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Adjuvant Versus Neoadjuvant Therapy in NSCLC

Panelists: Mark A. Socinski, MD, Florida Hospital Cancer Institute; Karen Kelly, MD, UC Davis Comprehensive Cancer Center; Corey J. Langer, MD, FACP, University of Pennsylvania; Benjamin P. Levy, MD, Sibley Memorial Hospital
Published: Monday, Aug 06, 2018



Transcript: 

Corey J. Langer, MD, FACP: How long would you be willing to wait to do the surgery?

Karen Kelly, MD: In the Cooperative Group SWOG trial, we waited for 2 to 3 cycles. So, there’s precedence for that—2 to 3 cycles of therapy. I think 3 cycles would probably be the most that you would wait. Neoadjuvant trials are challenging, right? We don’t see patients first.

Benjamin P. Levy, MD: Surgery buy-in.

Karen Kelly, MD: It takes a lot of surgery buy-in here. If we can’t complete a neoadjuvant trial in a timely manner with immunotherapy, we’ll never complete a neoadjuvant trial.

Mark A. Socinski, MD: When you think about it, though, it is impressive. The first nivolumab option was approved just 3 years ago in lung cancer, and so we’ve moved it from second line, or immunotherapy in general, to the first-line setting. There are all of these controversies—now in stage 3 disease, as well—and we have a plethora of trials going on in the adjuvant and neoadjuvant settings. That speaks to the collaboration between academia and industry in the community to advance non–small cell lung cancer with this new paradigm of immunotherapy. I think it’s wonderful.

Benjamin P. Levy, MD: If you would had told me that this was going to be happening 5 years ago, I would have said that there was absolutely no way.

Mark A. Socinski, MD: In this time span.

Benjamin P. Levy, MD: Yes, in this time span, to see an improvement in survival in the frontline for all patients, in combination with chemotherapy.

Mark A. Socinski, MD: Right.

Benjamin P. Levy, MD: Post radiation. And now we are seeing some of the signals in early-stage disease. I get excited about the perioperative and adjuvant immunotherapy trials, and that excitement often gets tempered by what we’ve learned so far for targeted therapies, for a specific genotype, for second-line cancer. We had a Chinese study last year that showed no difference in adjuvant TKI therapy versus chemotherapy in terms of overall survival. That’s the right genotype with a targeted therapy. But I hope things are different here. We’re batting much higher rates than we ever were, in terms of home runs. It’s an incredibly new world.

Corey J. Langer, MD, FACP: I don’t think I’ve ever been to an ASCO Annual Meeting where we have had so many positive trials.

Karen Kelly, MD: But I do think, again, that there are still knowledge gaps in immunotherapy. Remember, gap No. 1—we’re talking about performance status 0 to 1. Other patient groups deserve an opportunity to see these great drugs, and we need to do studies for those settings, as well. Also, not every patient can be operated on. SBRT is another area that I am personally interested in—in combining SBRT with immunotherapy. We have an ongoing trial that is looking very promising.

I just wanted to remind people that all patients really should have an opportunity. These drugs, for the most part, are so well tolerated. We have to think about the entire patient population. Remember, across the board, there are still many patients who, unfortunately, do not get treated. That is a sad but real fact.

Transcript Edited for Clarity 

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Transcript: 

Corey J. Langer, MD, FACP: How long would you be willing to wait to do the surgery?

Karen Kelly, MD: In the Cooperative Group SWOG trial, we waited for 2 to 3 cycles. So, there’s precedence for that—2 to 3 cycles of therapy. I think 3 cycles would probably be the most that you would wait. Neoadjuvant trials are challenging, right? We don’t see patients first.

Benjamin P. Levy, MD: Surgery buy-in.

Karen Kelly, MD: It takes a lot of surgery buy-in here. If we can’t complete a neoadjuvant trial in a timely manner with immunotherapy, we’ll never complete a neoadjuvant trial.

Mark A. Socinski, MD: When you think about it, though, it is impressive. The first nivolumab option was approved just 3 years ago in lung cancer, and so we’ve moved it from second line, or immunotherapy in general, to the first-line setting. There are all of these controversies—now in stage 3 disease, as well—and we have a plethora of trials going on in the adjuvant and neoadjuvant settings. That speaks to the collaboration between academia and industry in the community to advance non–small cell lung cancer with this new paradigm of immunotherapy. I think it’s wonderful.

Benjamin P. Levy, MD: If you would had told me that this was going to be happening 5 years ago, I would have said that there was absolutely no way.

Mark A. Socinski, MD: In this time span.

Benjamin P. Levy, MD: Yes, in this time span, to see an improvement in survival in the frontline for all patients, in combination with chemotherapy.

Mark A. Socinski, MD: Right.

Benjamin P. Levy, MD: Post radiation. And now we are seeing some of the signals in early-stage disease. I get excited about the perioperative and adjuvant immunotherapy trials, and that excitement often gets tempered by what we’ve learned so far for targeted therapies, for a specific genotype, for second-line cancer. We had a Chinese study last year that showed no difference in adjuvant TKI therapy versus chemotherapy in terms of overall survival. That’s the right genotype with a targeted therapy. But I hope things are different here. We’re batting much higher rates than we ever were, in terms of home runs. It’s an incredibly new world.

Corey J. Langer, MD, FACP: I don’t think I’ve ever been to an ASCO Annual Meeting where we have had so many positive trials.

Karen Kelly, MD: But I do think, again, that there are still knowledge gaps in immunotherapy. Remember, gap No. 1—we’re talking about performance status 0 to 1. Other patient groups deserve an opportunity to see these great drugs, and we need to do studies for those settings, as well. Also, not every patient can be operated on. SBRT is another area that I am personally interested in—in combining SBRT with immunotherapy. We have an ongoing trial that is looking very promising.

I just wanted to remind people that all patients really should have an opportunity. These drugs, for the most part, are so well tolerated. We have to think about the entire patient population. Remember, across the board, there are still many patients who, unfortunately, do not get treated. That is a sad but real fact.

Transcript Edited for Clarity 
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