Clinical Approach for Unresectable Locally Advanced NSCLC - Episode 6

Consolidation Immunotherapy in Locally Advanced NSCLC

Jyoti Patel, MD:This patient illustrates, really, what I’ve started to do in my practice. For patients who are eligible for checkpoint blockade because they don’t have a history of autoimmune disease, they don’t have HIV, and they’re otherwise well, certainly, I am talking about this data to them and bringing it into the clinic already. Things that may have changed for me are chemotherapy backbone. So, cisplatin/etoposide has become a regimen that I have started using a little bit more, as well as cisplatin/pemetrexed over just weekly carboplatin/paclitaxel.

When I meet a patient, I say, “This is what the long strategy will look like,” and I think it can be overwhelming to hear that they may be on maintenance therapy or consolidation therapy for a year. So, we say, “We’ll finish chemotherapy and radiation.” Our plan is to do immunotherapy, but we will always reassess and do imaging and discuss quality of life and toxicity periodically.

We have struggled with locally advanced disease for decades, with modest improvements in certainly staging and supportive care but really no breakthroughs. The introduction of immune checkpoint blockade for our patients—particularly durvalumab, as illustrated by the PACIFIC study—is a giant leap forward. Certainly, we’re seeing progression-free survival that we’ve seen in a clinical trial. And we await overall survival results, but at this juncture with the data that we have, this is a new standard of care for patients with locally advanced disease.

Transcript edited for clarity.

  • A 63-year-old man presented to his PCP with intermittent cough and difficulty breathing on exertion
  • PMH: hyperlipidemia well-managed on simvastatin; hypothyroidism, managed on levothyroxine, COPD on inhalers
  • Recently quit smoking; has a 40-pack-year history
  • PE; intermittent wheezing; ECOG 1
  • Creatinine clearance, WNL
  • Imaging Studies:
    • Chest X-ray showed opacity in the lung right upper lobe
    • Chest CT revealed a 3.1-cm spiculated mass in the right upper lobe and 2 enlarged right mediastinal lymph nodes measuring 1.5 cm and 1.7 cm; moderate emphysema noted
    • PET confirmed the lung lesion and mediastinal lymphadenopathy without evidence of distant metastasis
    • Brain MRI was negative
  • Bronchoscopy with transbronchial lung biopsy and lymph node sampling revealed adenocarcinoma with positive nodes in stations 4R and 7; level 4L was negative
  • Genetic testing was negative for known driver mutations
  • Staging: T2aN2M0, stage IIIA
  • Based on the extent of mediastinal disease and emphysema, the patient’s cancer was deemed inoperable, and he was referred for consideration of concurrent chemotherapy and radiation
  • He underwent therapy with cisplatin/etoposide and concurrent thoracic radiotherapy
  • Follow-up imaging showed a partial response with shrinkage of the primary and nodal lesions