When to Involve Pulmonology: Targeted Consultation Strategies for ADC-Related ILD in Breast and Lung Cancer

Dr. Hope Rugo and Dr. Aaron Lisberg discuss the role of baseline pulmonary evaluation and risk stratification for patients receiving antibody-drug conjugates (ADCs) with interstitial lung disease (ILD) risk, particularly trastuzumab deruxtecan (T-DXd) and datopotamab deruxtecan (Dato-DXd) in breast and lung cancer settings.

Dr. Lisberg clarifies that routine pulmonary consultation is not obtained prior to ADC initiation for all patients. However, pulmonary involvement is sought when there is concern about prior ILD history or when baseline imaging suggests active ILD or pneumonitis. He emphasizes that patients with active pneumonitis would not be appropriate candidates for ADC therapy without pulmonary input, framing this as a risk-benefit discussion that differs between clinical trial and real-world settings.

Dr. Rugo concurs that baseline pulmonary consultation is not standard practice in breast cancer, noting that pulmonologists are engaged when patients develop symptomatic ILD or experience delayed resolution. She reports that pulmonary function tests (PFTs), initially recommended for risk analysis, have not proven predictive—grade 1 ILD is detected on imaging before PFT changes occur. For lung cancer patients, baseline PFT abnormalities further limit their utility.

Both experts emphasize that holding the drug remains the most important initial intervention when ILD is suspected, with treatment individualized based on patient-specific factors. The discussion underscores that while multidisciplinary collaboration with pulmonology is valuable, it should be targeted to high-risk scenarios rather than applied universally, allowing efficient resource utilization while maintaining patient safety.