David Spigel, MD: What about somebody who’s not as fit, has a poor performance status, or is perhaps older, and you’re concerned about everything? That’s real life. That happens a lot. Not everybody has a performance status of 0 to 1. You approach this in the best way you can. I have recently had an older woman with poor performance status who simply couldn’t get through concurrent chemoradiation. In my mind, she was a candidate for sequential treatment and then still a candidate for when it happens for durvalumab.
The benefits for concurrent vs sequential are real but small. Sequential is not so bad. You should offer it to patients, or you can do sequential because it’s the right choice for that patient. That’s OK. Although PACIFIC was not designed for that—certainly the label does not include sequential use of treatment—that is how I treat my patients when I give them immunotherapy after sequential therapy if that’s the right way to treat them. Honestly, there are very few people I’ve given sequential therapy to, and it’s because performance status or advanced age are contraindications to concurrent therapy.
One controversial area I’ll bring up: What do you do with a patient who has stage III cancer that was resected? I’ll give you the take-home quickly. PACIFIC did not include those patients, and there is no role for immunotherapy in those patients. However, with all that said, there are patients who go to surgery for stage I or II disease, and then N2 disease is discovered at the time of surgery. The patient is treated and closed up. They go through surgery, but they have bona fide stage III cancer. You say to yourself, “Gosh, had I known that in the beginning.” Hopefully that patient was evaluated in the mediastinum but it was just passed over. I might not have sent that patient to surgery, and I would have treated them with chemoradiation and durvalumab. So here’s a patient in front of you now who just got surgery for stage III cancer. Well, that patient now gets adjuvant chemotherapy.
Not a topic for this section, but some recent data from ESMO [European Society for Medical Oncology Congress] actually advised against postoperative radiation therapy…. Again, that’s a topic for another session. But that patient probably doesn’t get radiation anymore. Should that patient be offered durvalumab? The simple answer is no, that’s not standard. Is it wrong to have a conversation about it or even to use immunotherapy in that setting? I don’t think anything is wrong, but it’s not approved to be used that way. As long as you have a thorough conversation with your patient about what we know, what we don’t know, you’re doing right by your patient. It’s important to know what PACIFIC was and what it wasn’t. The pivotal neoadjuvant and adjuvant trials for resectable lung cancer with immunotherapy are here. Those will read out in the next couple of years, and we’ll know more about the role of immunotherapy in those patients.
Transcript edited for clarity.