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CRT in Locally Advanced NSCLC

Panelists: Charu Aggarwal, MD, MPH, Hospital of the University of Pennsylvania; Hossein Borghaei, DO, Fox Chase Cancer Center; H. Jack West, MD, Swedish Cancer Institute
Published: Monday, Jan 14, 2019



Transcript:

H. Jack West, MD: Hello, and thank you for joining this OncLive Peer Exchange® discussion, “Practical Implications for New Data in Lung Cancer Systemic Therapy.” Research in the field of thoracic oncology continues to provide us with paradigm-changing data in terms of how we treat our patients with systemic therapy. Recently, I was joined by my colleagues, Dr Hossein Borghaei and Dr Charu Aggarwal in a Twitter chat, during which we discussed some of the practical questions that plagued the community oncologist when treating patients with locally advanced and metastatic non–small cell lung cancer.

In today’s OncLive Peer Exchange® discussion, we’re going to explore these questions further as we share the insightful comments that we gathered from both lung cancer specialists and community-based oncologists on Twitter. I’m Dr Jack West, medical director, Thoracic Oncology Program at the Swedish Cancer Institute in Seattle, Washington.

Joining me today are: Dr Hossein Borghaei, chief of the Division of Thoracic Medical Oncology and professor in the Department of Hematology and Oncology at Fox Chase Cancer Center in Philadelphia, Pennsylvania; and Dr Charu Aggarwal, assistant professor of medicine at the Hospital of the University of Pennsylvania, also in Philadelphia. We have a lot of exciting things to cover today. Let’s get started on our first topic, the treatment of locally advanced non–small cell lung cancer and some of the questions that we addressed on Twitter.

The PACIFIC trial looked at the benefit with consolidation durvalumab given for a year in patients who had received and not progressed on concurrent chemotherapy and radiation for unresectable stage III non–small cell lung cancer. That is really a standard of care, but, unfortunately, a lot of patients are not getting concurrent chemotherapy and radiation, though I think in our practice we generally do. But, certainly, in some parts of the world, in the UK in particular, there are a lot of patients who get sequential therapy and even in the United States and some other parts of the world. A lot of patients are not getting concurrent chemoradiation as much as we think they should. Hoss, do you have any ideas about why that might be the case?

Hossein Borghaei, DO: Thanks, Jack. I really can’t tell you that I have data to tell you why that might be the case, except that sometimes in discussions with some of our colleagues, a couple of points come up. One is access to a group that’s closely associated with radiation oncologists where you have the kind of coordination that it takes to do concurrent chemoradiation. I think, to some extent, I still hear this concern for toxicity for a patient population who, for the most part, might not be doing quite as well. Because in your locally advanced disease, it’s a difficult disease for a patient to tolerate. So I think there’s a little concern about the toxicity of concurrent approach. Sometimes it is felt that perhaps older, frailer patients should be treated with the sequential approach because that somehow makes it more tolerable. So I think there’s a lot of concerns like that that goes in to deciding whether someone should get concurrent chemo-RT [chemoradiation therapy] versus the sequential.

There might also be this idea that concurrent chemo-RT, although based on phase III results, is clearly superior. The superiority wasn’t like 15%, 20% overall survival, it was much less. So if it’s going to be too toxic, why not try the sequential approach? So I think there’s a combination of different factors that go into this decision of whether you should offer concurrent chemo-RT versus sequential.

Charu Aggarwal, MD, MPH: Yeah, and I think sequential chemoradiation should really be the exception rather than the rule. We certainly see patients who are offered sequential chemoradiation therapy, but usually it’s after careful thinking and the thought process of the risk/benefit ratio…. If there is somebody who is clearly PS2 [performance status 2] and not doing well, and you’re concerned about toxicity, older in a wheelchair, I think a multidisciplinary discussion is still warranted. But I agree, those may be the reasons why sequential therapy is used.

H. Jack West, MD: I suspect that some of it may be the practical aspects of coordinating, but I do think a lot of it is just concern about managing the potential for greater acute toxicities. But I think, unfortunately, it’s to the detriment of these patient outcomes. You raise the question of people maybe being skeptical and saying is it enough of a difference? But I think to some of us, the answer is yes. In a curative setting, you want to play for every percentage of cure you can get.

Transcript Edited for Clarity

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Transcript:

H. Jack West, MD: Hello, and thank you for joining this OncLive Peer Exchange® discussion, “Practical Implications for New Data in Lung Cancer Systemic Therapy.” Research in the field of thoracic oncology continues to provide us with paradigm-changing data in terms of how we treat our patients with systemic therapy. Recently, I was joined by my colleagues, Dr Hossein Borghaei and Dr Charu Aggarwal in a Twitter chat, during which we discussed some of the practical questions that plagued the community oncologist when treating patients with locally advanced and metastatic non–small cell lung cancer.

In today’s OncLive Peer Exchange® discussion, we’re going to explore these questions further as we share the insightful comments that we gathered from both lung cancer specialists and community-based oncologists on Twitter. I’m Dr Jack West, medical director, Thoracic Oncology Program at the Swedish Cancer Institute in Seattle, Washington.

Joining me today are: Dr Hossein Borghaei, chief of the Division of Thoracic Medical Oncology and professor in the Department of Hematology and Oncology at Fox Chase Cancer Center in Philadelphia, Pennsylvania; and Dr Charu Aggarwal, assistant professor of medicine at the Hospital of the University of Pennsylvania, also in Philadelphia. We have a lot of exciting things to cover today. Let’s get started on our first topic, the treatment of locally advanced non–small cell lung cancer and some of the questions that we addressed on Twitter.

The PACIFIC trial looked at the benefit with consolidation durvalumab given for a year in patients who had received and not progressed on concurrent chemotherapy and radiation for unresectable stage III non–small cell lung cancer. That is really a standard of care, but, unfortunately, a lot of patients are not getting concurrent chemotherapy and radiation, though I think in our practice we generally do. But, certainly, in some parts of the world, in the UK in particular, there are a lot of patients who get sequential therapy and even in the United States and some other parts of the world. A lot of patients are not getting concurrent chemoradiation as much as we think they should. Hoss, do you have any ideas about why that might be the case?

Hossein Borghaei, DO: Thanks, Jack. I really can’t tell you that I have data to tell you why that might be the case, except that sometimes in discussions with some of our colleagues, a couple of points come up. One is access to a group that’s closely associated with radiation oncologists where you have the kind of coordination that it takes to do concurrent chemoradiation. I think, to some extent, I still hear this concern for toxicity for a patient population who, for the most part, might not be doing quite as well. Because in your locally advanced disease, it’s a difficult disease for a patient to tolerate. So I think there’s a little concern about the toxicity of concurrent approach. Sometimes it is felt that perhaps older, frailer patients should be treated with the sequential approach because that somehow makes it more tolerable. So I think there’s a lot of concerns like that that goes in to deciding whether someone should get concurrent chemo-RT [chemoradiation therapy] versus the sequential.

There might also be this idea that concurrent chemo-RT, although based on phase III results, is clearly superior. The superiority wasn’t like 15%, 20% overall survival, it was much less. So if it’s going to be too toxic, why not try the sequential approach? So I think there’s a combination of different factors that go into this decision of whether you should offer concurrent chemo-RT versus sequential.

Charu Aggarwal, MD, MPH: Yeah, and I think sequential chemoradiation should really be the exception rather than the rule. We certainly see patients who are offered sequential chemoradiation therapy, but usually it’s after careful thinking and the thought process of the risk/benefit ratio…. If there is somebody who is clearly PS2 [performance status 2] and not doing well, and you’re concerned about toxicity, older in a wheelchair, I think a multidisciplinary discussion is still warranted. But I agree, those may be the reasons why sequential therapy is used.

H. Jack West, MD: I suspect that some of it may be the practical aspects of coordinating, but I do think a lot of it is just concern about managing the potential for greater acute toxicities. But I think, unfortunately, it’s to the detriment of these patient outcomes. You raise the question of people maybe being skeptical and saying is it enough of a difference? But I think to some of us, the answer is yes. In a curative setting, you want to play for every percentage of cure you can get.

Transcript Edited for Clarity
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