ADVERTISEMENT
Best Management Practices for a Patient With Early-Stage Non-Small Cell Lung Cancer
Sandip Patel, MD, University of California, San Diego, discusses the course of treatment he would take for a patient with early-stage non-small cell lung cancer (NSCLC).
Transcript:
Hi, I'm Sandip Patel, professor of medical oncology at the University of California, San Diego, and I'm delighted to be discussing the treatment of patients with early-stage non-small cell lung cancer.
Increasingly with the utilization of low-dose CT screening for the appropriate screening of patients who are at risk for lung cancer, though we can do better in our approach to low-dose CT screening across all our practices, we are starting to see diagnosis of lung cancer at an earlier stage. With that, our ability to utilize novel therapeutics, in particular immunotherapy and targeted therapy, in earlier stage disease has helped us improve outcomes and potentially cure rates for patients with this historically grim prognosis of non-small lung cancer.
There's several key facets for a patient who's diagnosed with early-stage non-small cell lung cancer. One is pathologic diagnosis, ensuring the patient has a primary lung cancer tumor type. This is based on the histology and the immunohistochemistry that's done for that patient. Secondarily, is addressing the imaging and ensuring the patient has adequate mediastinal staging. These are lymph nodes in the middle of the chest and having those sampled by EBUS, endobronchial ultrasound, in addition to the primary tumor, is key to ensure that we have accurate pathologic staging. Even for a patient who has a PET-CT, the need for endobronchial ultrasound and biopsy of the mediastinum and key lymph node stations is important because you can have false negatives on PET-CT based on some studies anywhere from 10% to 15% of the time.
For me, it's important to have the imaging, the mediastinal pathologic assessment, and third, in addition to histologic assessment, to have the molecular information, biomarker information for that patient. This at the very least now involves looking for EGFR, ALK, and PD-L1, as 3 of the key biomarkers that will help us determine the optimal treatment strategy for a patient.
Once we have optimal pathologic staging for a patient who has also undergone a PET-CT to look for occult metastatic disease, thinking about our neoadjuvant versus adjuvant strategy is key. For a patient with a driver mutation such as EGFR or ALK, the current state of the art is surgical resection up-front, followed by 4 cycles of platinum-based chemotherapy, whether it’s EGFR or ALK, followed by targeted therapy, whether it be osimertinib for 3 years or alectinib for 2 years. For patients who are EGFR- or ALK-wild type, these are patients who are candidates for neoadjuvant or perioperative, meaning neoadjuvant and then post-operative, immunotherapy. There are multiple approaches here, whether it be 3 cycles of chemotherapy and nivolumab before surgery, or perioperative chemotherapy and pembrolizumab for patients who are EGFR- or ALK-wild type. Many times patients with lower stage disease, stage IB or stage IIA, may wish to go to surgery directly, and for those patients who are PD-L1–positive, I consider adjuvant atezolizumab, particularly for patients with a PD-L1 greater than 50%.
Regardless of the stage, many of our advanced therapies, whether targeted therapies or immunotherapies, have moved to earlier stage. But, the importance of getting appropriate biomarker testing and mediastinal staging, pathologically with an EBUS, and most importantly encouraging our primary care colleagues to appropriately screen patients with low-dose CT for lung cancer, are key aspects to ensuring that we can offer these therapies for the benefit of our patients, and increase the number of patients who are potentially cured of this otherwise very aggressive disease that's the leading cause of cancer-related death.
And so with that, I appreciate folks listening to some of my perspectives on how we can manage early-stage non-small cell lung cancer. Thank you.
