Trilaciclib: Treatment Considerations

Advantages associated with the administration of trilaciclib in appropriate patients receiving a chemotherapy-containing regimen for extensive-stage small cell lung cancer.

Charu Aggarwal, MD, MPH: Trilaciclib has been included in the NCCN [National Comprehensive Cancer Network] Guidelines for management of myelosuppression, especially in patients who are receiving chemoimmunotherapy for extensive-stage small cell lung cancer or chemotherapy for extensive-stage small cell lung cancer. And I find that this may be a nice approach for patients who are older than the age of 65 and patients where I need to come in with a prophylactic approach and want to boost the immune microenvironment. One of the largest unmet needs is that growth factor support and ESA [erythropoiesis-stimulating agent] support often will support only a couple of lines; it doesn’t support trilineage hematopoiesis. Often, we come in with these agents after “the damage” has been done. The biggest advantage of using something like trilaciclib is that we’re coming in before cytotoxic chemotherapy, and the overall goal is to support the immune microenvironment. It does offer advantages from that standpoint. The older patients, who are more likely to experience overall myelosuppression, would be favored candidates for this approach.

Jared Weiss, MD: With trilaciclib we have a drug that reduces the myelosuppressive effects of small cell chemotherapy and improves patient-reported quality of life. It also makes treatment easier for the doctor and nurse. It’s a lot of work managing neutropenia, anemia, and to an extent thrombocytopenia. In my opinion, the data are sufficient that in my practice I use it for every patient getting carboplatin-etoposide, carboplatin-etoposide-atezolizumab—the most frequent use—and topotecan. There has been recent cost analysis that suggests that trilaciclib may be cost effective. In my mind, there isn’t a reason to not use it in any patient. I use it in every patient.

In thinking about adverse events from trilaciclib, we need to turn the paradigm on its head a little. What I mean is that normally, when we introduce a new drug, the question is how much improvement in PFS [progression-free survival] and OS [overall survival] is it worth to accept the additional adverse effects that the drug provides. In this case it’s the exact opposite. Trilaciclib globally reduces the adverse effects of small cell chemotherapy, and the safety question was, “Does it harm efficacy in terms of PFS and OS?” The answer was no. What I’ve observed the most in clinical practice are localized irritative effects at the infusion sites. In terms of what’s most helpful, if in your practice you use a port, the issue goes away for you. When a port is used for chemotherapy, there’s no issue. I don’t always use ports in my practice. What I’ll do if patients are experiencing this is I’ll ask the nurse to slow the infusion. We rotate sites, and ice packs have also been helpful.

Transcript edited for clarity.

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