Treatment Options in NSCLC After First-Line Therapy


Adam J. Schoenfeld, MD, provides key insights into treatment options for patients with non–small cell lung cancer whose tumors progress after first-line therapy.

Adam J. Schoenfeld, MD: I’m Dr Adam Schoenfeld, an assistant attending physician at Memorial Sloan Kettering Cancer Center in thoracic oncology.

The treatment options for lung cancer are continuously evolving and changing. It’s not a one-size-fits-all approach for either first-line treatment or treatment in the resistant setting. It’s important to take a step back and think about treatment options for metastatic stage IV disease. If a patient has a mutation, such as an EGFR or ALK mutation, then their first-line treatment options can be pill-based therapies, targeted therapies. On the other hand, if they don’t, treatment typically involves chemotherapy with immunotherapy or immunotherapy alone. Treatment in the resistant setting depends on what patients had in the first-line setting.

First-line therapy is based upon a number of factors for patients, including their clinical context of how they’re doing, and their molecular status, the mutations or alterations their tumors harbor. If a patient has certain specific mutations that are driving their cancer, that may determine that they are eligible for certain targeted therapies. If not, they typically receive immunotherapy with or without chemotherapy.

First-line therapy is very important in determining what patients receive in the later-line setting. If patients have a molecular alteration, they will typically receive targeted therapy in the first-line setting. They can still receive other therapies, such as chemotherapy with or without immunotherapy, in the later-line setting. If patients do not have a molecular alteration that’s driving their lung cancer, they typically receive immunotherapy with or without chemotherapy in the first-line setting. In the later-line setting, most therapies are limited to other chemotherapies that have low response rates.

Molecular testing impacts both first-line and later-line therapy options. It is often used to determine first-line therapy options for patients, but sometimes we do not learn about their molecular alterations in the first-line setting, and then they can go onto those therapies in the later-line setting. Molecular alterations can often be used to identify markers for experimental therapies, targeted therapies, or other targeted options.

Transcript edited for clarity.

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