Multidisciplinary Management of Patients With Stage III NSCLC

Mark Socinski, MD: There was a presentation at ASCO last year, I believe it was by The University of Texas MD Anderson Cancer Center group, and they describe this pseudo-progression where the mediastinal adenopathy looked worse. Obviously we get concerned about disease progression, although it’s pretty quick disease progression. They demonstrated that even in these scans, if I remember the scans correctly, the PET scans were pretty frightening in terms of bringing that patient to the OR, but they found that this was more reactive adenopathy and not pathologic adenopathy.

Any experience or any perspective on that from your vantage point?

Brendon Stiles, MD: I can comment a little. They referred to it as nodal immune flare, and they actually saw it in 10% of those patients and that was nivolumab versus nivolumab-ipilimumab and I think it was similar in both arms. We’ve seen it in the nodes, and we’ve seen it a couple of times in the lungs, at the same time each neoadjuvant group. I’ve seen a couple of cases of progression, and the take-home point is to biopsy everything. If you see progression on the PET scan, don’t assume it’s 1 thing. Don’t assume it’s just reactive disease either. Its critical to biopsy and know what you’re dealing with.

Mark Socinski, MD: Stephen and Roy, any experience in that area?

Stephen Liu, MD: I’ve shared several patients with some of the Johns Hopkins groups. We’ve seen that it takes a trained eye to recognize that. While the surgical complication rates were fairly low, you’re talking about highly trained surgeons. You’re talking about centers with a lot of experience. As neoadjuvant immunotherapy approaches become more integrated into standard care—right now only done through trials—it’s going to take some education, so we don’t assume someone has progressed when actually they’re having a great response to treatment, and so we don’t forgo surgery when we should be pushing forward. It’s going to take a little bit of education and a little bit of retraining to understand that there are some atypical response patterns here.

Roy S. Herbst, MD, PhD: All I can add is it speaks to the need for the multimodality tumor board and discussing these cases very carefully with your surgeon, pathologist, and oncologist.

Mark Socinski, MD: Thanks, all. This has been a fabulous, rich, and informative discussion. Before we close the program tonight, I’d like to get some final thoughts on this early stage non–small cell lung cancer from the resectable adjuvant setting to the PACIFIC setting if you will. I’ll start with Dr Herbst.

Roy S. Herbst, MD, PhD: I’m excited, Mark. It’s been 23 years since the advent of EGFR inhibitors. We’ve seen them used in the most metastatic unselected setting to selected with EGFR mutations discovered to more active and less toxic drugs like osimertinib, and now we’re seeing them used in the adjuvant setting. Still work to do, but very promising early results that I believe are practice changing.

Immunotherapy the same, we’re using it in the earlier stages of disease. One thing we have to think about with immunotherapy is we have to learn from the targeted therapy realm. We’re using immunotherapy in all patients, but clearly we need biomarkers. We need to find those patients in whom single immunotherapy works best. Some might need combinations, and early stage disease is going to be the perfect place to find that because we’re going to get tissue. We’re going to understand it.

The progress has been overwhelming with improved benefits for our patients.

Mark Socinski, MD: Thanks, Roy. Kristin, your final thoughts?

Kristin Higgins, MD: I’m excited about moving the needle in our stage III unresectable patients. The PACIFIC was a game changer. In the years to come we’ll have a lot of data about how to optimize the synergy between radiation and immunotherapy and even moving targeted therapies into the stage III setting with the LAURA study that’s ongoing. The targeted therapies and immunotherapies are moving the needle for a curable disease, which is really exciting for our patients.

Mark Socinski, MD: Dr Liu?

Stephen Liu, MD: What we’re seeing happen is our standard of care is rapidly changing for stage III unresectable, for resected EGFR positives, soon for preoperative setting for resectable non–small cell lung cancer and as our standard of care changes It’s important to keep referring patients to those trials. While these adjuvant and consolidation therapies have significantly improved outcomes, there's still a lot of room for improvement. Building on those as a backbone, taking the next step beyond these studies, will continue to be really important.

Mark Socinski, MD: Brendon?

Brendon Stiles, MD: I agree with all my colleagues. It’s an incredibly exciting time in lung cancer, early stage lung cancer in particular. I’m particularly excited that the science has led us to where we are and that it’s developed all these pathways that we now have to treat patients.

The data you heard presented puts the onus on surgeons and others involved in staging these patients to stage them well, to think about testing for molecular observations, and to have multidisciplinary consults on every early stage lung cancer patients because there are just so many options available.

Mark Socinski, MD: I must say, when that press release came out looking at the 2017 reduction in cancer mortality and lung cancer led the way, I’m sure all of you felt it. At least from when Roy and I started in this business and others, it was a pretty nihilistic disease setting. Therapies were not that effective, and many felt it wasn’t a very treatable disease. Now we’re at a time where we led the way in reduction of cancer mortality, so it’s very gratifying.

I want to thank all of you for joining me today. I want to thank our viewing audience. We hope this OncLive® Peer Exchange® discussion was useful and informative. Thanks for joining us.

Transcript Edited for Clarity