Immunotherapy in Unresectable Locally Advanced NSCLC - Episode 5

Practical Considerations for Durvalumab in Stage 3 NSCLC

March 20, 2018

D. Ross Camidge, MD, PhD:Our center was not involved in the PACIFIC trial, so we’ve only been able to use it since the NCCN and then later the FDA approval. The patients who go through definitive chemoradiotherapy, I think it is very reasonable to add it in for a year afterwards. There are the usual exclusions for anyone with immunotherapy—somebody with a solid organ transplant, somebody with very badly controlled autoimmune disease—where you’re going to think twice and probably 3 times before using these drugs. And as I mentioned earlier, the whole issue as to whether this is also something you can plug into somebody with a proven driven oncogene is much more debatable. And that may be the group that I’m probably less likely to recommend it and just say, “You know, the data are just not there yet.”

Any immunotherapy runs the risk of an autoimmune disease. In the setting of chemoradiotherapy, you worry about if you are exacerbating pneumonitis, which is at risk with the regimen in the first place. There definitely was more toxicity when durvalumab was added in, but it seemed to be manageable. The pneumonitis rate was probably only about 5% or so. There have been some recent guidelines published on managing immunotherapy toxicities, and they can come at any point. They can even come after the treatment has finished. So, you just have to be very mindful, particularly pay attention to hormonal levels, so it’s good to check TSH. It’s good to pay close attention to what your patient is describing in front of you, because there may be quite subtle manifestations of autoimmune disease, Addison disease, hypothyroidism, colitis, but some of these other things you have to look carefully for.

Transcript edited for clarity.