A Case-Based Approach to Second-Line Immunotherapy in Esophageal Cancer

In an interview with Pharmacy Times®, Scott Soefje, PharmD, MBA, BCOP, FCCP, FHOPA, director of pharmacy cancer care at Mayo Clinic, explores treatment options for a female patient with metastatic esophageal squamous cell carcinoma (ESCC) from the perspective of an oncology pharmacist.

Pharmacy Times: Can you discuss the case study of LJ, a 58-year-old patient with metastatic ESCC?

Scott Soefje, PharmD, MBA, BCOP, FCCP, FHOPA: Yeah, so in this case, we have a woman in her late 50s with metastatic esophageal cancer. She was diagnosed six months ago and initially received platinum-based chemotherapy alone. Now she's recurring—she has progressive disease. She’s had issues with hypertension, neuropathy, and, previously, fatigue. She’s now experiencing progressive dysphagia, so swallowing is becoming a significant problem. She also has a history of alcohol abuse, cirrhosis with ascites, and hypertension. She does have a support system in place. So, the question becomes, “What do we do next with this patient in the relapse setting?”

I think the controversy here is whether to use chemotherapy or immunotherapy—and whether this is the type of patient who can tolerate a combination, either together or separately. What we've seen in discussions around similar cases is that this patient would likely receive a single agent of some sort. Most would lean toward one of the immunotherapy products, especially since she only received chemotherapy in the first line and hasn’t yet received a PD-1 inhibitor. So, there's a general consensus to lean toward a PD-1 inhibitor as a single agent and then monitor for tolerability.

Chemotherapy would be challenging, though not entirely out of the question. It depends on the extent of her ascites, which isn't clearly stated here. She didn’t seem to tolerate the previous therapy too poorly, so some might consider switching up the chemo—maybe using a 5-FU/irinotecan-based regimen—and adding immunotherapy. That would be a more aggressive approach.

But I think most people, myself included, would be hesitant to be that aggressive in a relapse setting like this. So, what are we looking at? We're looking at a patient in second-line therapy with relapsed disease. According to the guidelines, the preferred recommendations are single agents. Most would go with a PD-1 inhibitor in this particular case, then focus on managing toxicities and side effects. We’d really need to monitor liver function closely, to avoid complications from potential endocrinopathy-related issues. So, that’s likely the direction we’d take here.