Mark A. Socinski, MD: What do you do second-line?
Thomas E. Stinchcombe, MD: This is a challenge because you sort of go all in with the first-line treatment when you use a 3-drug combination. The standard approaches would be docetaxel [Taxotere] alone or with ramucirumab [Cyramza]. I generally do docetaxel and ramucirumab in the better performance status of younger patients. I have some doubts about the incremental benefit, but the trial was positive. It is an option to consider, certainly. The challenge we face is patient enthusiasm for docetaxel, who are a bit disappointed, especially the ones referred in for a second option.
Mark A. Socinski, MD: Leora, your thoughts regarding second-line at this point?
Leora Horn, MD, MSc, FRCPC: Outside of trials, we’re back to docetaxel with or without ramucirumab. We always use the Japanese dose, which is typically better tolerated. Right now, there are not many good options. Many of the trials are coming out looking at immuno-feelers in the lung with next generation drugs, but it has not been promising.
Maximilian Hochmair, MD: We have 3 options in this situation. We can do a reinduction with platinum doublet; however, the problem is, should we add immunotherapy [I-O] in this situation? On the other hand, in Europe, we have the opportunity to use nintedanib [OFEV] in this situation instead of ramucirumab. It’s oral, and from my point of view, better tolerated; we have nice data for patients who are progressing. On the other hand, we have the possibility in clinical trials to switch from a PD-1 [programmed death cell 1] inhibitor to a PD-L1 [programmed death-ligand 1] inhibitor. Those are the 3 options we have to choose from. For docetaxel, I’m completely with you that it’s not well tolerated. Quality of life counts. Patients are coming from I-O and switching to docetaxel. We sometimes use it weekly or with the 60mg, which is better tolerated; but it’s palliative care.
Mark A. Socinski, MD: If that’s the option and there is some hesitancy or lack of enthusiasm for docetaxel as a cytotoxic drug, do you hang on to I-O? Do you treat through progression? What’s the impetus to switch when we’re not doing it with a great deal of enthusiasm?
Thomas E. Stinchcombe, MD: I don’t continue the I-O beyond progression. I’m also diligent to make sure it’s true progression and not an ambiguous CT scan. To my knowledge, there’s no data that continuing I-O through multiple chemotherapy platforms is beneficial.
Leora Horn, MD, MSc, FRCPC: The reality is, when these drugs are in the system, they hang around for a long time.
Mark A. Socinski, MD: We have people that may discontinue treatment because of toxicity and a lack of benefit. That’s a different situation. But to your point, the effect may be long-lasting.
Leora Horn, MD, MSc, FRCPC: We’ve had people with complete responses to docetaxel because they had I-O and continued to progress. We’re going to get that answer if the Cooperative Group trial ever opens—the ECOG SWOG trial, which is looking at carboplatin [Paraplatin] with pemetrexed [Alimta] and pembrolizumab [Opdivo], or pembrolizumab alone. If that trial finally opens, some of these questions will be answered: should you continue or should you stop?
Mark A. Socinski, MD: Stop beyond progression.
Transcript Edited for Clarity