Advice on Toxicity Management for SCLC Therapy

Vivek Subbiah, MD: One more question I have now is, what tactical advice would you share about the expected toxicity management, especially if you want to combine them with radiation all in the COVID-19 (coronavirus disease 2019) era?

Apar Ganti, MD: One of the things that becomes difficult in the COVID-19 era is if you see pulmonary infiltrates, you don’t know what they are. Of course, it’s important not just to trust your scans but also talk to the patient, see what other kinds of symptoms that they are having. My approach has been that if they have not had other classic symptoms of an infection, like fever, then I would not necessarily blame it on COVID-19, but rather consider this immune-related pneumonitis. I would have an intermediate threshold for stopping the immunotherapy because, yes, it is very beneficial, but at the same time, you don’t want pneumonitis to get out of hand. I would monitor them closely, check their symptoms, monitor that; this becomes even more important in the setting of those patients we give thoracic radiation to. You have to be very clinically alert in distinguishing between the pneumonitis due to checkpoint inhibitors due to radiation if you offer them thoracic radiation. With COVID-19, I’m not aware of any CT scan findings that would differentiate 1 from the other, except that radiation pneumonitis is within the radiation field, and if you see something outside, you have to worry about other things. That is 1 practical aspect.

The other things is, we’ve been taught that we have to use steroids for immune checkpoint inhibitor–induced toxicity. At the same time we have to be a little concerned about the possibility of higher doses of steroids affecting the response rate to the treatments. That’s a fine balance. What I tend to do is if I have a patient who is overtly symptomatic, then I would stop the checkpoint inhibitor and start them on steroids and try to ween them off steroids as quickly as possible. Of course, we need to understand that some of these patients need a much longer taper and then hold them off. Whether to rechallenge with the immunotherapy drug depends on how severe their initial symptoms were and how quickly they respond to steroids. So those are some of the practical tips I’ve learned while using these drugs in this particular setting, especially in the COVID-19 era.

Vivek Subbiah, MD: Perfect. Thank you, Dr Ganti. Do you have anything else to add, Dr Chiang?

Anne Chiang, MD, PhD: These drugs are very well tolerated. The grade 3, 4 in the studies, adverse events were really in the 2% to 5% range with rash, hepatitis, and colitis the main things that people were worried about. Obviously, we do worry about pneumonitis. In the COVID-19 era, we see some of our patients with telehealth. Just to follow what Dr Ganti said, these are patients probably who would be better not being seen by telehealth but in person, so you can really evaluate their oxygen saturation and their vitals, listen to their lungs, and see how they’re doing. With regard to the steroids, many of our protocols allow patients who are on prednisone of 10 mg or the equivalent, or below, to be on trial getting checkpoint inhibitors. There have been data within that realm to show that that seems to be okay. Rechallenge is possible, although I think you really have to be careful. Hepatitis is not something that we generally rechallenge for.

Transcript Edited for Clarity