NonDriver Metastatic Lung Large Cell Carcinoma - Episode 5
Lyudmila Bazhenova, MD:We have several second-line options approved in lung cancer patients. We have 3 immunotherapy agents: nivolumab, pembrolizumab, and atezolizumab. Because of the active Crohn’s disease in this patient, I would be very reluctant to give her immunotherapy because of an increased risk of immune-related adverse events, which could be pneumonitis, colitis, dermatitis, thyroiditis, hypophysitis, or myocarditis. The other drug that has been approved as second-line therapy, because it showed improved survival compared with best supportive care, would be docetaxel. So, for this patient, I would consider second-line docetaxel. Another correct answer for all of those patients who we treat with cancer is always clinical trials.
If this patient didn’t have active Crohn’s disease, if she had a history of Crohn’s disease that was in remission, then my decision to use immunotherapy treatments for her would be a little bit easier to make, even though we still know that patients with connective tissue disorders in remission have about a 20% chance of having immune-related adverse events. But I think in this situation, I would be more comfortable using that option. We don’t have any randomized clinical trials comparing the 3 immunotherapy agents I mentioned. At this point, the selection is based on physician’s habit and patient preferences. There is a different schedule for those agents. Nivolumab is given every 2 weeks, whereas pembrolizumab and atezolizumab are given every 3 weeks. There is no efficacy differential, in my view, between those 3 agents.
There are a lot of new developments ongoing in first-line therapy. Just a couple of days ago, we had the release of CheckMate-227 telling us that the study met its primary endpoint of improving progression-free survival in newly diagnosed patients with high tumor mutational burdens. So, in the future, maybe we will have a new biomarker for patient selection with immunotherapy, and tumor mutational burden could be emerging as one of those new biomarkers.
Transcript edited for clarity.