Managing Metastatic NSCLC With Rapid Progression - Episode 3

Frontline Treatment Options in Advanced Squamous NSCLC

July 19, 2018

Benjamin P. Levy, MD:For patients without an actionable mutation and those who have a PD-L1 that’s less than 50%, with squamous cell histology, we currently treat with cytotoxic chemotherapy without immunotherapy. This may change based on the ASCO Annual Meeting. Immunotherapy may be added very soon. The cytotoxic regimens that are really active in this histology are cisplatin/gemcitabine. That is based on data that were published many years back, showing preferential activity with cisplatin/gemcitabine when compared with cisplatin/pemetrexed. And there’s carboplatin/Abraxane. In my practice, this is a more common regimen used to treat squamous cell patients. From data published a few years back, we see a response rate north of 40% with this regimen, and so those are, in my mind, competing strategies.

Now, these are 3 chemotherapy backbones, and we’ll learn, probably very soon, whether adding immunotherapy to these backbones improves outcomes. If so, immunotherapy would be added the same way it’s been added for the adenocarcinoma patient population.

I don’t generally use cisplatin/gemcitabine. I think we see the response rates with that regimen in squamous cell patients to be around 30%, or 35% at best. In my practice, we’re more commonly using carboplatin and Abraxane. We are seeing response rates higher, north of 40% to 45%, and some of the prospective data we’ll see with immunotherapy may be higher than 50%.

These patients are generally symptomatic. These tumors grow locally, but they also cause a lot of symptoms. I’m really looking for a response. For those patients, I will use carboplatin/Abraxane, based on the response rate in the squamous cell patient population.

Transcript edited for clarity.

Case: A 53-Year-Old Woman with mNSCLC Rapid Progression

  • A 53-year-old woman presents with a lump in her left deltoid and no other signs or symptoms
    • PMH: insignificant, currently on no medications, no smoking history
  • Chest X-ray showed a 5-cm soft tissue mass
  • Biopsy showed advanced squamous cell carcinoma, TTF-1-
    • Molecular testing negative for known actionable mutations
  • PET CT revealed a liver lesion and adrenal mass
  • Brain MRI showed no evidence of CNS metastasis
  • Staging: T2aN3M1b
  • 22C3 antibody testing; PD-L1 TPS, 0%
  • The patient is started on cisplatin/gemcitabine
  • Imaging at 3 months shows widespread progression with new and enlarging lesions including a significant increase in her soft tissue and lymph node disease, collapse of her right lower lobe and new liver lesions