Global Perspectives in the Treatment of EGFR-mutant Resectable and Advanced NSCLC - Episode 10
Closing out their discussion on resectable NSCLC, experts review multidisciplinary care strategies and the role of neoadjuvant therapy in patients identified for resection.
Tony S.K. Mok, MD: Let’s carry on with our discussion on the role of the multidisciplinary team [MDT]. For adjuvant situations, do you think all cases should be discussed [with] your MDT? Let’s start with Lu Shun.
Shun Lu, MD, PhD: Yeah, for stage II and stage III we are discussing in a multidisciplinary team. For stage I right now we have so many patients. We do not have enough time for every patient to do the MDT. So only for the stage II and stage III.
Tony S.K. Mok, MD: Ming-Ju, how is it in Korea? Is [it] every patient or selective patient?
Myung-Ju Ahn, MD: Very selective patients who cannot judge by themselves. So we usually have the multidisciplinary approach. Usually, it’s stage III.
Tony S.K. Mok, MD: So in Korea, I just wonder in the multidisciplinary team does [INAUDIBLE] say everything and then everybody just follow?
Myung-Ju Ahn, MD: No. Every single part is very strong. Sometimes he is not. Actually, he’s gone.
Tony S.K. Mok, MD: I know. Tetsuya, how does it work in Japan about your multidisciplinary team?
Tetsuya Mitsudomi, MD, PhD: In Kindai Hospital we do not do the MDT discussion for the resected stage even stage III. In very special cases we may have the discussion, but usually we do not have any discussion.
Tony S.K. Mok, MD: I see. Is it because the surgeon says no, and then you decide?
Tetsuya Mitsudomi, MD, PhD: Yeah.
Tony S.K. Mok, MD: Even in Hong Kong, we only do selective cases. Mostly its disease case load because it is impossible to go through all the cases, every case in a very busy clinic like ours. Now to shift folks a little bit to neoadjuvant treatment. There is the CTONG1103 study that you can give 2 cycles of erlotinib. Should this be the right practice? Or what about the marginal resectable cases and EGFR mutation positive? Will you be tempted to give a neoadjuvant TKI [tyrosine kinase inhibitor] first?
Yi-Long Wu, MD, PhD: So because the CTONG1103 is also my design. At the time, why we have designed the CTONG1103 and the CTONG1104 is because this is a different population. So for the CTONG1104 this is the resectable data.
The CTONG1103, also my design. Why we designed the CTONG1104 and CTONG1103 because this is the who we targeted in the different population. For the CTONG1103, we targeted the population that had marginal resectable data. So this means the IIIAB or the 3 multiple metastases. But the CTONG1104 is resectable data. So basically, we give the patient adjuvant treatment. But for the marginal treatment, I think the testing for the surgery is very difficult. So that way I give the patient the neoadjuvant TKI treatment. Then we will screen the tumor and then we have the opportunity to resect the tumor. So I think this is a different population.
Tony S.K. Mok, MD: Myung-Ju, in Korea, do you give a neoadjuvant TKI?
Myung-Ju Ahn, MD: Never. So a long time ago, we [CROSSTALK].
A long time ago, we did a small phase 2 study with erlotinib as our neoadjuvant. Not molecularly selected, but clinically selected the patient. But we didn’t have good results. The thing is when given a neoadjuvant TKI and treated with the surgery, I think after then we should give another adjuvant TKI. Most of the studies just give the TKI as a neoadjuvant period. I think that’s not enough. Anyway, I do not use them.
Tony S.K. Mok, MD: Tetsuya, what about if a patient is marginally resectable? Meaning that the tumor is touching the mediastinum or if there is a very bulky N2 lymph node. Will you consider neoadjuvant TKI before the surgery or no surgery at all?
Tetsuya Mitsudomi, MD, PhD: Neoadjuvant TKI is not around, so we can’t use it.
Tony S.K. Mok, MD: I see. So you will just basically, if it’s not resectable, then go and give the concurrent tumor RT [radiation therapy].
Tetsuya Mitsudomi, MD, PhD: Yes. Maybe followed by surgery sometimes.
Tony S.K. Mok, MD: Lu Shun, what do you think, neoadjuvant here?
Shun Lu, MD, PhD: I will opt to using the neoadjuvant TKI right now. We’re awaiting the new ADAURA study, actually. But for the marginally resectable patient, still we will recommend chemotherapy radiation as our routine practice.
Tony S.K. Mok, MD: Let me put you on the spot, will you give neoadjuvant immunotherapy [IO] and chemotherapy like CheckMate 816?
Shun Lu, MD, PhD: Yeah. Right now we’re selecting patients. We’re using the chemotherapy plus IO in the neoadjuvant based on the CheckMate 816 study. In China, actually a lot of us in surgery are using this as the neoadjuvant.
Tony S.K. Mok, MD: I find interesting, though, you would use chemotherapy/IO for non-EGFR mutation positive disease. But you will not use EGFR TKI for EGFR mutation positive disease. But we know the response rate is probably higher to use the EGFR TKI in mutation positive disease.
Shun Lu, MD, PhD: They are completely different.
Tony S.K. Mok, MD: What’s different?
Shun Lu, MD, PhD: The response. Because [INAUDIBLE] response is higher in IO but for TKI it’s very lower.
Tony S.K. Mok, MD: So your point is that the high pathological response rate of pathology free response rate was the attractive feature. That’s why you use it, right?
Shun Lu, MD, PhD: Right.
Transcript edited for clarity.