago. Should we treat advanced lung cancer? Now we’re talking about first-, second-, third-, and even fourth- and fifth-line treatments. I think it’s critically important that we export the benefits we’ve seen in advanced disease to the curative setting. And I’m personally enthused about both the neoadjuvant and the conventional adjuvant trials. The majority of these patients still get surgery up front. ANVIL is accruing like gangbusters, comparing nivolumab to observation, to the point that we have to actively plan the successor trial because it’s ahead of schedule. That’s probably the component of the ALCHEMIST trial that’s ultimately going to save ALCHEMIST. We need to compare concurrent and consolidative versus consolidative in locally advanced disease. And maybe you can work on this, Heather. We need expedited mutation testing. Thirty bucks in 30 minutes is what I’ve heard. Some sort of liquid assay, and they’re getting better and better.

Heather A. Wakelee, MD: Yes, they are.

Corey J. Langer, MD: Granted, their sensitivity isn’t as good as their specificity. But the faster we know the answer, the better off we’ll be and the better off the patients are. It is so frustrating dealing with these constant phone calls. “When is my mutation testing going to be back? Should I start the checkpoint inhibitor? Should I wait?”

Heather A. Wakelee, MD: It’s a tough one, yes.

Corey J. Langer, MD: It wasn’t an issue in the past, but it’s a major issue now.

Mark A. Socinski, MD: Well, thank you all for your contributions. This has been fantastic. On behalf of our panel, we thank you for joining us, and we hope you found this Peer Exchange discussion to be useful and informative.

Transcript Edited for Clarity

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Transcript: 

Mark A. Socinski, MD: Well, guys, this has been an extremely robust discussion. It has been very informative. What I want to do in the few minutes that we have before we have to end our discussion is go around and get some final thoughts. Paul, for the audience, can you provide some parting wisdom for them about the management of lung cancer in the current era?

Paul K. Paik, MD I think it is quite impressive how quickly things have changed. Certainly, since I began looking at lung cancer as a Fellow, but even as an attending within the past few years, it is impressive just how quickly the field has shifted. The first immunotherapy, nivolumab, was approved for squamous cell back in 2015, and now there is this wave of monotherapy and combination therapy trials in the early stage space, which has given us a lot of gains and things to chase after. As much as we have done some measured criticizing of things, that’s against that backdrop of the enormous amount of progress that we’ve made in this very short period of time. So I remain sort of over-the-moon optimistic about where we’re going, particularly as we work hand-in-hand with our surgeons and radiation oncologists. It’s another era now, where we’re working much more closely with our colleagues who have really pushed things forward. That’s another reason why I’m pretty optimistic.

Mark A. Socinski, MD: Heather?

Heather A. Wakelee, MD: I share Paul’s enthusiasm, and I’m going to put a plug in to make sure that we’re remembering to do the testing up front for our patients and not get too swept up in the immunotherapy enthusiasm that we don’t provide the right care for our patients who do have the driver mutations. As that list keeps growing, the key driver mutations where we can act differently for our patients if we know about them, I’m just going to mention that. And don’t jump as soon as you get that PD-L1 [programmed death-ligand 1] level. Get that mutation testing result back, and then we can carefully craft the best treatment for each of our patients. But, yes, there is so much happening. It’s really exciting.

Mark A. Socinski, MD: Paul made me remember that when I think Corey and I started in lung cancer, we used to argue as to whether lung cancer was even treatable.

Corey J. Langer, MD: We had debates of that sort.

Mark A. Socinski, MD: Yes, and I can show you editorials written in the early 1990s, some of them by current lung cancer thought leaders. And we had this rash of trials against best supportive care. And so, that’s what I remember. And to your point, the progress seen is exponential in our understanding. Ticiana?

Ticiana A. Leal, MD: I’ll echo what the panelists have said so far. I would add really understanding better how to manage immune-related adverse events. I think we’re extrapolating the data and how to manage that from what we’ve seen in other diseases. But really, how do we manage immune-mediated pneumonitis? What is the best way to approach immune-related myocarditis? These are severe toxicities that are becoming increasingly common because we’re treating more patients. So certainly, I think there needs to be more efforts in that, in educating patients and making sure that we really focus on how to optimize that management.

Mark A. Socinski, MD: Kristin?

Kristin Higgins, MD: I would say multidisciplinary care is best, and we can do more when we work together.

Corey J. Langer, MD: And I echo what everybody else has said. By the way, that was firmly debated exactly 25 years ago. Should we treat advanced lung cancer? Now we’re talking about first-, second-, third-, and even fourth- and fifth-line treatments. I think it’s critically important that we export the benefits we’ve seen in advanced disease to the curative setting. And I’m personally enthused about both the neoadjuvant and the conventional adjuvant trials. The majority of these patients still get surgery up front. ANVIL is accruing like gangbusters, comparing nivolumab to observation, to the point that we have to actively plan the successor trial because it’s ahead of schedule. That’s probably the component of the ALCHEMIST trial that’s ultimately going to save ALCHEMIST. We need to compare concurrent and consolidative versus consolidative in locally advanced disease. And maybe you can work on this, Heather. We need expedited mutation testing. Thirty bucks in 30 minutes is what I’ve heard. Some sort of liquid assay, and they’re getting better and better.

Heather A. Wakelee, MD: Yes, they are.

Corey J. Langer, MD: Granted, their sensitivity isn’t as good as their specificity. But the faster we know the answer, the better off we’ll be and the better off the patients are. It is so frustrating dealing with these constant phone calls. “When is my mutation testing going to be back? Should I start the checkpoint inhibitor? Should I wait?”

Heather A. Wakelee, MD: It’s a tough one, yes.

Corey J. Langer, MD: It wasn’t an issue in the past, but it’s a major issue now.

Mark A. Socinski, MD: Well, thank you all for your contributions. This has been fantastic. On behalf of our panel, we thank you for joining us, and we hope you found this Peer Exchange discussion to be useful and informative.

Transcript Edited for Clarity
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Online CME Activities
TitleExpiration DateCME Credits
Advances in™ Therapies for Patients With ALK-Positive Lung Cancers: More Options…More Decisions…Better OutcomesAug 30, 20191.5
Oncology Briefings™: Treating Advanced NSCLC Without Actionable MutationsAug 30, 20191.0
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