Current Approaches in Advanced Non-Driver Lung Adenocarcinoma - Episode 8
Transcript:Anne S. Tsao, MD: The majority of patients with non—small cell lung cancer will not have a driver mutation—that’s close to about 70% or 75%. So, in those patients, it’s very critical to look for the PD-L1 immunohistochemistry to see if they’re a candidate for pembrolizumab frontline, and if not, the remainder of those patients should be receiving a systemic chemotherapy.
In nonsquamous non—small cell lung cancer, I like to give platinum pemetrexed with or without bevacizumab, and then I consider pemetrexed maintenance or bevacizumab maintenance in those patients. In patients who are squamous cell carcinoma, we usually use a platinum doublet, and you’d have your choice for that. But I usually like to use a platinum taxane.
Heather Wakelee, MD: When meeting a patient with newly diagnosed lung cancer, I always talk about the 3 different ways to treat the disease and try to emphasize the importance of chemotherapy. I found that, especially in this era where we do have other options such as immunotherapy or targeted treatment, most patients come in wanting one of those and not wanting chemotherapy. And yet, chemotherapy remains one of the key treatment options for almost all patients, even if they start with immunotherapy or with targeted therapy. Even in patients where we have those options, they’re eventually going to get chemotherapy, and in patients who don’t have one of those options, we’re going to start with chemotherapy.
Chemotherapy helps far more people than it harms, but there’s this perception people have that chemotherapy is going to make them feel terrible—that it’ll make them worse overall. So, we spend a lot of time on educating about how many of our chemotherapy combinations can help people feel better. If they’re having symptoms from their cancer, we’ll work with them to manage symptoms and side effects, such as nausea. We’re pretty good with that today. There are options where people aren’t going to lose their hair; that tends to still be a big concern. There are ways that we’re going to work with patients to help maintain their appetite, general well-being, and quality of life.
Carboplatin/pemetrexed is the most commonly used regimen in the United States and in my practice. The reasons we choose it are its efficacy, better tolerability, and response rates—keeping in mind that response rate mean the tumor has to have shrunk in the way you’re measuring it by at least 30%. So, there are a lot of patients who benefit who wouldn’t necessarily hit that definition of having had a response.
When I talk with patients about it, I talk about the fact that the vast majority of patients are going to have some benefit. The drugs don’t work in maybe 10% to 20% of people, and I always make sure to emphasize that so they know it’s not a guarantee. The tumor’s going to shrink significantly in maybe 30% to 40% of patients. Those are the numbers we talk through as we think about what we are going to gain from this and how we are going to benefit from this.
For patients who have symptoms related to breathing issues—especially those who have a lot of smaller nodules in the lungs—even though we wouldn’t qualify it as a response by the usual criteria, a lot of those patients feel better in a fairly short time period if they are getting benefit.
David Spigel, MD: Over the last many years, we’ve been focused on finding alterations to use very effective oral therapies against, for example, EGFR-mutated or ALK-rearranged lung cancers, where the therapies are fantastic. It’s important to emphasize that chemotherapy is still a main part of first-line care for the majority of patients. It’s worth mentioning immunotherapies. Immunotherapy is technically not chemotherapy or a targeted therapy. That certainly is a new way to help a lot of patients who have a high expression of PD-L1 in the first-line setting.
And then you have everybody else who really aren’t candidates for targeted therapy and are not candidates for immunotherapy. That’s when chemotherapy is used. And chemotherapy, I often remind people, is very effective in the first-line setting. It can be very well tolerated. For example, in the nonsquamous non—small cell lung cancer setting, regimens that include things like carboplatin and pemetrexed can be quite easy for patients. You don’t have to lose hair. It’s not often that your blood counts get so low that you end up in the hospital or needing to be on antibiotics or needing transfusions. Fatigue and just not feeling well are sometimes part of that care.
But there are a lot of patients who can do quite well with that treatment. Other than having to come into the office every 3 weeks, folks can do very well and have good responses with that care. Chemotherapy often gets the short end of the stick, and I think we’re all trying to get away from chemotherapy. But I think it’s going to be here for a while—either alone or with immunotherapy in combination strategies—and it remains an important standard in lung cancer treatment.
Transcript Edited for Clarity