Lung Cancer Management Methods Expand to Encompass Multiple Treatment Perspectives

Kathryn Mileham, MD, FACP

New treatment methods in patients with small cell lung cancer (SCLC) and non–small cell lung cancer (NSCLC) are on the horizon, with the introduction of combination immunotherapy, biomarker assays, and supportive oncology programs for patients and care partners, according to faculty from an OncLive^® Institutional Perspectives in Cancer webinar on lung cancer.

The event, chaired by Kathryn Mileham, MD, FACP, chief of the section of Thoracic Medical Oncology, Levine Cancer Institute, Atrium Health, focused on the clinical benefits of immunotherapy in the frontline setting in advanced NSCLC, the evolving management of SCLC, the role of testing aberrations to discover and treat mechanisms of resistance, and the importance of oncology departments that identify and support patients’ unmet needs.

Mileham was joined by her colleagues:

• Daniel Haggstrom, MD, oncologist, Levine Cancer Institute, Atrium Health
• Daniel Carrizosa, MD, oncologist, Levine Cancer Institute, Atrium Health
• Dori Beeler, PhD, research scientist, Levine Cancer Institute, Atrium Health
• Michele Szafranski, RD, CSO, LDN, dietician, Levine Cancer Institute, Atrium Health

Below, Mileham, Haggstrom, Carrizosa, Beeler, and Szafranski summarize the main points from their presentations.

Frontline Immunotherapy for NSCLC

Haggstrom: The role of immunotherapy in the frontline setting for [advanced] NSCLC continues to expand. Combination immunotherapy with ipilimumab [Yervoy] and nivolumab [Opdivo] and combination chemotherapy [and] immunotherapy are viable first-line options.

Patients that experience immune-related toxicities, now that the recognition and management protocols are in place, can still receive clinical benefit even after cessation without negatively affecting response. Patients who respond [to] or can complete 2 years of maintenance immunotherapy have a significant and durable survival benefit compared with those who cannot.

Additional comparative studies across histologic subtypes in potentially high-risk groups such as patients with active brain disease [that are] powered to compare frontline [immuno-oncology (IO) agents] with chemotherapy/IO combinations continue to be needed.

Current Management of SCLC

Carrizosa: At this point in extensive-stage SCLC, we have what we now know is a standard of care using immunotherapy either with durvalumab [Imfinzi] or atezolizumab [Tecentriq] in the first-line setting. This improves overall survival and has changed the course of SCLC.

Unfortunately, remembering the curves [from the data that led to these approvals], a bunch of patients [don’t] respond to this [approach]. We are still looking for second-line therapies.

Lurbinectedin [Zepzelca] is a new option that we’ve been able to come up with recently, and we will see in the next several years if combinations [with this agent] are necessary or where [lurbinectedin] will go in the landscape. We still have both oral and intravenous topotecan that is FDA approved, and we can try and find other ways of trying to treat our patients in the second-line setting. With studies, we’re trying to find other ways to improve maintenance or other forms of treatment that may help these patients.

Unfortunately, as we all know, [SCLC] is a very difficult disease. We have been moving that marker some, as the 2-year [overall] survival [(OS) rate] was very low, less than 10% in historical data, and the 5-year overall survival [rate] was [0%]. Looking at the data with durvalumab, we have improved [OS] significantly. At this point, we’ll have to see how things change over the next several years, but hopefully we will get newer drugs for [SCLC] that will start looking like what we have for [NSCLC].

Targeted Therapy for NSCLC

Mileham: [Selpercatinib (Retevmo) and pralsetinib (Gavreto)] are standard first-line therapies for RET fusion–positive [NSCLC]. Additional RET inhibitors are under development, and off-target resistance appears to be a dominant mechanism in [patients] who have progressed on prior therapies for RET fusions, MET amplification being one.

The overarching message for this comprehensive, and yet, still touching-the-surface discussion on targeted therapies in [NSCLC] is really that there is no mutation unless you test. Unless you test to identify the aberration, you don’t know if it exists.

Selective treatment, although beneficial, ultimately leads to progression, and, that mechanism of resistance needs to be identified. If you do not test for that mechanism of resistance, you don’t know the direction for the next selective treatment that can be utilized, whether that’s a standard of care, or [one that is] being developed and available in a clinical trial.

Development and Coordination of a Lung Cancer Supportive Oncology Program

Beeler: Myself and my colleague Michelle Szanfranski presented information regarding some collaborative work we did with [Atrium Health’s Levine Cancer Institute’s] thoracic oncology department to support the unmet needs of patients and their caregivers, or care partners. This work was presented to demonstrate the ways in which a needs assessment can support departments in supporting their patients and [introduce] the programs that were generated from that work.

[My biggest take-home message regarding this program is] an emphasis on health literacy. It’s certainly good to put these programs together, but they don’t accomplish anything if patients and care partners don’t understand the material. Also, having the support of a leading expert in the department and the section is necessary as well. Dr Mileham served that end and continues to do so.

Another take-home is to constantly reassess the program. Don’t view it as a static piece of information, but rather something that is a living, breathing entity that needs to be revised on occasion.

And, in relation to coming out of the pandemic, one of the things that we learned was to have multiple touchpoints. It’s good to see people in person, but what we also find is that as people have grown more accustomed to these virtual platforms, we can reach a wider audience now, and people can get support when and how it suits their needs.

Szafranski: We’re [going to] have a continuous review of [patient] unmet needs going forward. We want to continue to engage the patients and their care partner voices. We really want to focus on health literacy. That was one of the things that really shone through in the data we got back. Patients need to be able to understand what our programs and services are about. [Our work also focused on] ease of access and self-referral—we wanted to make it very easy for patients to be able to self-refer to most of these programs.

Beeler: What we presented the other night was also a call, a soft sell, to say that what we put together is a model that can serve other departments as well outside of just thoracic [oncology]. This is something that can expand to other departments, other sections, other areas altogether. It’s a model that we hope we can expand on in other areas as a supportive oncology department so other patient bases can benefit from this approach.