Clinical Management of NSCLC With Bone Metastases - Episode 4
Roy S. Herbst, MD, PhD:In my practice, which is an exclusive lung practice, you can imagine that I see many patients who have chemotherapy-refractory disease. And certainly, in those patients who are nonsquamous, such as the one we’re discussing today, who’ve already had pemetrexed, your second-line choice of chemotherapy is docetaxel. Certainly, you have the choice of whether to give a docetaxel-based combination, docetaxel alone, or immunotherapy. Many people are going right to the immunotherapy now, just because the curves overlap for the 2, even in PD-L1negative patients, and the side effects are perhaps less. I think that’s true. That has been my experience for immunotherapy and then chemotherapy.
Now, in most cases, people would give immunotherapy in the second-line and save the second-line chemotherapy, so to speak, the docetaxel, for third-line use. My experience with the docetaxel/ramucirumab regimen has been in immuno-oncologynaïve and immuno-oncology–treated patients. It has been available to us for almost 3 years now, and was also available before that in clinical trials. I’ve used it in both cases.
I think it’s a well-tolerated regimen. It doesn’t add much to the docetaxel. It can be used in squamous and nonsquamous tumors. There are not many issues with bleeding. My sense is that it improves the outcomesthe response rates, progression-free survival, and overall survival, as shown in the REVEL trial.
We must not forget that we still have chemotherapy to offer. Immunotherapy’s all the rage, and we’re using a great deal of it at Yale right now. In fact, if patients can’t get immunotherapy as standard care in the frontline setting, they’re getting immunotherapy in some sort of clinical trial. But do you know what? Most of what I see, on a day-to-day basis, in the clinic are patients who are failing immunotherapy. Only 18% to 20% of patients, in 5 years, are doing great on immunotherapy, which is a phenomenon. Who would have thought we’d see metastatic disease at 5 years, at 20%? That means 80% of the patients are either primary refractory to immunotherapy, or they get immunotherapy and they become resistant.
My experience has been that about half of those patients that you treat with immunotherapy become resistant. At that point, we need another agent. You need new targeted agents, such as ones that targetVEGF. You need another chemotherapy. For the patient who has had immunotherapy and is progressing, you have to make a change. That’s where I would look to a docetaxel/ramucirumab combination, as we’re talking about here. This is in a little bit of a different order from how I would treat the case today. It will probably be different in a week from now, after new data emerge. That’s how quickly this field is moving. That’s why it is really important to stay on top of the most recent data.
Transcript edited for clarity.
Case: A 62-Year-Old Man With NSCLC and Bone Metastases