Targeted Therapies and Lung Cancer

Immunotherapy for Lung Cancers

From Medscape:

This roundtable discussion on important issues in immunotherapy for lung cancer was filmed at the American Society of Clinical Oncology (ASCO) 2017 annual meeting in Chicago on June 4.

H. Jack West, MD: Hi. I’m Dr Jack West from Swedish Cancer Institute in Seattle, Washington. Joining me today for Medscape Oncology Insights are two colleagues who are experts in immunotherapy for non-small cell lung cancer (NSCLC) and the whole field of thoracic oncology. First, I have Dr Hossein Borghaei from Fox Chase Cancer Center in Philadelphia and Dr Eddie Garon from University of California, Los Angeles. Thanks for joining me.

Edward B. Garon, MD: Thank you.

Hossein Borghaei, DO: Thank you.

Pembrolizumab for First-Line Therapy in NSCLC

Dr West: The field [of NSCLC] has been very dynamic recently. Let’s start with how we would approach a patient in the first-line setting. In late 2016, pembrolizumab was approved for first-line treatment of patients with high programmed death-ligand 1 (PD-L1) expression, which affects about 30% of patients regardless of whether they have squamous or nonsquamous histology. At the same time, we had a presentation of phase 2 data in the KEYNOTE-021 G cohort on 123 patients.[1] Now [pembrolizumab] is approved as an option for patients with nonsquamous histology regardless of PD-L1 expression.

What do you think of this option? Is it something you are going to be inclined to widely adopt or selectively adopt? Also, how do you think it’s going to affect the broader general oncology community? I’ll start with you, Eddie.

Dr Garon: It’s an excellent question and one that we colleagues have been debating amongst ourselves for a while. As you talk to different people, you get very strong opinions that differ from one another. In my practice, I must admit that I’m very cautious of these data. There are reasons to be cautious of the data based on the fact that this was a small study.

The bigger question to me is: What is achieved by using both chemotherapy and pembrolizumab in this case, or any other programmed death-1 (PD-1) or PD-L1 inhibitor, together rather than sequencing them one after the other? With the available data, I would argue at least that while response rate and progression-free survival (PFS) have improved with the combination, there are no data that survival has improved, and until I see a benefit in survival, my concern is that the combination basically adds more time on drug and more toxicity for more people without a resultant survival benefit. For me, that does not hit the bar that says it should be used as part of my practice in any routine way. Again, that is something that people disagree about.

Dr Borghaei: I absolutely agree with you. For the standard-of-care practice, for anybody with 50% expression of PD-L1, I think I am going with single-agent pembrolizumab.
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