Insights From: Nicolas Girard, MD, Curie Institute
Nicolas Girard, MD: One recommendation for the management of patients with stage III unresectable non–small cell lung cancer is probably to have this close follow-up of the patient with multidisciplinary management of the patient, including the radiation oncologist and also the pathologist, so that everyone is aware about the treatment strategy and the requirement of this strategy—the requirement in terms of imaging, in terms of PD-L1 [programmed death-ligand 1] assessment, and in terms of organization of the patient pathway. Meaning that the patient will receive chemotherapy, then concurrent chemoradiotherapy. And then there is a need to plan the early assessment, with a CT [computed tomography] scan, to be in a position to initiate consolidation treatment with durvalumab.
We also need clearly to have the patient involved and have the patient informed about the global strategy, meaning that up front we need to discuss with the patient the duration of the treatment, which will be chemotherapy, radiotherapy, usually 2 to 3 months; followed by consolidation, which will be for 1 year of treatment; and 26 injections of durvalumab. Again, this is very important to have everyone involved, including the patients.
The management of patients with stage III non–small cell lung cancer has completely changed. Before we had those patients in the medical oncology clinic for the delivery of chemotherapy. Then the patient was somehow referred to the radiation oncologist during the chemoradiotherapy phase of the treatment. But now we have those patients and back in the medical oncology clinic for the delivery of consolidation. We also have regular visits of those patients. It has also changed the way we organize the patient pathway at the hospital, because those patients are actually cured who received chemoradiation, which is a curative intent treatment. And durvalumab treatment, and delivery of treatment, has to be organized in a way that this is smooth for the patient. We have to minimize the duration of stay at the hospital. Because at the end, durvalumab injections are every 2 weeks, and we cannot have a patient in the hospital for 4 hours only for this injection. So we have to modify the patient pathway. Those patients usually are doing very well because they are considered as being cured from their disease.
It Institut Curie, we developed an initiative to have a nurse dedicated to those patients, which I know is very common in the US, for example. But in Europe, and especially in France, it is something very innovative to have someone who is not a physician prescribing immunotherapy and performing clinical examination of the patient and administering the treatment.
Durvalumab consolidation is clearly an opportunity to change our organizations, to modify the patient pathway. And this is very important actually for all patients with lung cancer because we know that some strategies of treatment include maintenance; for example, in the metastatic setting, with chemotherapy plus immunotherapy combination. We have also some trials as adjuvant treatment after resection of an early-stage non–small cell lung cancer.
This is only the beginning. And at the end we have to expect many patients to receive maintenance consolidation treatment, adjuvant treatment with immunotherapy. And we have to organize a dedicated patient flow, patient pathways at the hospital but also at the home; some patients may present with some toxicities, and we need to prevent that and have also the patient be aware about what to do in such a situation.
At the Institut Curie, we also develop patient education programs, meaning groups of patients—maybe 10 to 15 patients—discussing together about specific topics, including the disease, non–small cell lung cancer, understanding what are the key points from a patient perspective. Discussing immunotherapy; discussing the toxicity; how and what to do in specific situations that they may experience at home.
We also have patients working with patients and learning from one another regarding those treatments, because we need to expect those patients treated with immunotherapy in a long-term setting to have new expectations. Ten years ago, the management of patients with lung cancer was very difficult, with many patients presenting with multiple progressions of the disease and we had short-term survival. Now it’s completely different. We have patients treated for many years. This is true with targeted agents. This is also true now with immunotherapy. So we have to revisit the way we interact with patients, and the way patients are organized. And at the end we need to optimize the patient pathway.