The Proactive Lung Cancer Patient: How to Get Tomorrow’s Medicine Today | Transcript | Lung Cancer | Patient Power


The Proactive Lung Cancer Patient: How to Get Tomorrow’s Medicine Today

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.

That said—and Don, you’re living proof that there is a subset of people that respond to them. And one of the things at the current time is that I try to get almost all my patients on immunotherapy at one time or another, with the idea being, is that of the treatments that we have available, it’s one of the few where you have some kind of confidence, or maybe, albeit small, but a chance that they’ll be alive and have their cancer controlled for years. So even though some of these EGRF are mutant positive, and the odds are not as high as you’d like, I still do what your doc did, and that is to get people a shot at the immunotherapy agents and check what works.

Andrew Schorr:

Mm-hmm. Dr. Spira, you too. And I know there are more and more of these immunotherapies. I don’t know if they’re all equal, but a lot of companies are working on it. 

So, this strategy, if the EGFR medicines are sort of pooping out, if you will, that immunotherapy might be worth a try?

Dr. Spira:

Yeah, so, you almost never say never. I think we can all give you the example, and I think as Dr. Johnson said, Don is the greatest example there. I told one patient it was unlikely to work, and lo and behold, she’s been on it for seven months so far. And that’s a lot more than I would have thought. I also do think it’s a prime situation if you have an easily available or a semi-easily available clinical study. We do know that the standard checkpoint inhibitors don’t work very well. So, if you’re willing and game, it’s a good chance to try one of these new combinations or new immuno-oncology drugs, because you’re a prime setup for that as well.

Andrew Schorr:

Yeah, I will say, just meeting people at ASCO, gentlemen, there are a lot of companies working on this. And I know you all do the trials. But there are a lot. So, the ones you see on TV, and there are others coming, and there’s a lot of work going on here. Okay, Don. So, Don, let’s get another question. 

Don Stranathan:

Okay. This question is from Nisha. She’s EGFR. She says she’s on a clinical trial for Tarceva. She had testing, and the testing was positive for T790. And what she’s asking, she says she doesn’t have progression yet on Tarceva. And since Tarceva only works, she feels, 11 to 12 months, should she stay in Tarceva or switch? And I was wondering—I didn’t think you could get T790 unless you already had the...

Andrew Schorr:

Mm-hmm. So, Dr. Spira, you’d better tell us what T790 is, and then maybe you can help answer that.

Dr. Spira:

So, T790M is a mutation one can get. The typical pattern of what you do is you follow somebody till it’s not working. Usually, you get a scan. The first line therapy here, and Tarceva’s not working, you get a scan, you’re gonna get a biopsy, you get a blood test, then you find the T790M.

There’s a lot of interest now in finding these mutations a little bit early. Certainly, you can detect T790M in the blood probably before you even have progression on imaging. Knowing that the reason T790M is present, it basically prevents first-line drugs, afatinib (Gilotrif) or erlotinib(Tarceva) and gefitinib (Iressa) from working. If I had T790M at that point, despite having radiographic progression, I probably would switch, only because you can make a pretty sure guess that it’s not gonna work fairly soon. If your oncologist decides not to, it’s not wrong, but I would anticipate needing to switch pretty soon. They’re actually doing a couple of studies looking atosimertinib (Tagrisso) in the first-line setting to see if you can get prolonged survival. And they actually have seen, preliminarily, some good outcomes. So, again, the caveat’s an individual test, but if I had it, I probably would plan on switching now, or you’re likely gonna switch soon regardless.

Andrew Schorr:

Mm-hmm. Dr. Johnson, any comment from you about—it’s kind of like when to switch? 

Dr. Johnson:

We’ve been working on doing blood tests on our patients, and this is led by Jeff Oxnard, and one of the members of our group, and Adrian Satcher published something in the Gem Oncology. And one of the things that happens is you can pick it up in the blood on average of about two months before you see radiographic progression. And when I say you pick it up in the blood, that’s what Dr. Spira talked about, this T790M, which is a mutation that arises in people exposed to this class of drugs that inhibit the epidermal growth hacking cell. In general, we wait until we get radiographic evidence of progression.

And one of the things we’ve also done some research on—and I don’t know what Matt’s and what Don’s experience is—but one of the things we always say is slow progression in lung cancer’s not necessarily bad. And there’s quite a bit of research to show that people can remain asymptomatic for an average of four months from when you can first see it start to grow, and lots of the trials have built that in. So I’m one that waits a while until it starts showing up. The other caveat I always say, and I won’t speak for Dr. Spira. One of the caveats I always try to say is that when people ask us about a specific medical condition, this isn’t really a very good venue to offer medical advice. So, we’re saying in general how we would approach this.

Andrew Schorr:

Right. 

Dr. Johnson:

But when we say this, you can go and discuss it with your doc. But what we’re saying is this is how we generally handle it if we were seeing somebody in our practice.

Andrew Schorr:

Of course, of course, yeah. Let me just reaffirm that. 

So folks are sending in some pretty questions. What should I do? And again, you’re gonna need to sit across from your doctor who you have faith in, or if you seek a second opinion, and say, “Let’s look at my situation. What would you recommend?” And in the end, it’s gonna be your decision. But it’s difficult for Dr. Johnson or Dr. Spira to really say do this or do that just based on their Internet conversation. Don, go ahead. What’s another one?

Don Stranathan:

Question’s from Peggy. She said, “Great strides have been made in targeted therapies and immunotherapies for people that expressed PDL1.” Her question is, for people that have a low-term tumor burden and don’t have driver mutations, is chemotherapy the only option?

Andrew Schorr:

Okay. Dr. Spira, you talked about that. You talked about chemotherapy.

Dr. Spira:

Yeah. I mean, so chemotherapy has gotten a little short shrift, because it’s not new. It’s old. But yeah, chemotherapy, as I said, still works.

And we still use it. There’s some new data whether or not you should be combining with immunotherapy in all comers. It’s actually interesting, and there’s still not an answer despite some wonderful data and even FDA approvals. That being said, chemo is still what we give to most of our patients. And chemo works. And chemo’s not as toxic as it used to be. It does have a bad rap, but that’s what the backbone of our treatments have been for a long time, and although less, still probably makes up the majority, or at least 50 percent of our patients. And it’s not a bad thing. You should not feel bad. You should not feel upset. Patients coming in that are smart that have read, they want a driver mutation, or they want high PDL status. And if you get neither, they are disappointed, for obvious reasons. You can’t change it, but you shouldn’t be upset. You should just deal with it as a problem and hope that chemo’s gonna work for you.

Andrew Schorr:

Mm-hmm. Your comment, Dr. Johnson? 

Dr. Johnson:

Well, number one is I agree with what Dr. Spira said. The thing I want to emphasize is that a lot of these classes of immunotherapy drugs are approvedwhether you do or do not have evidence of PDL1. So nivolumab (Opdivo) and another drug called atezolizumab (Tecentriq) are both approved without the presence of the PDL1. So we mentioned before that at some point, and as Dr. Spira mentioned, the first line of therapy in this setting should be—in general, we approach this and give chemotherapy. But there are people who test negative for that test that we’ve talked about, the predictive test for PDL1, who still respond and can respond for a long time. It’s less than if you have the marker, but it’s a subset. So, we think chemotherapy first, but keep in mind that immunotherapy and the second line, after you’ve had one treatment, is the agent of choice at the current time, even if you’re PDL1 negative.

Andrew Schorr:

Okay. Don, let’s see if we can get to another one.

Don Stranathan:

Okay. This question is from Byron. Byron was EGFR, non-small cell lung cancer. He had been on a targeted therapy, Tarceva, and then his cancer mutated to small cell lung cancer. He had the spot radiated. He’s asking, even after the radiation for the spot for small cell, should he continue to stay on a targeted therapy like Tarceva? 

Andrew Schorr:

Hmm. Dr. Johnson, you were kind of nodding your head. It sounds like you’ve seen that change from non-small cell to small cell. But what should he do?

Dr. Johnson:

Well, first of all, what ends up happening is that—and one of the things that we talked about before is that they’ve done those studies that were published a couple years ago that defined the genetic changes in small cell lung cancer. And one of the ones that you can’t target but is real consistent is loss of a gene called retinoblastoma. 

It’s a gene that was originally observed to be mutated in kids that got a cancer in their eyes. And it was one of the first inherited cancer syndromes discovered. So, it turns out that that genetic change in small cell also takes place after you put this under the selective pressure of an EGFR inhibitor. What one generally does if it’s the—and once again, I’m saying this as a general approach—if there’s only one spot that you can find, and you treat it locally, and there’s no other small cell evident, you can keep the EGFR inhibitor going. If there’s small cell that’s disseminated, we usually switch to chemotherapy and attempt to treat them with a small cell-like regimen. 

Andrew Schorr:

Right, great. I want to take one more, Don, and then we’re gonna get some final comments from everyone. I just want to also plug the fact that we at Patient Power, and working with SURVIVEiT and some of the other organizations have been working hard to interview a lot of experts—Dr. Spira’s been on programs before.

Dr. Johnson’s been on programs. I want to mention, look at the totality, not just what we are doing today. And we hope to do more. But take a look at a program we did from ASCO with Dr. George Simon from MD Anderson; Dr. David Carbone from Ohio State. There have been other interviews with a number of advocates, some of the European doctors as well. So, resources to look at—our number, including patientpower.info, and also look at the Precision Medicine For Me website we set up, which is precision-medicine.me. And you can see a lot of programs there, including some of the leaders from some of the advocacy organizations who are very devoted to you, as Matt is today with SURVIVEiT. Okay, let’s take one more, Don. 

Don Stranathan:

Thank you, Andrew. This question is from Leanne. It’s a two-part question.

First, she wanted to know what new promising research is being done on small cell lung cancer. And then if somebody could comment, is there any promising treatment for TP53 indication?

Andrew Schorr:

Okay, who wants to do that? Dr. Spira, any comment about that?

Dr. Spira:

Sure. And I think Dr. Johnson mentioned it a little before. So, small cell’s been a tough disease. We haven’t had a lot of new drugs approved. There’s only been one drug approved in about 25 years. However, there’s probably headway in a couple of things this year. I mean, you heard about Robate, which is a completely new mechanism of action. It’s an antibody drug conjugate, and Dr. Johnson talked about it before. And there actually is some data for immunotherapy as well. So, I think for the first time, we do have a couple promising things. I think you could probably make a safe bet that something’s gonna get approved, probably in the next 12 to 24 months.

So, there is, for the first time in a long time, a little excitement. In terms of P53, there are a few drugs in development right now. We’re looking at things that have worked with DNA repair, perhaps in combination with chemotherapy. We actually were participating in the study as well. But P53 has been a challenge for a long time, and it’s unclear how much headway we’re gonna make. But people are studying it. 

Andrew Schorr:

Well, I think the news is very positive. Dr. Johnson, any comment about that P53?

Dr. Johnson:

Well, P53 has been around a long time. It’s been known to be mutated in lung cancer for more than 30 years. I mentioned before the retinoblastoma gene that when it’s mutated when you get small cell, like from the EGFR mutant lung cancer. It’s from a class of drugs called tumor suppressors, which are ones that are important for the development of cancer, but are very difficult to target. And at least in my opinion, so far, the ones that are directed against P53 are not our most promising avenue of research, but stay tuned.

Andrew Schorr:

Okay. Well, I think that’s the message overall, is really stay tuned. Have hope. And I know that—I don’t mean to be trite about it, but we’ve covered a lot in these 90 minutes. And so, I really want to thank the doctors for being with us. Dr. Spira, from Virginia Cancer Specialists. Dr. Bruce Johnson from Harvard and Dana Farber, and your leadership in ASCO, and helping this knowledge proliferate throughout ASCO. And your leadership within the US Oncology Network in Virginia Cancer Specialists, Dr. Spira. Don, I want to thank you and wish you well with all you’re doing, and thank you so much for being here. And Matt, I guess a final word from you, okay? You’ve been listening. Thank you to SURVIVEiT and your leadership in this as well. What do you want to leave people with?

Matt Ellefson:

Yeah. I would like to first thank Dr. Spira and Dr. Johnson for their great work that they’re doing, and the colleagues that they work alongside every day, because that provides people like me and Don and the rest of the people that are watching today—it provides us with hope.

And without hope, we don’t have much, you know? We just don’t have much. And as we hear about the level of passion that both of you have brought to this webinar today, and that you bring to the rest of the industry when you go out and talk, we can’t be more thankful. I just don’t know how to express that in a bigger and deeper way. And I just—I feel very fortunate to be the beneficiary of some of your research and some of your colleagues’ research. And I want to leave it with—I want everyone to know that there is hope. And I want people to know that you can have the same opportunity that I’ve had. You can take this initial diagnosis of living eight months and turn it into working on to eight years.

And there’s nothing secret about me living in Sioux Falls, South Dakota being able to do that. It’s just getting to the right place, getting to the right people, doing the right things at the right time. And this webinar is providing you with just a wealth of information. Continue to look, continue to be thankful for what you have, and don’t ever lose hope.

Andrew Schorr:

Amen. Thank you so much for those comments. Thanks to our whole team, our producer, Tamara Laban Jones, the team at Virginia Cancer Specialists and Dana Farber, and ASCO, who’ve worked with us and the SURVIVEiT, of course, your organization, Matt. And thank you to you and Joy. Well, we hope to have future programs. But remember, the replay will be available soon. There’s a survey that we will be sending you via email.

We’ll send you the links to that, to all the resources we said we’d put together, the glossary, the start here graphic, the questions to ask your doctor, remote second opinions—to what degree that makes sense to you and your doctor, and also, the patient guide that we were very grateful to Foundation Medicine for providing us. And I want to thank our sponsors, Celgene, AbbVie, Foundation Medicine, Novartis, and Garden Health, and also additional support from Vivify. They’re all working together from different directions. Drug companies, diagnostic companies, decision support groups help you and your doctor. And we didn’t have all this to talk about not so long ago, and now we have a lot more. So, signing off from Philadelphia for the folks in Virginia, and Boston, and Sioux Falls, South Dakota, and California, I’m Andrew Schorr. Remember, knowledge can be the best medicine of all. Thanks for joining us.

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 April 3, 2019