Dr Rotow on Challenges With Targeting CNS Metastases in Lung Cancer

Julia Rotow, MD, clinical director, Lowe Center for Thoracic Oncology, Dana-Farber Cancer Institute; assistant professor, medicine, Harvard Medical School, discusses existing unmet needs for patients with lung cancer and central nervous system (CNS) metastases, as well as the importance of multidisciplinary collaboration throughout all aspects of cancer care.

The lung cancer field’s understanding of the efficacy of both established and novel agents in patients with lung cancer and CNS involvement remains limited, necessitating prospective clinical trials that may elucidate CNS-specific responses, Rotow begins. Although the mechanism of the blood-brain barrier is well understood, the blood-tumor barrier may be even more permeable, she notes. Recent data indicate that the blood-tumor barrier may allow for therapeutic responses in the CNS that are comparable to those observed systemically with agents that are not typically considered to have CNS activity, Rotow explains.

The field’s grasp on the mechanisms of resistance to current therapies in the CNS is still in its infancy, according to Rotow. However, this area of research is challenging to study because CNS biopsies are not possible and plasma-derived circulating tumor DNA is unlikely to reliably detect genomic profiles in the CNS, Rotow says. Emerging cerebrospinal fluid–based DNA profiling technologies may offer less invasive alternatives for studying CNS genomics, although their clinical utility requires further investigation, Rotow emphasizes.

Furthermore, the complexity of lung cancer treatments, including the integration of neoadjuvant, perioperative, and adjuvant regimens into the paradigm, underscores the necessity of multidisciplinary collaboration early in each patient’s disease course, Rotow reports. Surgeons, medical oncologists, and radiation oncologists should all be present during treatment decision-making conversations, according to Rotow. Although this multidisciplinary approach is well established in many academic centers, it needs to be effectively facilitated in community oncology settings to ensure that all patients with lung cancer receive comprehensive care from the outset, Rotow concludes.