Episode Details

We strongly recommend you listen to our previous episodes metastatic lung cancer (Episodes 0032 and 0033) to better be able to follow along with this conversation. Key trials mentioned in this episode include:

CHECKMATE 227

KEYNOTE 024

Q:Do you send molecular testing (PDL1 and NGS) on the biopsy, peripheral blood or both?

* Yield is highest from the tissue sample

* Peripheral blood (circulating DNA) samples are dependent on the burden of disease and so often the yield is lower

** One of the benefits is that it can be sent quickly and having a fast turn-around; Tissue samples are dependent on being able to schedule a biopsy

* Dr. West says he definitely sends this on a non-smoker with non-squamous lung cancer, as they are more likely to have molecular targets

* Dr. West has not personally adopted the idea of sending peripheral and tissue samples for NGS testing for everyone

Q: Do you ever use Ipi/Nivo in patients with PDL1 <50% (ref: CHECKMATE 227)?

* There are a lot of other options so he does not use this, as it is harder to predict the side effects with therapy like this

* “Chemo-free does not mean side-effect free”

Q: We understand there is a lack of randomized trial data on the use of consolidative radiation after IO based treatment in the metastatic setting. If patients have a good response to systemic treatment, when do you consider using consolidative radiation for cure?

* A systemic therapy that is effective that leaves you with oligo-residual disease, radiation can be considered for the right patient

** We need to balance what a radiation oncologist says he/she can radiate vs. what is actually the right thing to do

** Sometimes, it’s best to give the cancer some time to “declare itself”.

* A nuanced discussed, but it may be worth considering especially in patients who have disease that is

** (a) growing at a clinically meaningful rate

** (b) in patients with a few sites of disease, but otherwise great control

* This is much more effective in patients with driver mutations being treated with TKIs with oligo-residual disease

Q: Do you ever give chemo along with IO in patients with PDL1 >50%?

* KEYNOTE 024: First study to show that IO was superior to chemo in high PDL1 patients lead to an instant change in our approach

* More recent data suggests that there are differences between patients with PDL1 90% vs. someone at like 50, 60, or 70% (not all PDL1 >50% is created equal!)

* If there is a patient with a lot of cancer burden, a lot of symptoms, and rapid progression of disease, you don’t want to miss an opportunity to do what is best for the patient. There is always a chance that IO may not work as monotherapy. This is a case-by-case discussion, but in cases like this, he discusses with his patient about using chemo + IO

** Essentially attacking the cancer from multiple angles

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