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Challenging Cases Podcast: Experts Weigh in on Adjuvant Chemo Option for Smaller Node-Negative NSCLC with Some Higher Risk Features
Continuing with this series of case-based podcasts we’ve done in partnership with LUNGevity, we’ll again have a series of experts offer their own perspective to another challenging scenario. All are with the same format of me hosting and presenting the case to Drs. Bob Doebele from University of Colorado and Jyoti Patel from Northwestern University, who participated in the live webinar version of this, then followed in the recording by other terrific colleagues of mine weighing on the same case. These experts are:
- Dr. Suresh Ramalingam, from Winship Cancer Center, Emory University in Atlanta, GA,
- Dr. Jonathan Goldman, from Premier Oncology in Santa Monica, CA.
- Dr. Julie Brahmer, from Sydney Kimmel Cancer Center at Johns Hopkins University, in Baltimore, MD
- Dr. Heather Wakelee, from Stanford University Cancer Center in Palo Alto, CA
- Dr. Karen Reckamp, from City of Hope Cancer Center in Duarte, CA
This case is of a woman with a tumor that is in the range that is smaller than that for which we would routinely recommend post-operative (adjuvant) chemotherapy to reduce the risk of recurrence, but the tumor has some higher risk features that lead her, and might lead us, to be more inclined to recommend it despite the smaller size of the tumor (which is still within a pretty debatable range). Here’s the links to the audio and video versions of the podcast, along with the transcript:
adjuvant-chemo-for-smaller-nsclc-tumor-with-high-risk-features-audio-podcast
adjuvant-chemo-for-smaller-nsclc-tumor-with-high-risk-features-transcript
Podcast: Play in new window | Download (32.3MB) | Embed
The National Lung Screening Trial: Results are in
The much-anticipated manuscript from the NCI-sponsored National Lung Screening Trial (NLST) was just published on line in the New England Journal of Medicine, with an editorial by Dr. Harold Sox. As Dr. West outlined in a previous post, we’ve known since last year that this trial demonstrated an improvement in lung-cancer specific survival with low-dose spiral CT screening of high-risk individuals. However, we have not had access to the details of this study until now. One of the fundamental problems we face is that lung cancer is most often diagnosed in an advanced stage. This has generated intense interest in screening and early detection. However until this trial, no screening test has been shown to reduce the risk from dying from lung cancer, which is the benchmark we use to judge the effectiveness of any screening modality. As the first trial that shows lung cancer screening can save lives, the NLST will no doubt have a significant impact on how we practice in this country and should be viewed as a very hopeful result for lung cancer advocates. However, many questions remain and as is the case with any medical intervention, individuals considering low dose CT screening will need to weigh not only the potential benefit (as defined for the first time by this trial), but also the potential risks associated with this approach. The NLST will go a long way towards informing this decision.
Details on the Debate over Who to Test and for What Molecular Markers
The following is laden with personal opinion as much as actual evidence. Feel free to take it or leave it.
In my last post, I introduced the key questions we’re facing in my own institution, and many other oncologists and their own hospitals are doing the same thing: which patients do we now routinely test for molecular markers in their lung cancer tumors, and what markers do we request? Here’s an outline of the questions where there’s still back and forth, and why:
Challenging Cases in Lung Cancer Podcast Series: Adjuvant Chemo for a Small NSCLC Tumor with a Satellite Lesion
This is the first of a series of podcasts we’ve done, developed in partnership with LUNGevity Foundation, in which I present the same challenging cases in lung cancer management to a series of experts to learn the range of views offered by them, then the multiple thoughtful comments by all of them discussing the same single featured case for each podcast. The first discussants in each podcast will be Drs. Bob Doebele from University of Colorado and Jyoti Patel from Northwestern University, who are then followed by other terrific colleagues of mine:
- Dr. Suresh Ramalingam, from Winship Cancer Center, Emory University in Atlanta, GA,
- Dr. Jonathan Goldman, from Premier Oncology in Santa Monica, CA.
- Dr. Julie Brahmer, from Sydney Kimmel Cancer Center at Johns Hopkins University, in Baltimore, MD
- Dr. Heather Wakelee, from Stanford University Cancer Center in Palo Alto, CA
- Dr. Karen Reckamp, from City of Hope Cancer Center in Duarte, CA
Our first case is a discussion of how they would approach a patient who has a small primary tumor that also has a separate microscopic satellite lesion nearby. Here’s the links to the audio and video versions of the podcast (there isn’t a lot of video to see, by the way), along with the transcript:
case series: small nsclc tumor w/satellite lesion video podcast
case series: small nsclc tumor w/satellite lesion audio podcast
case-series-small-nsclc-tumor-wsatellite-lesion-transcript
Podcast: Play in new window | Download (26.9MB) | Embed
Amrubicin for SCLC: Recap from ASCO
Though there are many presentations to discuss in the wake of ASCO, we’ll need to pace ourselves on these. I and some of the other faculty members will offer thoughts on some of these in the coming weeks, and we also have our upcoming post-ASCO review on June 23rd (click here to learn more and sign up for this free online program).
Today we saw the results of a couple of long-awaited trials of treatment approaches that represented a couple of the more promising concepts for moving forward in our treatment of extensive SCLC, and I’ll cover the first of these today (though only with the benefit of my notes, rather than as many details as I’d like, so these comments are subject to revision and added details later). Amrubicin has been the subject of some prior discussion here, but that discussion focused on smaller, phase II trials; we’ve needed the results of a randomized phase III trial that directly compares the chemo agent amrubicin as a single agent to our current standard for Hycamtin (topotecan). The ACT-1 trial in enrolled 637 patients with extensive disease SCLC who had all received first line therapy and then relapsed — the trial included patients who had a “sensitive” relapse, 3 or more months after prior chemo had ended, as well as “resistant” relapse, which is marked by progression within 3 months of prior chemo ending (pretty evenly split at nearly 50/50 on the trial). Patients were randomized 2:1 to either amrubicin at 40 mg/m2 IV on days 1-3 of a 21 day cycle, or topotecan at 1.5 mg/m2 IV days 1-5 of a 21 day cycle.
Quick Update from ASCO
I apologize if it seems that the updates about ASCO have been slow in coming. This is mostly because the lung cancer program this year has most of the higher profile presentations occurring in the second half of the meeting, which we’re just getting into. And, truth be told, this isn’t going to be a blockbuster year for developments in lung cancer. But let’s review what we’ve found out about thus far.
Balancing Risks of Undertreatment vs. Overtreatment of Locally Advanced NSCLC
Our multidisciplinary thoracic oncology tumor board is dynamic and a highlight of the week, facilitated in equal parts by the fact that our group genuinely enjoys each other’s company and that it is the source of some engaging debate about the potential best way to manage several complex scenarios in lung cancer. There are a few that have become recurring debates, among them the question of whether to pursue surgery for a patient with a locally advanced NSCLC, perhaps felt to be unresectable or on the outer limits of resectability, who has undergone chemotherapy and concurrent radiation to a potentially curative dose, has encouraging but ambiguous imaging findings, and is now being considered for surgery. Essentially, this is a troubling struggle of trying to balance our concern for over-treating vs. potentially under-treating this patient.
Interview with Dr. Tony Mok, Part 2
Continued from part 1
Dr. West: You have a huge portion of your patients who have an EGFR mutation and we know that over time patients develop acquired resistance. So how do you approach the patients who have a great response initially, have a known EGFR mutation, and then you see that slipping away at slow progression? Do you continue the EGFR inhibitor? Do you add something to it? Do you change the dose? How do you approach that?
Dr. Mok: I think this is one area where we still have a lot to learn. First of all, let’s define resistance, or progression. If you use the Jackman criteria (Jackman, J Clin Oncol 2010), that still incorporates the RECIST criteria, which mean if the lesion that has increased by about 30%, then it’s progression. But then one factor we didn’t look into was in the rate of progression within this definition. The second concern is about the occurrence of a new lesion that’s also progression. Now, whether this is directly applicable to a targeted like Tarceva or another EGFR TKI or not, I have some doubts, because simply from your experience and my experience, some of these patients get a new nodule, but they can take a long time to grow and the patient lives a normal life. And we also know the fact that if we take them off the TKI, the disease can progress rapidly. So some of these are slow progressors, then we just keep them on a TKI. Continue reading
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