Howard L. “Jack” West, MD
A lung cancer researcher who has served on the editorial boards of major medical journals, Howard L. “Jack” West, MD, has made communicating with oncology specialists and patients a part of his professional mission.
West is the president and CEO of Global Resource for Advancing Cancer Education (GRACE), a nonprofit organization that grew out of an Internet-based information service that West founded in 2006. He also is medical director of the Thoracic Oncology Program at the Swedish Cancer Institute in Seattle, Washington.
In this interview with OncologyLive
, West discusses strategies for integrating emerging therapies into the treatment of patients with non–small cell lung cancer (NSCLC).OncologyLive: How do you form a personalized treatment plan for your patients with NSCLC?West:
You need to start with the stage of the cancer. Look at the histological subtype of the lung cancer, the bulk of it, the molecular features, and whether there is a specific molecular marker that could change your treatment. Then, examine the characteristics of the patient: his or her health, goals, and ability to tolerate aggressive treatment safely. There are a great many variables that affect and lead to individualization of the treatment path from one patient to another.What is the importance of histological subtyping and molecular characterization in deciding to treat with conventional or targeted therapy?
In the setting of advanced-stage disease, there is an early branch point for whether a patient has squamous or nonsquamous histology, with molecular testing being less clearly valuable and indicated for squamous lung cancer. Particularly for nonsquamous disease, especially adenocarcinomas, the presence or absence of an activating mutation, which is most commonly an endothelial growth factor receptor (EGFR
) mutation or an anaplastic lymphoma kinase (ALK
) rearrangement, is going to lead to an immediate diversion of the treatment plan between recommending first-line chemotherapy-based treatment and recommending a pill-based targeted therapy as the treatment most likely to lead to a beneficial effect for the patient.Which first-line conventional and targeted therapies are preferred?
There are many different doublet chemotherapy regimens—that is, a two-drug combination—and they have largely shown an efficacy that is more similar than different. There are subtle differences that would often lead us to favor one doublet regimen over another, depending on the histology. You can have a preferred chemotherapy regimen, but they really come out quite comparably.
In terms of targeted therapies, however, you have EGFR inhibitor-based treatment, such as erlotinib or afatinib, which are FDA approved and extremely appropriate for first-line treatment of patients with an EGFR
These days, you should look specifically at the subtype of an EGFR
mutation. This might lead you to use afatinib for someone with the specific del19 mutation (a deletion in exon 19), but not use it for another common EGFR
mutation, an L858R mutation (an exon 21 substitution), which seems to not do especially well with afatinib. It is becoming more and more granular all the time: we have gone from finding a single common activating mutation to now having to look at specific EGFR
mutations, where you might individualize therapy to one EGFR tyrosine kinase inhibitor over another.How do you treat patients who have progressed after first-line therapy?
That is largely based on whether they have a mutation. If not, I would favor docetaxel, or a clinical trial if you have that available. There are only a few agents that have been proven to have a survival benefit in previously treated patients, and that is really limited to erlotinib, docetaxel, and pemetrexed. We have typically favored using pemetrexed in patients with nonsquamous histology; not that it is absolutely the best, but it is certainly a well-tolerated option that seems to be among the most effective, for adenocarcinomas at least.
In the last few years, there have been a couple of trials that directly, head-to-head compared docetaxel with erlotinib in predominantly EGFR
wild-type mutations: one based in Italy1
and one in Japan.2
Both indicated that second-line docetaxel was at least modestly superior.Are there any recent or ongoing clinical trials with emerging therapies that have the potential to greatly impact future treatment of NSCLC?
Yes. At an international meeting in Chicago [the 2014 Chicago Multidisciplinary Symposium in Thoracic Oncology], there was a presentation of second- or third-line nivolumab, which is an immune-checkpoint inhibitor that specifically blocks a target called PD-1.3