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One of the reverberating themes of 2021 that should carry into 2022 is the importance of molecular testing.
One of the reverberating themes of 2021 that should carry into 2022 is the importance of molecular testing, said Melissa L. Johnson, MD, who added that the frequency of the alteration, be it EGFR, RET, or KRAS, should never determine whether to pursue next-generation sequencing (NGS).
“As I reflect on our State of the Science Summit™ presentations, I realize how much more complicated the care of [patients with] lung cancer has become with all these new strategies. Yet, we are developing guidelines and pathways and avenues with which to care for our patients. You need PD-L1 testing and NGS testing, and those either open or close doors in terms of treatment,” Johnson said in an interview with OncLive® during an Institutional Perspectives in Cancer webinar on lung cancer, which she co-chaired.
In the interview, Johnson, program director, Lung Cancer Research, lead, Solid Tumor Immune Effector Cellular Therapy Program, Sarah Cannon Research Institute, discussed the focus of each presentation, which centered on immunotherapy vs chemoimmunotherapy in the frontline metastatic setting, the surgical perspective of treatment in early-stage non–small cell lung cancer (NSCLC), best practices for molecular testing, and EGFR-, RET-, and KRAS-targeted therapies for patients with advanced disease.
Johnson: At the State of the Science Summit™ presentation, I talked about the targeted therapies that have led to FDA approvals during 2021. I included selpercatinib [Retevmo] and pralsetinib [Gavreto], which were approved in late 2020, as well as sotorasib [Lumakras], which [was approved in 2021]. I also talked about amivantamab-vmjw [Rybrevant], as well as mobocertinib [Ekivity], which also gained approvals during 2021 and followed it up with a discussion of adjuvant osimertinib [Tagrisso]. When I received the topic [of EGFR-targeted therapies to present on], I thought that all those mutations were sort of a disparate group. What I realized is, each of those mutations is just a few patients, but together, it comprises quite a big group of patients with lung cancer.
The take-home lesson for my presentation was the importance of molecular profiling. When we do NGS testing, we’re not always sure what we’re going to find. In the past, when we were evaluating selpercatinib at Sarah Cannon, for example, many of the doctors would say, well, 1% of lung cancer RET rearrangements are so uncommon, I’m not going to see those. But you don’t know whether you’re going to find a RET alteration or maybe a KRAS mutation, which occurs in 30% of patients. In 30% of those KRAS mutations, we see G12C. All of that to say: we’re learning as we go. We also talked about getting those results faster. How can we bring patients to their most appropriate therapies sooner? That should be some of the focus of 2022. We know these tools are important. How do we utilize them with more efficiency?
That becomes important when we move into the adjuvant space. We are still discussing with our pathologists how we test for EGFR and other alterations in the adjuvant setting if [these targeted therapies are] not all approved [in that setting]. Here again, the same take-home lesson is applicable. Yes, EGFR L858R mutations and exon 19 [deletions] will only be found in 10% to 15% of patients after their surgery. For those patients, osimertinib is really going to improve their disease-free survival, and likely overall survival, although we don’t have those results yet. Coming soon are all the other targeted agents I talked about in the metastatic setting that we’re going to move into the adjuvant setting and to early-stage disease. NGS testing is going to be as important for early-stage disease as it is currently for patients with metastatic disease.
I also talked about new drugs in the metastatic setting for patients with EGFR exon 20 insertions. Here again, [this subset comprises] a small group of patients. In general, doctors will say to me, I’m not seeing that, or I see that once a year. But remember, you don’t know what you’re going to find when you do the testing. We saw 2 new approvals during 2021 for patients with EGFR exon 20 insertions: amivantamab, which is an intravenous drug given with a loading dose followed by once-every-2-week [dosing], as well as mobocertinib, which is an oral drug given daily. These drugs have very different safety profiles, and they’re administered very differently. They’re probably going to be a good fit for different groups of patients. It was important to begin to talk about the difference in the profiles of the drugs and how you might choose for your patient which drug is the best match.
Dr Spigel gave a great presentation on frontline immunotherapy vs chemotherapy options. He reviewed all the options that exist, including chemotherapy plus pembrolizumab [Keytruda]. We now also have chemotherapy plus nivolumab [Opdivo] and ipilimumab [Yervoy], nivolumab plus ipilimumab alone, as well as PD-1 monotherapy in pembrolizumab, atezolizumab [Tecentriq], and cemiplimab-rwlc [Libtayo], which are all approved for patients in the frontline setting.
The challenge is: How do you select [a regimen] for your patient? We talked through some of the biomarkers: PD-L1, tumor mutational burden, and molecular profiling, [all of which] we use to assign therapies. There are some [regimens], we think, that are more effective for patients with squamous histology, and others that may be more effective for patients with nonsquamous histology. That’s a new theme that reverberated at the end of 2021: that there is a difference between how patients with squamous lung cancer respond to immune therapy compared with those with nonsquamous lung cancer. I predict that there’ll be more discussion of this in 2022. All of that to say, there is no wrong option, but we all as oncologists have the sense that there probably is a better option for each patient. We spent some time discussing that for patients with metastatic disease as well as in the early-stage setting as these drugs and immunotherapy and chemotherapy combinations gain approval for patients in the neoadjuvant and adjuvant spaces as well.
I was so thrilled to have Dr Dennis Gilmore participate in the State of the Science Summit™ presentations. He did such a great job. He’s been with us for several years at TriStar Centennial and with Sarah Cannon. It was great to hear his perspective. There’s no debate among medical oncologists about the importance of moving immunotherapy and chemotherapy into the neoadjuvant care of patients with early-stage disease. The surgeons, who are the ones that are seeing these patients initially, are a group that we need to work on educating in the next year or 2. Our surgeons at our hospital are used to us asking whether we can put a patient on a trial and get a little therapy in in advance of them taking the patient to the operating room, but that’s a message that probably needs to be repeated and expanded upon.
The CheckMate 816 trial [NCT02998528] data that Dr Gilmore presented was a great illustration of why. The pathologic complete response rates were better when immunotherapy was added to chemotherapy. The major pathologic response rates were better when immunotherapy was added to chemotherapy. Probably even more importantly, the surgical outcomes were improved, including the length of stay, the morbidity associated with the operation, and how much normal lung had to be taken out. There were several measures that surgeons care about that were reported. Dr Gilmore went through them very nicely. We had a great multidisciplinary discussion. I was proud to showcase that because it shows the new discussions that are taking place at tumor boards across the country. For those who are starting to have those conversations with their thoracic surgeons, it probably gave them some talking points to begin to discuss regarding adjuvant atezolizumab as well as chemoimmunotherapy, which we know is coming.
Dr Andy Mackenzie also joined us at our State of the Science Summit™. I love when he participates, because he really has a way of driving home the importance of molecular testing. He talked about several key aspects of testing tissue vs plasma, sequential testing, as well as how you can use those results in the care of your patients. He’s a critical leader at Sarah Cannon who oversees our personalized medicine program and spends time talking to doctors about what targeted options to use in the care of their patients. He brought all of that with him in his presentation, which is just as good as it always is and was one of the favorites from the event, I’m sure.