Immune Checkpoint Inhibitors Making Strides in Outcomes of Patients With Small Cell Lung Cancer

In a virtual symposium titled Clinical Updates in Extensive-Disease Small Cell Lung Cancer: A Primer for Pharmacists Caring for Patients, 2 expert speakers discussed pivotal changes in the treatment landscape for small cell lung cancer (SCLC). SCLC represents just 15% of all new lung cancer cases, but the 5-year overall survival (OS) for patients with stage IV SCLC is only about 2%. More than 40 phase 3 clinical trials for first-line, extensive-stage SCLC have been conducted in the past 50 years, although, until recently, none have resulted in FDA approval of a medication for SCLC.

Jacob Kettle, PharmD, BCOP, kicked off the symposium with a quick recap of SCLC diagnosis, risk factors, and staging followed by a review of standard of care treatment for SCLC. For the past 30 years, a platinum plus etoposide has been the standard initial therapy of extensive-stage SCLC and the lone second-line treatment option was topotecan. Dr Kettle indicated that although SCLC is a tumor associated with a high mutation burden and genomic instability, previous attempts at targeted therapies have been unsuccessful. Clinical trial data were presented, showing the role of both nivolumab and pembrolizumab in patients progressing on first-line therapies. Atezolizumab or durvalumab are also recommended therapies in combination with traditional treatments, such as with a platinum and etoposide, as they have shown an improved OS in patients with extensive-stage SCLC. Dr Kettle described how the shift toward use of immune checkpoint inhibitors (ICIs) in SCLC led to approval of 4 ICIs by the FDA in the past 3 years, and in June 2020 lurbinectedin was also approved.

Kelly Gaertner, PharmD, BCOP, BCPS, began by reporting on several promising new therapies under investigation, including veliparib, olaparib, anlotinib, and apatinib, as well as combination therapies with lurbinectedin.

Dr Gaertner provided an overview of the pharmacist’s role in managing patients with SCLC, including:

• Patient education
• Toxicity monitoring and management
• Medication adherence
• Management of drug—drug interactions
• Supportive care
• Smoking cessation

Dr Gaertner presented the adverse effects associated with ICIs and tyrosine kinase inhibitors. Immune-related adverse effects (irAEs) may occur in up to 90% of patients receiving anti—CTLA-4 therapy and in up to 70% of patients receiving anti–PD-1/PD-L1 therapy. Corticosteroids are the backbone of management of irAEs, with aggressive supportive care based on the organ affected. Dr Gaertner highlighted the role of the multidisciplinary team in management of irAEs as well as its impact on enhancing patient outcomes.