Taofeek K. Owonikoko, MD, PhD:Dr [Konstantinos] Leventakos, can you give us a brief overview of the landscape of the second-line treatment options, and what the different classes of agents that you typically use are?

Konstantinos Leventakos, MD, PhD: Definitely. First of all, let me start with the idea that we have second-line options, and research has shown that we do not offer second-line treatment as much as we should. I think a very strong message is that we should always discuss the available options with the patients. So definitely the case highlights the fact that we can always go back to the same chemotherapy by means of platinum-doublet. I would agree that this is maybe a good time that we’re looking at a chemotherapy-free interval. And this is something that I usually use when we have a chemotherapy-free, or at least I feel more comfortable when it is more than 6 months to say that I would repeat the same regimen. The old classic second-line treatment is a topoisomerase inhibitor with classic topotecan, in this part of the world, some other places might use irinotecan. I think in the United States, topotecan used to be the main second-line treatment. I think that things have changed a lot since lurbinectedin [Zepzelca] because it has become very strong in the second line mainly due to characteristics that we will be discussing. When it comes to other agents, I have to be honest, I don’t use that much in the second line. Someone could use taxane, so gemcitabine with very specific patient characteristics. But I think that the main 3 options would be repeating the same regimen, topotecan, or lurbinectedin. And actually, I said that of the 3, my best option is always a clinical trial. I think that especially given the prognosis of the recurrent disease, and the lack of data that we have for this disease. I think that prioritization for a clinical trial is very important.

Taofeek K. Owonikoko, MD, PhD: Thank you. Dr [Anne] Chiang, what are your approaches when you have all these options? How do you select a second-line option for patients?

Anne Chiang, MD, PhD: I agree with my colleague, we do have second-line treatments, so that’s No. 1. And many of these patients are actually doing OK because we’ve detected their disease at a point where it’s still pretty minimal, so they can respond pretty well. If it’s been 6 months or more, then we really do consider platinum re-treatment and adding immunotherapy to that. I think that’s the nice part of that. If we are looking at somewhere in between 3 to 6 [months], sometimes, as in your patient who really wants immunotherapy, sometimes we’ll end up doing that. If it’s somewhere 4 to 5 months, we might platinum re-treat with immunotherapy. Lurbinectedin is a great tool for us. I think that those patients tolerate the treatment very well, and we’ve had some very nice responses to that. I think it’s the second-line tool for most folks. It would be great if we could combine that with immunotherapy. And I think some of those trials are ongoing because I know that our patients are looking for that. In that lurbi [lurbinectedin] trial, if the overall response rate was in the 30% range, and then if the patients were platinum- sensitive, they actually had a little bit higher response rates, sort of in the 40%, 45% range. If they were platinum-resistant, they were a little lower. So they were somewhere in the 20%, 25% range for those patients who did well. So chemo-free treatment interval of 180 days or more, they were up at a 60% response rate. I think, again, those patients who do well are hopefully going to continue to do well, but we have to do better for the other folks as well.

Taofeek K. Owonikoko, MD, PhD: A lot of our patients will get a second line. We know we’re not curing them. In the front line maybe we can talk about curing a few patients, but in the second line, that’s not what we’re talking about. So when the patient progresses on your second-line regimen, what’s your approach?

Anne Chiang, MD, PhD: Clinical trial.

Taofeek K. Owonikoko, MD, PhD: I know that is going to be the right answer. But there is no slot available, is there something else that you can offer the patient?

Anne Chiang, MD, PhD: I think we have agents and we have tools. We can use topotecan. We can use irinotecan. And we can use taxanes. I have some colleagues that swear by taxanes. As you know, brain mets [metastases] are a real issue in our patient population. So sometimes we’ve already done whole brain [radiation] or sometimes we’ve done Gamma Knife [radiosurgery]. And sometimes something like temozolomide [Temodar] is helpful to maybe cross that blood–brain barrier and have some efficacy in the brain. I do think we have some options. I have even given CAV [cyclophosphamide, Adriamycin [doxorubicin], vincristine] that comparator arm in my patients who’ve progressed through different therapies and really still have the performance status. I think that you do need to talk to your patient about [the] best supportive care so that they understand that at some point, unfortunately, diminishing returns in terms of response rates [can happen], and that we have to prepare them for a time when we’re really going to focus on quality of life and not necessarily anticancer treatment.

Transcript edited for clarity.