Promising Cancer Therapies in Advanced Lung Cancer
Philippa Cheetham, MD; Leora Horn, MD, MSc; and Evan C. Osmundson, MD, PhD, highlight the use of immunotherapy and targeted therapy and consider the appropriateness of radiation therapy in advanced lung cancer.
PUBLISHED November 13, 2017
Philippa Cheetham, MD: With these newer drugs that are coming out, do you think that most of the developments, Dr. Horn, are in end-stage lung cancer? Is that where we’re seeing the most bang for our buck with the newer treatments? That survival is being improved in patients with more end-stage disease or advanced disease?
Leora Horn, MD, MSc: So, end-stage disease can really be from the time of diagnosis, and not after multiple therapies. A lot of drugs are first developed for patients with advanced-stage disease. Once we see the success in patients with advanced-stage disease, we’ll see them taken to earlier stage disease. And then, we see if we can improve cure in patients with early-stage disease. So, right now, yes. The progress is being made in patients with advanced-stage or end-stage disease, as you say. But I think with time, we’re going to see improvements in early-stage disease as well.
Philippa Cheetham, MD: Now that we have these newer immunotherapy treatments available, does that mean that you’re more likely to prescribe these medications for older, sicker patients that might not have done so well with traditional chemotherapy regimens? Is it opening up the spectrum of treatment to more patients as a result of the better side effect profile?
Leora Horn, MD, MSc: Immunotherapy and targeted therapies have been easier to administer in patients with more comorbid disease, but we have to remember, we’ve got to select the right patients and give the right drug in the right order. For patients who are too sick to even get out of bed and come to therapy, I still don’t think that we should be treating them with systemic therapy. We should continue to involve palliative care with discussions of goal of care and a focus on quality of life. But it’s definitely been easier to give these drugs to patients with multiple comorbid illnesses, because the toxicity profiles are so much easier to manage.
Philippa Cheetham, MD: And when a patient asks about targeted therapy, how do you educate them about what targeted therapy actually means? How would you have that conversation with a patient and their relative?
Leora Horn, MD, MSc: We generally tell them, “We’re going to do molecular profiling of your tumor, and do PD-L1 testing. And, based on the information, we’re going to decide what the best therapy for you is.” When we talk about targeted therapy, I explain that it’s not traditional chemotherapy. I say that there is something that’s making their tumor grow. And by giving this targeted therapy, we’re sort of turning off the light switch. Their tumor will stop growing and it will often shrink.
We also have to temper expectations. We know that with targeted therapy, you can often get dramatic shrinkage of the tumors. I do tell patients shrinkage or staying the same size is success. On subsequent scans, you’re not going to see more shrinkage. You’re going to get that maximum shrinkage with that first scan. But as long as we don’t see growth, we consider the treatment to be working and we continue on the therapy.
Philippa Cheetham, MD: So, explaining to patients what scan findings mean so that they really understand that stable disease doesn’t necessarily mean that they’re not cured?
Leora Horn, MD, MSc: Absolutely.
Philippa Cheetham, MD: We’ve heard that radiation has a role not just for treating the primary tumor in its more advanced stage but for tumors that have gone beyond the chest. Can you talk a little bit about what you see for the future of those treatments for patients who have disease beyond the primary chest site?
Evan C. Osmundson, MD, PhD: One of the main indications for radiation in patients with metastatic disease is brain metastases, because we know that they can cause havoc very quickly. There’s not a lot of room to grow. Patients can become symptomatic and it can really impact their quality of life. So, if a patient presents with brain metastases, we are very eager to treat that sooner rather than later. Sometimes, in very good performing patients, that may even include neurosurgery. But oftentimes, it involves radiation therapy. And, with very few metastases to the brain, we’ll often do very focused stereotactic radiation.
Radiation may be used in patients with advanced or metastatic disease as palliative therapy for relieving pain. As patients start to live longer and longer, the addition of radiation therapy in oligometastatic patients, that’s patients with few metastases, can improve their progression-free survival. We can perhaps give them that chemotherapy holiday that they may need to give them a break from toxicity. So, as our systemic agents improve, I do believe that the importance of local control and radiation therapy will grow.