Immunotherapy in lung cancer with Dr. Jack West, Part 2

Thursday, November 14, 2019

Jack West, MD, joins the podcast to discuss the immunotherapy in the treatment of lung cancer. Dr. West is an associate clinical professor in medical oncology at City of Hope Comprehensive Cancer Center in Duarte, Calif., and a thought leader in thoracic oncology. Dr. West and Blood & Cancer host David H. Henry, MD, of Pennsylvania Hospital, Philadelphia, discuss assays, liquid biopsy, and review a recent case in part two of their interview.

Plus, in Clinical Correlation, Ilana Yurkiewicz, MD, of Stanford (Calif.) University, reminds us that even when just “covering” a patient for another physician, you could be in for some difficult discussions.

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This Week in Oncology

Atezolizumab bests chemo in NSCLC patients with high PD-L1 expression
by Jennifer Smith

Atezolizumab monotherapy can improve overall survival in treatment-naive patients with stage IV non-small cell lung cancer and high PD-L1 expression according to the results of a phase 3 trial presented at the 2019 annual meeting of the Society for Immunotherapy of Cancer.

Assays

Important to rapidly test for PDL1, EGFR and ALK status and have all results before committing to first-line therapy.
- PDL1 testing results often take 24 hours, while EGFR and ALK results can take several weeks; committing to immunotherapy without knowing the status of molecular drivers is not ideal.

Liquid biopsy

Measures DNA from tumor cells circulating in the blood.
Testing takes about a week.
A positive result can be trusted.
A negative result cannot be trusted, given low sensitivity, especially in patients with low tumor burden.

Adverse effects of immunotherapy

Striking variability in toxicity profiles among patients.
Although overall better tolerated than chemotherapy, the “unknown” aspect of immunotherapy toxicities may be anxiety provoking for patients.
Fatigue, rash, and thyroid abnormalities are most commonly seen.
However, there is a broad array of toxicities that oncologists may not be familiar with, necessitating a multidisciplinary approach.

Case discussion

An otherwise healthy, middle-aged woman presents with two lung nodules: a 1.4 cm lesion in the left upper lobe, and a 3.1 cm lesion in the left lower lobe.
Both are biopsy proven to be non–small cell adenocarcinoma. Both lesions are excised with clear margins. There is no lymph node, vascular, or pleural invasion.
In this case, it makes sense to view these as two independent cancers.
Unclear if the chance of recurrence is increased based on the presence of two, less than 4 cm lesions with negative prognostic features and adequate excision with clear margins.
The anticipated benefit of adjuvant chemotherapy must be weighed against toxicities, and the individual patient’s ability to tolerate chemotherapy must be considered.

Resources

Dr. West’s cancer education website for patients and caregivers: cancergrace.org

Show notes by Sugandha Landy, MD, resident in the department of internal medicine, University of Pennsylvania, Philadelphia.

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Podcast Participants

^{David Henry, MD}

David Henry, MD, FACP, is a clinical professor of medicine at the University of Pennsylvania and vice chairman of the department of medicine at Pennsylvania Hospital in Philadelphia. He received his bachelor’s degree from Princeton University and his MD from the University of Pennsylvania, then completed his internship, residency, and fellowship at the Hospital of the University of Pennsylvania. After 2 years as an attending in the U.S. Air Force, he was drawn to practicing as a hem-onc because of the close patient contact and interaction, and his belief that, win or lose with each patient, one can always make a difference in their care and lives. Follow Dr. Henry on Twitter: @davidhenrymd.

^{Ilana Yurkiewicz, MD}

Ilana Yurkiewicz, MD, is a fellow in hematology and oncology at Stanford University, where she also completed her internal medicine residency. Dr. Yurkiewicz holds an MD from Harvard Medical School and a BS from Yale University. She went into hematology and oncology because of the high-stakes decision-making, meaningful relationships with patients, and opportunity to help people through some of the toughest challenges of their lives. Dr. Yurkiewicz is also a medical journalist. She is a former AAAS Mass Media Fellow and Scientific American blog columnist, and her writing has appeared in numerous media outlets including Hematology News, where she writes the monthly column Hard Questions. Dr. Yurkiewicz is on Twitter: @ilanayurkiewicz.