Non-Driver NSCLC: Practice Considerations - Episode 6
Mark Socinski, MD:As I previously mentioned, I typically continue immunotherapy for up to a couple of years. That’s assuming the patient’s benefiting from it and not having undue toxicity. If I think they’re not benefiting from it, what do we do third-line? I think in a patient like this, the third-line option, in my mind, would be docetaxel. And typically, when I use docetaxel, I combine it with ramucirumab. We know from the REVEL trial that the addition of ramucirumab to docetaxel improved response rates, progression-free survival, as well as overall survival. And assuming that the patient didn’t have any contraindications to an anti-VEGF agent like ramucirumab, I would use that agent in this particular setting. So, that would be my third-line choice.
So, as I mentioned, I view this patient as having treatable but not curable disease. What’s going to happen in the next 3 to 5 years? Well, there are some efforts looking at, are there clearly oncogenic driver pathways in squamous carcinomas that can be targeted? There’s a very important trial ongoing in the United States, called the Lung-MAP trial, that’s run by the Southwestern Oncology Group. That is looking at squamous patients in the second-line setting, trying to define oncogenic drivers and then trying to match them with targeted therapy. So, it’s an important trial. Have we seen any successes to date in squamous? No, but we must remain hopeful that we will uncover something.
The other issue that we talked about is the role of immunotherapy. And I think that we’ve just kind of scratched the surface with immunotherapy with the antiPD-1 and anti–PD-L1 agents. We’re beginning to see some early data with combination immunotherapy strategies, particularly combining the PD-1, PD-L1 access with CTLA4 combinations. The data are still very, very early. But I think, particularly in squamous, that there may be hope and enthusiasm for various immunotherapy combinations that may yield a greater benefit. Some of the early data do suggest that, but we haven’t seen a lot of the data. And there are certainly lots of potential agents that could be combined in this particular setting to benefit the patient.
So, I’m more optimistic about the immunologic approach than I am about the targeted approach in squamous patients. But I think we need to keep an open mind and keep enrolling on to important clinical trials.
Transcript edited for clarity.