Experts consider the mainstays in ILD management and factors that may dictate one treatment strategy over another.
Joyce A. O’Shaughnessy, MD: I wanted to summarize grading as I recall it. I learned this first in taking care of patients who were on everolimus and relearned it with the trastuzumab deruxtecan, with grade 1 being asymptomatic, and imaging changes found on chest imaging. Grade 2 is being symptomatic, even beginning to interfere with activities of daily living, and then grade 3 being oxygen dependency, and grade 4 being very serious, needing intubation or ICU [intensive care unit] care, etc. The question that is tough for us is what do we do with grade 1? It’s asymptomatic, and we’ve got these interstitial lung abnormalities. Let’s start to talk about some management issues and particularly around these early grades that we’re going to be picking up. Charles, you could help us with that.
Charles A. Powell, MD, MBA: Yes. This is really when the multidisciplinary collaboration becomes of paramount importance because what we have to take into consideration are several things. One is we have to take into consideration what is known about the particular cancer agent. What is known in terms of its likelihood to progress to severe pneumonitis or ILD [interstitial lung disease]? We need to know about the drug, the patient’s tumor, and the history of prior treatments, as well as whether there are other treatments available if by some chance this medication may be associated with drug toxicity. It’s a multidisciplinary collaboration that also involves the patient. A lot of these management options that we end up having involve a shared decision-making process. Some drugs have a history of presenting with a grade 1 pneumonitis, and it’s transient and it goes away despite continued treatment with medication. In the lung world, a good example of that is the third-generation tyrosine kinase inhibitor [TKI] osimertinib, where patients can develop these transient pulmonary opacities that go away despite continued treatment.
There are other drugs that are associated with potentially a higher likelihood of progressing to grade 2, 3, or 4 with continued treatment. Based upon our knowledge to date of the drugs and the toxicities associated with them, then we’ll make different decisions about what to do in the grade 1 patient. We also will make decisions in a grade 1 patient based upon what appears to be the extent of disease. By that, we look at the imaging studies. There will be some patients who on an imaging study will have just a very small patch of opacity, a little area that looks like an organizing pneumonia. That has a very good probability of being stable and/or resolving over time, sometimes with continuation of medication depending on the drug, but often with holding the medication.
However, some patients are asymptomatic, and they have quite a bit of disease. In those patients one would be less comfortable in continuing with the medication. One might even consider using steroids in a patient who has extensive disease on an imaging study and is asymptomatic. It depends again upon the interactions between the treating physicians, the patient, and those evaluating the interstitial lung disease from pulmonary, radiology, and other disciplines.
Joyce A. O’Shaughnessy, MD: Yes, and it would be very helpful to talk about as well because the different agents, as you say, are going to require different management strategies.
Transcript edited for clarity.