A Lung Cancer Roundtable: Takeaways From ASCO 2018 | Transcript | Lung Cancer | Patient Power


A Lung Cancer Roundtable: Takeaways From ASCO 2018

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Andrew Schorr:

How about you, Dr. Kim? I mean, still chemotherapy is still around, still in combination.  People understand there are side effects, not that there are not side effects with the new immunotherapies, but people would like to skip to the most effective treatment first.  So what recommendations would you have for our listeners?   

Dr. Kim:

Yeah.  You know, we're talking strictly about the advanced lung cancer patients.  The new standards in non?small cell, both nonsquamous and squamous, now contain an immunotherapy combined with chemotherapy in markers that are lower selected or unselected.  I agree with Jeff.  You know, the biggest struggle we always want to tell our patients is be patient.  Do not let the chemotherapy start without having the results of your markers.  

And that's where sort of this new diagnosis of cancer comes in, the fear of it growing while you're waiting a couple of weeks for the results of these markers, but we have to reassure patients it's okay because if you just wait the extra one to two weeks.  

And I understand it could take longer getting the biopsy to get enough tissue, sending it away, taking three weeks, and then your doctor, who is maybe not as sophisticated at reading these very, very, 18?page reports, take some time to evaluate it.  It could be five weeks right there very easily, and we don't like to wait that long.  

But if you do have a marker present, and if it is—and now almost 50 percent of the patients with non?small cell have this, have a marker, maybe we'll be able to give you something in lieu of chemotherapy that's not a pill, single?agent immunotherapy.  And certainly as a default now we're seeing again new standards of care.  New standards of care are combination therapy, chemotherapy with immunotherapy based on data that's been presented in the last couple months.  

And so as a biomarker person I love seeing marker?enriched populations receiving less therapy, but as we begin to incorporate these drugs in our standard regimens we're seeing improvements that are undeniable and are forcing us now to readjust or new standards. 

Andrew Schorr:

Dr. Crawford, so I've heard along the way, and I know knowledge is expanding, whether or not some of these newer approaches apply to people whether—you know, whether they smoked or not, whether they had a history.  Where are we now with having the widest array of approaches for the widest array of people whether they're smokers or not?   

Dr. Kim:

So smoking is clearly an important factor in outcome for patients, and it's also somewhat predictive of likelihood of different things.  We know smokers have a lower rate of EGFR and ALK translocations, mutations. We also know that they have a higher rate of PD-L1 expression and may be more likely to respond to some of these immunotherapies, but those are just generalized statistics.  And we have smokers who have EGFR mutations, and we have never smokers who respond beautifully to immune checkpoint therapy, so the answer is we have to do the molecular testing and sort out who has what. Smoking may influence that frequency, but on any individual patient basis we have to have the tests to know how to best to treat them.   

Andrew Schorr:

That's good news.  So, Dr. Kim, you had referred earlier about cancer being kind of wily, if you will.  So is it possible that the molecular testing results at time of diagnosis further down the road may be different?  In other words, some other gene is driving the cancer should it come back or it's still going, and you need a different approach.  In other words, you have to change horses, if you will.  

Dr. Kim:

Yeah, that's a great point, Andrew.  You know, back in 10 years ago, almost 11 years ago when we initiated this trial while I was at MD Anderson called BATTLE, the whole principle was to re-biopsy patients once they completed or once the first line of therapy stopped working. And for that very point you brought up is that these tumors change.  If you use a baseline tissue, that's a very different environment that that tissue was exposed to.  It has not been treated with chemotherapy, it's not been under different stressors, and nor has it now begun growing after getting chemotherapy.  

So a patient, just as you say, who has been treated maybe there was some success but then it—with chemotherapy it's always a little transient, and then now the tumor is growing despite being treated, that could be a different tumor.  It's been shown also by the Boston group that you get transformation to small cell, of all things, in about 15 percent of patients.  And so different histologists altogether.  So who knows what will evolve out of the cancer that's been treated that is now beginning to grow.  

And so I think it's really important to have a repeat biopsy when this occurs to help again drive the appropriate treatment.  And, as we talked about earlier, if it's difficult sometimes a liquid biopsy can even be done at this setting if it's difficult or the patient is has a difficult area to get tissue.  

Andrew Schorr:

So, Dr. Crawford, you have lung cancer meetings throughout the year, but the ASCO meeting with like 40,000 people across all cancers from around the world, it's a big meeting. You're involved in research and, of course, with existing therapies as well, how positive do you feel about change and even the rate of change to offer hope for people dealing with lung cancer today?   

Dr. Crawford:

I'm as excited about lung cancer as I've ever been, and I've been doing this for quite a while.  The rate of change is, as Ed has pointed out, is dramatic.  The number of new agents that we have seen over the last year, both targeted therapies and immunotherapies, and the rate of change, it's not just ASCO every year. AACR, a meeting that's normally more basic research, had major breakthrough discoveries as well I'm sure this year, and Europe will have additional new discoveries as they did last year.  

So it's really changing every few months, our guidelines through NCCN have to be changed almost monthly, and I think that's a good thing.  It's telling us that new knowledge is really being moved very quickly into the patient care arena.  

Andrew Schorr:

Dr. Kim, so we've talked largely about non small?cell lung cancer, and you've rattled off some of the different types.  There's a percentage of people, smaller percentage, but people with small cell?lung cancer.  Were there things you were hearing there at ASCO that could offer hope or in research to help this population as well?  

Dr. Kim:

And certainly Jeff is the expert here.  He's had a long career with it.  Small cell has always been that tough cancer where you get teased a little bit. Again, if you're fortunate enough to find someone in limited stage, you can try to deliver curative intent therapy. If they happen to be in an extensive stage, it really becomes about trying to give chemotherapy that has a high response rate, and so you feel good about that, but then the difficult aspect of it is that in fact it doesn't last forever.  And so when it does again not respond, it's not responding, we've got to figure out some things.  

The immunotherapies have been very widely tested, and so there are some therapies that are coming. There are some that are approved, nivolumab (Opdivo), ipilimumab (Yervoy) have been used.  They're trying to incorporate in combination with chemotherapy with these immunotherapies.  There are some other drug classes, Rova-T (Rovalpituzumab Tesirine) and others that are being looked at very closely in small cell.  So I love the fact that there's spillover in the small cell, because it wasn't really a high area of importance for a lot of development of drugs, which was unfortunate because we still see those patients, but it's nice to see that there's a lot of studies been looking at these types of drugs.  

Andrew Schorr:

Okay.  Dr. Crawford, any other comment you wanted to make about small cell?  

Dr. Crawford:

I would say it's an area that's been difficult to see advances.  Small cell presents generally at more advanced stage, so very few patients can have surgery.  Chemo and radiation can still be curative for early?stage patients with lymph node involvement who don't have distant disease, but in the advanced stage setting we've been using the same chemotherapy for 20 years.  Our supportive care has gotten better, we've made some advances, but we're hoping immune therapy and others will make a difference.   

It's kind of interesting. Small cell, you would think, since it's prevalent largely in smokers, people with smoking exposure, could be very—a lot of mutations being present.  We know that total mutation burden is a nice predictor of benefit in non small?cell lung cancer, so we think that would—might play out here. There is PD?L1 expression in small cell but it's not as intense.  And there is some separation by PD?L1 score of benefit for immune checkpoint therapy in small cell, but the responses in general are less than they have been in non?small cell.  So we're going to need more, more homework to figure this one out, but I think we're taking some steps in the right direction.  

And as Dr. Kim pointed out, Rova-T is a targeted therapy, maybe one of the first targeted therapies we've had in small cell that attacks antigen present on a lot of small cell called BLL3, and there are other therapies being developed against that BLL3, because we know that's an important marker.  So I hope we will see agents that are truly targeted therapies in small cell in the next few years.  

Andrew Schorr:

Okay.  So I think as we pull this together, and I think you were rattling off some acronyms, and that's sort of what we've been seeing a lot in lung cancer now.  We've talked about EGFR and ALK and ROS1, and we talked about also PD?L1.  So I know for patients it can be confusing, but look back, review this program with Dr. Crawford and Dr. Kim were saying about if you have someone diagnosed with advanced lung cancer to get that molecular test and get that more complete biopsy to make sure that the experts like this and your local doctor if you’re not treated in a university or in your major center like this, that they have the information.  And then if you need to get a second opinion, Dr. Kim, you said it’s an 18-page report you may get back.  So obviously the community oncologist has a lot to sort through, but there's help in second opinions from people like this.  Dr. Crawford, did I get it right?   

Dr. Crawford:

I think you did.  You're a good student.  

Andrew Schorr:

Okay.  All right.  Well, we have two professors with us, Dr. Edward Kim from the Levine Cancer Institute in Charlotte, North Carolina, my old home town, and Dr. Jeffrey Crawford from Durham and Duke University.  I'll say that even though I went to the University of North Carolina eight miles down the road.  

Dr. Kim:

You had to say that.  

Andrew Schorr:

Yeah.  Thank you.  Thank you both for your work in treating patients and in researching, helping give us a window into this ASCO conference, but I get the sense you—you said it, Dr. Crawford—you're having meetings every couple of months and talking to your peers all the time, and this is a faster changing field. Thank God, right?  So thank you so much.  Dr. Crawford from Duke, thank you so much for being with us.  

Dr. Crawford:

Andrew, thank you so much and thanks to all the patients who are joining in today.  It's for you we do all that.   

Andrew Schorr:

Yeah, thank you.  And Dr. Kim, thanks.  I interviewed you years ago, and you were at MD Anderson. Now you're in Charlotte, and you have a wonderful program there.  Thank you for being with us.  

Dr. Kim:

Thank you, Andrew.  It's our pleasure, and again, we're just as excited as the patients, because we get to offer them these really cool therapies and research studies.  

Andrew Schorr:

Right.  Okay.  All right. All the best to our patients and family members watching.  For the Patient Empowerment Network, I'm Andrew Schorr from Patient Power. Remember, knowledge can be the best medicine of all. 

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you. 

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Page last updated on June 22, 2018