Choosing the Right Checkpoint Inhibitor Combination Therapy for First-Line Advanced Non–Small Cell Lung Cancer

For first-line advanced non-small cell lung cancer therapies, oncologists are hoping to work on identifying issues that tend to emerge when making treatment decisions, according to a session at the 2021 American Society of Clinical Oncology Annual Meeting.

The panel was led by moderator Shirish M. Gadgeel, MD, from the Henry Ford Cancer Institute, Henry Ford Health System and featured panelists Kathryn Finch Mileham, MD, FACP, Levine Cancer Institute/Atrium Health; Luis G. Paz-Ares, MD, PhD, Hospital Universitario 12 de Octubre; and Rosalyn A. Juergens, MD, PhD, Juravinski Cancer Centre, McMaster University.

While discussing a few case studies, the panel was able to make appropriate treatment decisions for each patient and emphasized the importance of communicating with patients as a physician. For example, in case 1, while analyzing a 62-year-old woman who was very symptomatic and showed a superior sulcus tumor invading into vertebral bodies and multiple bone metastases, what stood out the most to the panel was her history of not being a smoker.

“We test those with never-minimal smoking history, but as the landscape continues to change, we need to be testing all patients regardless of histologic subtypes,” Mileham said. “Further, if you did not have sufficient tissue given history of never smoking, I would advocate getting additional tissue or blood-based testing.”

In choosing a treatment among combination therapies carboplatin/taxane/pembrolizumab, carboplatin/paclitaxel/nivolumab/ipilimumab, pembrolizumab or atezolizumab or cemiplimab, nivolumab/ipilimumab, or chemotherapy alone, Juergens reiterated that physicians have to use clinical judgments based on the information that is given.

“This case was hard since the patient is very symptomatic, so getting a response from the patient is critical,” she said. “In a young, healthy woman with no comorbidities, the best served therapy is combination therapy versus a single agent.”

Paz-Ares mentioned that it is crucial to take into account the clinical presentation and how much tumor burden a patient has, such as their aggression of disease and their symptoms.

“Another important issue to tackle is gender,” he said. “As a woman using immunotherapy, a single agent may not be doing as well.”

Case 2 looked at a 67-year-old man with a 10-year smoking history who presented with progressive dyspnea on exertion. Due to COVID-19 concerns, he sought evaluation at an urgent care clinic. Since he had 1600cc removed resulting in post-procedural pleuritic pain, coronary artery disease, and a history of hepatitis C treatment, the panelists felt this was an example of a situation in which the choice of therapy is based on the conversation between physician and patient.

“Some issues are considering PD-L1 expression, comorbidities, and convenience, and expectations are important,” Paz-Ares said. “The second most important parameter is how many patients are alive, as this is something to discuss with them directly, but we are not getting a lot of comparative data at this time.”

Mileham said that the most important question for physicians to consider when making treatment decisions is how can they can continue to ensure they are not making the wrong decision. Juergens added that looking at patients’ goals for care and discussing these at the very beginning of treatment is what will make an oncology team successful.

REFERENCE

Finch Mileham K, Gadgeel SM, Juergens RA, Paz-Ares LG. Making Heads or Tails Out of Checkpoint Inhibitor Combination Therapy for First-Line Advanced Non–Small Cell Lung Cancer. Presented at: ASCO 2021 Annual Meeting. June 7, 2021. Accessed June 7, 2021.