Dr. Farago on Eligibility Criteria for Frontline Immunotherapy in SCLC

Anna F. Farago, MD, PhD, attending physician in the Center for Thoracic Cancers at Massachusetts General Hospital and assistant professor of medicine at Harvard Medical School, discusses patient eligibility criteria for frontline immunotherapy in small cell lung cancer (SCLC).

The National Comprehensive Cancer Network guidelines list the combination of atezolizumab (Tecentriq) with carboplatin and etoposide as a category 1 recommended and preferred regimen for patients with extensive-stage SCLC, says Farago. However, data from the phase III IMpower133 trial, which served as the basis for the regimen’s approval, did not reflect patients with active autoimmune diseases, as they were excluded from the trial. There is concern about the risk of autoimmune disease flares or other autoimmune complications for patients with an autoimmune condition. However, the risk depends on the severity of the disorder or history therein. An autoimmune disorder does not disqualify a patient from receiving a checkpoint inhibitor, explains Farago.

The other population that was excluded from the trial was patients with untreated brain metastases. Similarly, untreated brain metastases do not disqualify a patient from immunotherapy. Rather, the decision comes down to clinical judgement. It's not uncommon that patients with SCLC present with small asymptomatic brain metastases. Historically, these patients receive standard carboplatin and etoposide and are followed closely. The same approach could be taken with the addition of atezolizumab, says Farago. However, these patients are likely to require whole-brain radiation at some point in their treatment, which warrants additional consideration.