Academic Versus Community Practice Considerations and Performance Status in ES-SCLC

Dr. Sands discusses geographic and practice setting variations, noting lurbinectedin presents no administration challenges anywhere, whereas tarlatamab's rollout has been slower, initially concentrated in academic centers with clinical trial experience managing T-cell engagers and cytokine release syndrome. He anticipates eventual transition toward outpatient tarlatamab administration while maintaining inpatient options for higher-risk patients with poor functional status or high disease burden experiencing more complicated CRS.

He highlights concerning geographic disparities, with some US cities lacking any tarlatamab-administering centers, creating access tragedies given the drug's paradigm-shifting potential. His practice involves receiving community referrals for initial dosing before returning patients to community oncologists for subsequent cycles.

Dr. Chiang addresses patients with an ECOG performance status of 2, excluded from IMforte, advocating for shared decision-making considering whether functional impairment stems from disease versus comorbidities. She mentions exploring subcutaneous atezolizumab administration potentially reducing CRS/ICANS risk, with successful outpatient pilot programs for low-risk patients, though emphasizes overnight observation remains generally well-tolerated, described to patients as comparable to "a spa night."

Dr. Sands shares a compelling case of a patient with symptomatic brain metastases after radiation, told hospice was the only option, who achieved 7 months of high-quality life with tarlatamab including attending a grandson's birthday party. He emphasizes the importance of providing realistic opportunities for meaningful benefit while being transparent about risks, noting real-world data from Emory and other centers shows lower efficacy and higher CRS rates in patients not meeting trial eligibility criteria, though individual patients may still experience meaningful, realistic possibilities for long-term disease control warranting informed shared decision-making.