Clinical Decisions in Non-Driver NSCLC - Episode 1
Benjamin P. Levy, MD:This is a patient, a 55-year-old female never-smoker, who presents to her primary care physician with a chronic cough and a 10-pound weight loss. The primary care physician orders a chest X-ray that reveals a very large opacity in the left upper lobe. The patient then has a CT scan that reveals a 5-cm mass in the left upper lobe with bulky mediastinal lymphadenopathy. Following this, the patient does have an EBUS bronchoscopy that samples these mediastinal nodes, and the biopsy is consistent with a TTF1-positive, CK7-positive adenocarcinoma. The adenocarcinoma is sent for next-generation sequencing. It is negative for all driver mutations, includingEGFR,ALK,BRAF, andROS. And a PD-L1 by IHC is 0%.
The patient then has a full-staging brain MRI and PET/CT. The brain MRI reveals no intraparenchymal metastases, and the PET/CT confirms the mediastinal adenopathy in the left upper lobe but also reveals a 4-cm adrenal metastasis. This metastasis is biopsied to confirm adenocarcinoma, which it is. Based on the fact that the patient has a stage 4 adenocarcinoma and has no contraindications to antiangiogenic strategies, the patient is started on carboplatin/pemetrexed/bevacizumab. The patient receives 6 cycles of this triplet regimen and has a nice response and then goes on to receive maintenance pemetrexed and bevacizumab for 9 more months.
Unfortunately, at that time, the patient complains of worsening cough and further weight loss. A repeat CT scan of the chest, abdomen, and pelvis shows that the tumor has enlarged in both the lung and the lymph nodes. The adrenal metastasis is also enlarged, and the patient has new liver metastases. Based on this disease progression, the patient has been placed on atezolizumab, which she receives for up to 12 more months.
It’s important to know that young patients who do present with lung cancer unfortunately present with advanced-stage disease. We’re just not capturing most of these patients with early-stage disease. Most of my young patients, particularly never-smokers, present with significant cough. Often times, they have bone pain from disease metastases to the bone. And, unfortunately sometimes, specifically for patients who areEGFRorALKrearranged, these patients can present with headaches, blurry vision, and dizziness and have brain metastases at the time of diagnosis. I think a lot of the times, many of the symptoms that younger never-smoker patients have are ignored by their primary care physicians. Often times, they’ll be treated with several rounds of antibiotics before they finally get a chest CT and a biopsy, because they’re a never-smoker.
I think we need to remember that 20% to 25% of all nonsmall cell lung cancer is never-smokers, and this is just not a fact that’s well known by the primary care physicians and the pulmonologists. So, I can’t think of one time where I’ve had a young patient who’s a never-smoker in their 50s, or even 40s, where we’ve caught a stage 1 lung cancer. I think most of the time we’re capturing these at a much later stage, unfortunately.
Transcript edited for clarity.