Key Decisionmaking Factors in Resectable Non–Small Cell Lung Cancer


Expert oncologists reflect on key factors that aid in the selection of therapy for patients diagnosed with resectable non–small cell lung cancer (NSCLC).


Balazs Halmos, MD, MS: Hello, and welcome to this OncLive Peer Exchange® titled “Recent Updates in the Role of Immunotherapies in Non–Small Cell Lung Cancer: Translating Evidence to Clinical Practice.”I’m Balazs Halmos, MD, MS, from Montefiore Einstein Cancer Center, and joining me today in this discussion are my colleagues.

Kristen A. Marrone, MD: Hi, my name is Kristen A. Marrone. I am a thoracic oncologist at Johns Hopkins in Baltimore, Maryland.

Martin Dietrich, MD, PhD: Hello. I’m Martin Dietrich. I’m a medical oncologist with Florida Cancer Specialist at the University of Central Florida in Orlando.

Joshua Reuss, MD: I’m Joshua Reuss. I’m a thoracic medical oncologist at Georgetown University. Happy to be here.

Balazs Halmos, MD, MS: Thank you so much for joining us. Today we are going to discuss the most recent updates in immunotherapy for advanced non–small cell lung cancer. We will discuss the latest research in the field and the impact of recent clinical trials on making decisions around treatment selection.

Let me introduce a patient case so that we can start our discussion. This is a patient from my practice who I saw a couple of weeks ago. A 60-year-old African American man, heavy smoker [in] the past. He comes in with a couple of months’ history of left-sided back pain. Got some CAT [computed axial tomography] scans. The CAT scans show a 5-cm lung mass in the left upper lobe, invading the rib cage. The patient undergoes further testing, including a PET [positron emission tomography]-CT scan that does not suggest any nodal uptake or metastatic disease. A brain MRI is also done. The patient gets a CT-guided biopsy that shows squamous cell carcinoma. It appears to be [a] chest wall invasion, maybe a T3 and 0, stage IIB squamous cell lung cancer, and we need to make some big decisions for this patient [pertaining to] the treatment selection.

Is there some more information that you would need prior to making a decision? What would be your [top] choice?

Kristen A. Marrone, MD: We would need to understand the patient’s performance and functional statuses. Then we could think about if we are going to attempt neoadjuvant therapy prior to definitive surgical resection. And then we need to understand the staging of the disease. We would make sure there is a brain MRI that’s done to complete that. We can then talk with the patient about the exciting new therapies that are available to him, depending on what those results are.

Balazs Halmos, MD, MS: Fortunately, a brain MRI was done, and it’s negative. The patient doesn’t seem to have a lot of comorbidities. Is there anything else you wouldwant to have in your hands to make a treatment decision? What would be your recommendation for such a patient?

Joshua Reuss, MD: I would be sure to do a PET-CT scan to rule out any distant metastatic disease. A full NGS [next-generation sequencing] profile might be [too much] for squamous cell lung cancer. But I would want to get the basic NGS testing for actionable drivers, as well as PD-L1 results, so I can better guide my patients in what they would expect in a neoadjuvant approach. I think the surgeon’s input is super important here, too. We want to know, is this truly resectable, or do you have to call your radiation colleagues?

Balazs Halmos, MD, MS: We’ve seen some major surgical updates with the Cancer and Leukemia Group B [CALGB] study reading of Dr [Nasser] Altorki’s New England Journal of Medicine paper ... But we need to remember that is not for this type of case. The CALGB study and the Japanese study were very small, [focusing on] less than 2-cm peripheral lesions, suggestive of sublobar resection. Resections achieved excellent outcomes, matching that of lobectomy. For select patients with very small peripheral lesions, that might be an appropriate approach.

In our case, we need the technical expertise of an excellent surgical team. The chest wall might be borderline for resection. What’s your thought in such a case? Would the TPS [tumor proportion score] make a difference as to your treatment selection, or anything else?

Martin Dietrich, MD, PhD: We need to consider lung function and surgical resectability. This is the last piece of the puzzle, from a patient perspective. I do not really know that we have a good head-to-head data comparing radiation [with] neoadjuvant approaches in this case. This would certainly be my big discussion. We have seen some very exciting data for neoadjuvant chemotherapy immunotherapy options, especially if there’s a PD-L1 score that would be suggestive of a good response, to see if we can actually convert this. Sometimes we are trying these approaches and it may turn out that a patient does not respond as well. In retrospect, this is more of an induction chemotherapy rather than a truly neoadjuvant therapy. The decision about surgery is really one that we make after neoadjuvant therapy, as much as we do it beforehand. We have 2 good options here. The early introduction of immunotherapy in an intact tumor environment is a very useful contextualized use of immunotherapy. In a patient like this, we would follow the CheckMate 816 [trial] [NCT02998528] regimen: give 3 cycles of neoadjuvant [chemotherapy immunotherapy], then image again and see if the patient has converted. If not, then I would proceed with chemoradiation, followed by immunotherapy.

Balazs Halmos, MD, MS: We shouldn’t forget about radiation being a definitive curative strategy for many of our patients. Especially, if the PET scan suggested some nodal disease, and maybe we would confirm it with an EBUS [endobronchial ultrasound]. If you have a borderline-resectable patient with nodal disease, the conversation might shift. But the PET-CT didn’t show any of that. A careful EBUS was done, and the patient is not negative.

Transcript edited for clarity.

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