GRACE :: Lung Cancer
Luis E Raez

More Immunotherapy Agents are in Development for Lung Cancer

 
Luis E. Raez, MD, FACP, FCCP

Luis E. Raez, MD, FACP, FCCP, Chief of Hematology/Oncology and Medical Director of Memorial Cancer Institute (Miami, FL) Clinical Associate Professor of Medicine, Herbert Wertheim College of Medicine, Florida International University

In the last 2 years we were very happy to have seen: nivolumab, pembrolizumab and recently atezolizumab approved for non-small cell lung cancer (NSCLC). If you remember all of them are approved for second line therapy of NSCLC and pembrolizumab has been moved and approved already for first line NSCLC therapy if the tumor expresses PDL-1 immunohistochemistry staining (IHC) more than 50%. All of these agents block the interaction between the receptor PD-1 present in T lymphocytes and the ligand PDL-1 present in tumor cells and they are called “checkpoint inhibitors”. Some of them like atezolizumab block the PDL-1 ligand and the others are PD-1 inhibitors, there are no clear differences among them other than the current FDA indications. Soon we will know if there are differences in these 2 types of inhibitors among themselves regardless effectivity or toxicity. However these are not the only agents, we have more PDL-1 inhibitors in development like: avelumab (also known as MSB0010718C) that is in priority review for urothelial cancer but results from the JAVELIN trial were recently reported in December in Vienna during the 17th International Association for the Study of Lung Cancer (IASLC) Annual Meeting showing good responses and toxicity profile similar to the other inhibitors. The same happened with another anti-PDL-1 called durvalumab that was also presented at the IASLC meeting too with similar outcomes. But not only anti PD-1/PDL-1 antibodies are considered check point inhibitors we also have to remember that we have anti-CTL4 antibodies called ipilimumab and tremelimumab; none of them are approved for lung cancer yet but the first is already commercially available for melanoma. The importance of these anti-CTL4 antibodies is in the fact that they stimulate the immune response by a different mechanism of the PD-1/PDL-1 inhibitors then the great interest from the research community in combining these 2 different type of drugs to try to enhance the immune response as already has happened successfully in melanoma where the combination of ipilimumab + nivolumab is becoming standard. Other investigators are already combining durvalumab with tremelimumab for NSCLC, the first phase I study was published in the journal “Lancet” in February 2016 where they showed a manageable tolerability profile, with antitumour activity irrespective of PD-L1 status. During World Lung IASLC conference in December 2016 the combination of ipilimumab + nivolumab was presented showing good tolerance for the patients and enhancing the immune response of single agent nivolumab and the final paper was published also in “Lancet” in January 2017.

But this story even gets better: while some pharmaceutical companies are developing similar check point inhibitors to the 2 types described (anti PD-1/PDL-1 and anti-CTL4) other companies are exploring other targets and checkpoints so there is a large list of potential candidates that can be targeted with  the hope to achieve an immune response like: A2AR, B7-H3, also called CD276, B7-H4, also called VTCN1, BTLA also called CD272, IDO, short for Indoleamine 2,3-dioxygenase; KIR, short for Killer-cell Immunoglobulin-like Receptor, LAG3, short for Lymphocyte Activation Gene-3, TIM-3, short for T-cell Immunoglobulin domain and Mucin domain 3, and VISTA (protein), Short for V-domain Ig suppressor of T cell activation, among others.

The future is very exciting these days for the possibilities that is bringing to our NSCLC patients.


 Luis E. Raez, MD, FACP, FCCP is the Chief of Hematology/Oncology and Medical Director at Memorial Cancer Institute. He is also the Oncology Research Director of Memorial Healthcare System and Director of the Thoracic Oncology Program, Clinical Associate Professor of Medicine at Florida International University and Visiting Professor of Medicine at Cayetano Heredia University in Peru. He is also an Affiliate Associate Professor of Clinical Biomedical Science for Florida Atlantic University.


 

 

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Denise Brock

Lung Cancer Video Library – Spanish Language: Video #42 Stage IIIA N2 Non-Small Cell Lung Cancer

 
GRACE Cancer Video Library - Lung

 

We are pleased to continue this series of informational videos for our Spanish speaking community.  GRACE is pleased to welcome Dr. Rafael Santana-Davila, Assistant Professor with the University of Washington School of Medicine and Seattle Cancer Care Alliance.  In this 42nd video for the Spanish lung cancer video library, Dr. Santana-Davila joined GRACE to discuss Stage IIIA N2 Non-Small Cell Lung Cancer.


 

 

 

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TRANSCRIPTS – Spanish and English
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Tratamiento del Paciente que Tiene Estadio Tres, cuando los Ganglios del Mismo Lado del Mediastino están Involucrados

Stage IIIA N2 Non-Small Cell Lung Cancer

 

Rafael Santana-Davila, MD
Assistant Professor of Medicine
University of Washington Seattle Cancer Care Alliance
Seattle, Washington

 

Spanish TRANSCRIPT

Cuando esto ocurre, el tratamiento varía mucho dependiendo de la institución que este viendo al paciente. En la Universidad de Washington lo que hacemos es que si hay un solo ganglio linfático involucrado preferimos dar quimioterapia. En un principio de 3 a 4 ciclos, después repetimos los estudios de imágenes y si el cancer no ha avanzado se lleva al paciente a cirugía donde lo primero que se hace es ver cuáles de los ganglios del mediastino están involucrados. Si el cancer no ha avanzado, se trata posteriormente con una lobectomía (remover el lóbulo del pulmón). Después, si los ganglios del mediastino se vieron afectados, entonces el paciente se hace candidato para ser tratado con radioterapia para erradicar esos ganglios del mediastino.

Cuando el cancer de pulmón está en más de un ganglio en el mediastino, lo que hacemos es quimioterapia y radiación al mismo tiempo. Son de cuatro a seis semanas de radiación con quimioterapia, dependiendo de que quimioterapia se elige, se puede dar una por semana o dar dos ciclos de quimioterapia en toda la radiación. La quimioterapia que se escoge depende mucho de la discusión entre doctor y paciente para ver qué efectos adversos se prefieren y cuáles son los riesgos y beneficios. 


  

English TRANSCRIPT

When the patient is in stage three, there are many options for the treatment depending on the institution the patient is being treated. In the University of Washington, if there is only one lymph node affected, we prefer to give chemotherapy. At first, we’ll give three to four cycles then we’ll do again imaging studies to see if the cancer has not spread. If the cancer has advanced to other parts, the patient will go into surgery to see which lymph nodes from the mediastinum are involved. However, if the cancer has not spread, the procedure used will be a lobectomy (remove one of the lobes of the lung).  Then, if the lymph nodes of the mediastinum are affected, the patient will be candidate to be treated with radiotherapy. 

When the lung cancer is in more lymph nodes in the mediastinum, we’ll then use chemotherapy and radiation at the same time. This consists of four to six weeks of radiation and chemotherapy. Depending on the type of chemotherapy selected, the treatment could be one cycle per week or two chemotherapy cycles in all the radiation process. The type of chemotherapy selected depends on the doctor-patient discussion about the side effects, risks and benefits.


Denise Brock

Lung Cancer Video Library – Spanish Language: Video #41 Molecular Marker Testing for Advanced NSCLC

 
GRACE Cancer Video Library - Lung

 

We are pleased to continue this series of informational videos for our Spanish speaking community.  GRACE is pleased to welcome Dr. Rafael Santana-Davila, Assistant Professor with the University of Washington School of Medicine and Seattle Cancer Care Alliance.  In this 41st video for the Spanish lung cancer video library, Dr. Santana-Davila joined GRACE to discuss molecular marker testing for advanced NSCLC.


 

 

 

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TRANSCRIPTS – Spanish and English
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Marcador Molecular para Estadio Avanzado de Cancer de Células no Pequeñas

Molecular Marker Testing for Advanced NSCLC

 

Rafael Santana-Davila, MD
Assistant Professor of Medicine
University of Washington Seattle Cancer Care Alliance
Seattle, Washington

 

Spanish TRANSCRIPT

Cuando tratamos a un paciente en estadio tres lo que esperamos es curar al paciente, desafortunadamente esto solo se lleva en el 20 al 25% de los casos y en la mayoría de los pacientes el cancer aparece de regreso. Algo que hacemos comúnmente es la terapia de consolidación, que es dar más quimioterapia después de la quimioterapia y radiación. Para escoger si se da terapia de consolidación o no es según el régimen se haya escogido. Si el régimen incluyo carboplatino y paclitaxel se le da dos ciclos más de quimioterapia después de la radiación. Cuando la quimioterapia no incluye éste último, la ventaja de dar más ciclos de quimioterapia es controversial y se debe de discutir entre el paciente y el doctor.


  

English TRANSCRIPT

When we treat a patient in stage three we hope to cure the patient, but that only happens in about 20 to 25% of them and in most cases cancer comes back. Something we commonly use is consolidation therapy in which we give more chemotherapy after the one used in the chemotherapy and radiation therapy. Choosing if consolidation therapy is the best option is based on the regimen used. If the regimen included carboplatin and paclitaxel, we will give two more chemotherapy cycles after the radiation is over. When the chemotherapy did not include paclitaxel, the benefits of giving more chemotherapy are controversial and you have to discuss it with your doctor.


Denise Brock

Lung Cancer Video Library – Spanish Language: Video #40 The General Approach to Extensive Stage Small Cell Cancer

 
GRACE Cancer Video Library - Lung

 

We are pleased to continue this series of informational videos for our Spanish speaking community.  GRACE is pleased to welcome Dr. Rafael Santana-Davila, Assistant Professor with the University of Washington School of Medicine and Seattle Cancer Care Alliance.  In this 40th video for the Spanish lung cancer video library, Dr. Santana-Davila joined GRACE to discuss the general approach to extensive stage small cell lung cancer.  


 

 

 

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TRANSCRIPTS – Spanish and English
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Los Principios de Tratamiento Cuando el Cáncer de Células Pequeñas está en Estadio Extendido

The General Approach to Extensive Stage Small Cell Cancer

 

Rafael Santana-Davila, MD
Assistant Professor of Medicine
University of Washington Seattle Cancer Care Alliance
Seattle, Washington

 

Spanish TRANSCRIPT

Cuando el cáncer de células pequeñas está en estadio extendido es básicamente cuando el cáncer está en otras partes del pulmón o en otras partes del cuerpo. En este tipo de cáncer, el principio no es curar al paciente si no tratar de extender su vida y mejorar la calidad de ésta. En la mayoría de los casos el principio es quimioterapia, hay varios tipos de ésta que se pueden usar pero dependen de la conversación del doctor con el paciente para que conozca los riesgos, beneficios y los efectos adversos de cada tipo de quimioterapia. Se dan regularmente dos ciclos de quimioterapia y después se vuelven a hacer estudios de imágenes para ver cómo está respondiendo el cáncer. Lo más común es dar cuatro ciclos de quimioterapia y después de esto se puede usar radiación para consolidar las ganancias que obtuvo la quimioterapia.


  

English TRANSCRIPT

When small cells lung cancer is in extensive stage is when the cancer cells are in other parts of the lung or even in other parts of the body. In this type of cancer, the goal is not to cure the patient but to try to extend their life and improve their life quality. In most cases the treatment suggested is chemotherapy, which has different types of approaches and they all depend on the conversation the doctor and the patient have in order for the patient to understand the risks, benefits and possible side effects. Regularly, we give two cycles of chemotherapy and then we make again imaging studies to see how the cancer is responding. Four cycles of chemotherapy are the most common treatment to give and then we use radiation to concentrate the good effects chemotherapy had in the cancer cells.


Denise Brock

Lung Cancer Video Library – Spanish Language: Video #39 General Approach to Limited Stage SCLC

 
GRACE Cancer Video Library - Lung

 

We are pleased to continue this series of informational videos for our Spanish speaking community.  GRACE is pleased to welcome Dr. Rafael Santana-Davila, Assistant Professor with the University of Washington School of Medicine and Seattle Cancer Care Alliance.  In this 39th video for the Spanish lung cancer video library, Dr. Santana-Davila joined GRACE to discuss the general approach to limited stage small cell lung cancer.  


 

 

 

How Did You Like This Video?

Please feel free to offer comments and raise questions in our Discussion Forums.


 

TRANSCRIPTS – Spanish and English
download transcripts
 

Enfoque General Para El Estadio Limitado de Células Pequeñas de Cancer de Pulmón

General Approach to Limited Stage Small Cells Lung Cancer

 

Rafael Santana-Davila, MD
Assistant Professor of Medicine
University of Washington Seattle Cancer Care Alliance
Seattle, Washington

 

Spanish TRANSCRIPT

Cuando el cancer de células pequeñas se encuentra en estado limitado, el tratamiento es a base de radiación y quimioterapia al mismo tiempo (quimioterapia y radiación concurrente). Regularmente es cuatro a seis semanas de radiación con dos ciclos de quimioterapia al mismo tiempo. Una vez que ha pasado esto lo que esperamos es que se haya erradicado todo el cancer dentro del pulmón y curar a las personas. En algunos casos, también se da radiación al cerebro para prevenir que el cancer lo afecte, a esto se le llama por sus siglas en inglés: PCI.


  

English TRANSCRIPT

When the lung cancer of small cells is in limited stage we use at the same time a radiation and chemotherapy treatment (chemotherapy and radiation concurrent). Regularly, is four to six weeks of radiation with two cycles of chemotherapy at the same time. Once this is over, we hope the cancer is eradicated in the lung and the person is cured. In some cases, we also give PCI which is radiation to the brain to prevent its damage.


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