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NSCLC

Denise Brock

Lung Cancer Video Library – Spanish Language: Video #21 Treating stage IIIA N2 NSCLC

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GRACE Cancer Video Library - Lung

 

We continue to provide informational videos for our Spanish speaking community and welcome Dr. Luis Raez, MD FACP FCCP, Chief of Hematology/Oncology and Medical Director at Memorial Cancer Institute, and Clinical Associate Professor of Medicine at Florida International University.  Dr. Raez joined GRACE to discuss the basics of lung cancer.  In this 21st video for the Spanish lung cancer video library, Dr. Raez discusses treating stage llla N2 non-small cell lung cancer (NSCLC).


 

 

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TRANSCRIPTS – Spanish and English
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Tratamiento para el cáncer de pulmón de células pequeñas en estadio IIIA N2

Para estadios III de cancer de pulmón, el tratamiento es más complicado, porque se trata de una multimodalidad. Idealmente en unos pacientes con estadio III, tienen que ir a una reunión multidisciplinaria donde tengamos al cirujano, al radiooncólogo y al oncólogo médico porque muchas veces los pacientes en estadio III pueden ir a cirugía y después de la cirugía se les da quimioterapia y radiación (cuando hay compromiso mediastinal o estadio N2), sino a los pacientes en estadio III solo le damos quimioterapia adyuvante después de la cirugía.

El estadio III es complicado porque a veces el paciente no puede ser operado o no estamos seguros de que pueda ser operado. A veces, hay que disminuir el tamaño del tumor por lo que se da quimioterapia primero para reducir el tamaño y ya después se va a cirugía.

Hay varias combinaciones, a veces la tercera opción es que el paciente va a cirugía porque parece operable, pero después de la cirugía descubrimos que hay enfermedad mediastinal (ganglios comprometidos), entonces no solo se le da quimioterapia después de la cirugía, pero también se le tener que dar radiación.

Esas son las tres posibilidades que hay para un estadio III, por eso lo mejor es hacer una reunión multidisciplinaria para decidir en grupo qué es lo mejor para el cancer de pulmón en este estadio.


Treatment for small cell lung cancer in IIIA N2 stage

For lung cancer in stage III, the treatment is more complicated because it is multimodality. Ideally stage III patients should go to a multidisciplinary reunion with a surgeon, radio-oncologist and the oncologist, because sometimes these patients go into surgery and then receive chemotherapy and radiation (only when the mediastinum is affected or is in N2 stage), when they could only receive adjuvant chemotherapy after surgery.

Stage III is complicated because sometimes the patient cannot go into surgery or we are not sure if he is a candidate. Sometimes, we have to reduce the size of the tumor by giving chemotherapy first and then go into surgery. 

There are several combinations, sometimes the third option is the patient going into surgery, but after the procedure we sometimes identify mediastinum affection (lymph nodes are affected), so the treatment has to be of chemotherapy and radiation.

The three options for stage III treatment are available, but it is better to make a multidisciplinary reunion to decide which is the best treatment for the patient.


Denise Brock

Lung Cancer Video Library – Spanish Language: Video #20 Treating Early Stage Non-Small Cell Lung Cancer (NSCLC)

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GRACE Cancer Video Library - Lung

 

As we continue with information for our Spanish speaking community, we welcome Dr. Luis Raez, MD FACP FCCP, Chief of Hematology/Oncology and Medical Director at Memorial Cancer Institute, and Clinical Associate Professor of Medicine at Florida International University.  Dr. Raez joined GRACE to discuss the basics of lung cancer.  In this 20th video for the Spanish lung cancer video library, Dr. Raez discusses treating early stage non-small cell lung cancer (NSCLC).


 

 

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TRANSCRIPTS – Spanish and English
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Tratamiento para el estadio temprano del cáncer de pulmón de células no pequeñas

A veces es difícil recordar cual es el estadio I o II y uno se puede perder hablando del estadio. En general, el estadio I y II son sencillos porque son tumores que son confinados al pulmón, son tumores que no han invadido el mediastino y son operables. Para el estadio I y II lo que haces es cirugía como primera intervención y dependiendo de los hallazgos patológicos después de la cirugía, hacemos quimioterapia porque muchas veces a pesar de que hemos resecado tumores pequeños, como del estadio IB que son tumores pequeños de 3.5 cm, hay un riesgo de recurrencia y mortalidad grande.

Desafortunadamente, incluso en la cirugía más perfecta que es el estadio IA que pueden ser tumores de 2cm de cáncer de pulmón, los pacientes no necesariamente se curan después de los 5 años. Vemos que una parte del 10 al 20% igual van a morir por la recurrencia del cáncer de pulmón, he ahí la necesidad de dar quimioterapia.

Ahora, la quimioterapia tampoco es para todos. Hay mucha evidencia clínica que para estadio II no es discusión, se da la quimioterapia de 4 ciclos de cisplatino más el agente de elección como etopósido, pemetrexed, vinorelbina, taxanes. Después de eso, solo es observación y seguimiento del paciente.

Para estadio IA, el beneficio de la quimioterapia no existe o no está documentado, por eso no hacemos quimioterapia. Por eso es un área de mucha investigación para tratar de clasificar que pacientes tienen un riesgo alto que justifique quimioterapia u otra intervención y que pacientes no. 


Treatment for early stage non-small cell lung cancer

Sometimes it’s difficult to remember which cases are stage I and which one are stage II, one can get lost talking about the stage. In general, stage I and II are simple because the tumor is not confined to the lung, they are tumors that have not invaded the mediastinum and are surgically removed. For stage I and II, what we have to is surgery as first intervention and depending on the pathological findings, we can then do a surgery. We do chemotherapy because sometimes despite the small resected tumors like in stage IB (tumors smaller than 3.5 cm), there is a high risk of recurrence and mortality.

Unfortunately, even in the most perfect surgery in stage IA, than can be tumors of over 2 cm, patients don’t necessarily heal after 5 years. We see that a part of 10 to 20% will still die for lung cancer recurrence, so we need to give chemotherapy.

Now, chemotherapy is not for everybody. There is clinical evidence that for stage II chemotherapy the option is to give 4 cycles of cisplatin and the choice agent like etoposide, pemetrexed, vinorelbine or taxanes. After that, it’s only observation and the follow up of the patient.


Denise Brock

Lung Cancer Video Library – Spanish Language: Video #19 Second Line Therapy for NSCLC and ALK +

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GRACE Cancer Video Library - Lung

 

For our 19th video in the GRACE Spanish Lung Cancer Library, Dr. Brian Hunis, Medical Director, Head and Neck Cancer Program, Memorial Cancer Institute, Miami, Florida, joined GRACE to discuss the basics of Lung Cancer for Spanish-speaking patients and caregivers.  In this video Dr. Hunis discusses second line therapy for non-small lung cell cancer patients with anaplastic lymphoma kinase (ALK) positive.


 

 

 

 


 

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TRANSCRIPTS – Spanish and English
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Terapia de segunda línea para pacientes con cáncer pulmonar de células no pequeñas y con la cinasa de linfoma anaplásico (CLA) positiva.

Para los pacientes que progresaron a crizotinib, en este momento hay dos fármacos: ceritinib que se puede considerar si el paciente progresa con crizotinib, y hay otro fármaco llamado alectinib que es la tercera línea para pacientes que progresan en terapia dirigida para ALK.

Lo que uno tiene que saber, es que, por la resistencia adquirida a uno de estos fármacos, uno tiene que checar la biopsia porque puede ser que el paciente no responda a estas terapias y necesite quimioterapia.


Second line therapy for non-small lung cell cancer and with anaplastic lymphoma kinase (CLA) positive

For patients that progressed to crizotinib, in this moment there are two drugs available: ceritinib that can be considered if the patient progresses with crizotinib and the other drug is alectinib which is a third line treatment for patients that progressed with ALK targeted treatment.

What we have to know is that, for acquired resistance to one of these drugs, one has to check the biopsy because the patient might not respond to these therapies and might need chemotherapy.


GRACE Video

Immunotherapy Combinations

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Dr. Jack West, Swedish Cancer Institute, discusses current trials seeking to determine the efficacy of combining immunotherapy agents in lung cancer.

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Transcript

The class of agents known as immune checkpoint inhibitors have really invigorated our study of lung cancer, and many other cancers over the last few years. Agents like Opdivo, also known as nivolumab, and Keytruda, known as pembrolizumab, are now commercially available, FDA approved as a second line therapy for patients who have progressed on first line standard chemotherapy. We are now actively asking the question of whether we might be able to move these immunotherapies into the first line setting and also asking whether we might do well by giving a combination of immune therapies, rather then just one treatment at a time.

So these agents, immune checkpoint inhibitors, are largely categorized into PD-1 or PD-L1 inhibitors, and those are just targeting two separate sides of an interaction between two receptors. The PD-L1 is on the tumor cells, PD-1 is on the immune T cells, and so blocking either side of this can lead to a beneficial effect because this effect leads to a braking mechanism on the immune system — you take away that braking system and you turn off the brakes and lead things to move forward, and that’s what we often see.

There are other agents that can also lead to braking mechanisms and that have been studied in other cancers. An agent such as Yervoy, which is known as ipilimumab is a CTLA-4 inhibitor and this is an agent that’s been approved in melanoma. In fact, the combination of Opdivo (nivolumab) and Yervoy (ipilimumab), as two different ways of blocking the immune system, have been shown to be beneficial as a combination in melanoma compared with either one on its own. Because of that, we’re looking at combinations of immunotherapies compared with single immunotherapy approaches, or standard chemotherapies.

One interesting study being done right now is called CheckMate 227 and it is looking at first line treatment of patients with advanced lung cancer that is either squamous or non-squamous histology. It does not require any level of PD-L1 expression on the tumors, the protein associated with tendency toward better efficacy of immunotherapies, partly with the thought that the combination of two immunotherapies may make even the cancers that don’t express PD-L1 respond well. This trial is looking at first line therapy with either standard chemotherapy of cisplatin or carboplatin with Alimta for non-squamous cancers, or Gemzar (gemcitabine) for squamous cancers, compared with either Opdivo alone or a combination of Opdivo and Yervoy — Opdivo being a PD-1 inhibitor, Yervoy being a CTLA-4 inhibitor — and asking the question of whether immunotherapy is as good, better, or worse than standard chemotherapy as a first line treatment, and whether the combination of two immunotherapies is better than first line therapy. 

I should mention that there are other trials looking at very similar versions of this question using different combinations of immunotherapies. There are many companies looking at several different immunotherapies in development and they are overall really very comparable and all quite exciting.

You can learn more about this specific trial from the link on the screen,

CheckMate 227 Clinical Trial

but I would encourage you, if you talk to your doctor and they recommend a trial with an immunotherapy in the first line setting, potentially comparing it to chemotherapy, to carefully consider it — it does not have to be this specific trial to be of interest.

We’re going to learn more about this in the coming years and we’re going to figure out the best way to integrate immunotherapies with our standard treatment approaches today.


GRACE Video

Immunotherapy as First-Line Treatment

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Dr. Jack West, Swedish Cancer Institute, raises the question of whether to use immune checkpoint inhibitors as first-line treatment of lung cancer, alone or in combination with chemotherapy.

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Transcript

A class of agents known as immune checkpoint inhibitors has really incredibly invigorated the field of lung cancer and many other cancers over the last year or two. These agents are given intravenously and essentially take off a braking mechanism for the immune system and by doing that, can stimulate it to recognize and attack your own cancer. These agents, at least a couple of them, have been approved by the FDA as of now, in late 2015, and the question is whether they should be used earlier than the second line setting where they’ve already been approved.

Two agents, one known as Opdivo or nivolumab, and another known as Keytruda or pembrolizumab, are approved in patients who have already demonstrated progression after receiving a first line chemotherapy. So the question is: should these treatments be given earlier in therapy? There are two leading considerations in how we might do this. One is that we might give an immunotherapy in combination with standard chemotherapy. There are other ways to do this that might give the immunotherapy instead of standard chemotherapy. There are studies looking at various combinations being done with any of the many immune checkpoint inhibitors that are in development right now.

An interesting trial that is being done now is with pembrolizumab, or Keytruda — this is the KEYNOTE-189 trial that is looking at whether the addition of Keytruda to standard chemotherapy improves outcomes for patients when they get it first line. Specifically this trial is for patients with a non-squamous cancer and these patients can have any level of PD-L1 expression, the protein that tends to be associated with better activity of the immune checkpoint inhibitors — there’s no restriction on PD-L1 expression and patients just have to have not received prior therapy for advanced lung cancer. These patients are then randomized to receive the two drug chemotherapy combination of cisplatin or carboplatin with Alimta, or that same chemotherapy combination with Keytruda (pembrolizumab). That study is being done now and we hope to learn more about it in the next year or two, to learn whether it is beneficial to give these immunotherapy agents in combination with chemotherapy, compared to giving them sequentially.

Another very similar study, though looking at squamous lung cancer, is called EMPOWER 131 — this is with an immune checkpoint inhibitor known as atezolizumab. This agent is being looked at in combination with either carboplatin and Taxol, or carboplatin and Abraxane, a very similar agent. There are two arms of this study where a patient gets a combination of chemotherapy and the immune therapy, and the third arm is just carboplatin and Abraxane alone. We should learn more about the potential benefits of combining immune checkpoint inhibitors with chemotherapy in the first line setting from this, looking at both patients with squamous and non-squamous histology in different trials.


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