KEYTRUDA AS FIRST LINE TREATMENT OF STAGE IIIA NSCLC W/ HIGH PD-L1 EXP. - 1290324

Hi Naz,

Welcome to GRACE. The question of the appropriate initial therapy for stage III disease is often difficult, but if the decision is made to use systemic therapy as opposed to local therapy (surgery or radiation), then an immunotherapy such as Keytruda could be a good choice. If it's the only therapy pursued, the thought process is no different than more advanced NSCLC - you're trying to kill as many cancer cells as possible, wherever they may be found, so if PD-L1 expression is high, it makes sense to go with the best treatment indicated.

Although Keytruda in the first line setting is not standard at this point, even for patients with very high PD-L1 expression, it is being tested, as you can see in this report from Dr. West. There's another discussion of this issue here.

Maintenance treatment when a patient is NED is always a tough call, and the same considerations apply to immunotherapy. Is the therapy necessary, and how can you tell if it's doing anything? A NED patient may stay that way for a lengthy period, with or without treatment. If maintenance is continued for a year or two, and scans are still NED, when do you decide to stop the therapy?

JimC
Forum moderator

Hi Naz,

Welcome to Grace. We have a new blog post I'll share with you. I don't know that it has any new info since Dr. West's post in November but it does list several immune therapies currently in trials.

All best,
Janine

oops edit for link, http://cancergrace.org/lung/2017/03/07/more-immunotherapy-agents-are-in…

Nazimi, are they telling you they're going for the cure? Since immunotherapy is newer, chemo and or rads along with surgery is a standard treatment going for the cure in stage IIIA.
Take care, Judy

Right Judy, though radiation is shown to be a very good choice for those who can't have surgery for whatever reason (including not fit enough or the cancer can't be surgically removed because of location). There has been an attempt or 2 to study if radiation is as good as surgery but it wasn't able to accrue enough people who were able to choose surgery but agree to possibly be assigned to the radiation/chemo only arm of the trial. So surgery remains the treatment of choice. BTW, Don's tumor wasn't removable and is over 7 years from initial chemo/radiation and NED.

The point about cure is a good one. The only way known to cure solid tumor cancers is through local treatment, surgery or radiation; unfortunately there are cases where stage III nsclc can't be safely removed or radiated and systemic treatment is the only choice to keep cancer at bay for as long as possible. It's still a good point to emphasize as Jim did said, "...if the decision is made to use systemic therapy as opposed to local therapy (surgery or radiation), then an immunotherapy such as Keytruda could be a good choice."

Thanks,
Janine

I'm aware of radiation vs surgery as first line tx as this is what I had the first time because of two tumors in different lobes. I had SBRT then chemo, stage IIIA. I was just pointing out that they normal protocol for cure in this stage would be surgery either before or after chemo and/or rads. Each situation is definitely different.
But I've yet to hear any info about immunotherapy being used in stage IIIA going for the cure. Is there any research out there? Are you thinking do immuno then surgery?
Take care, Judy

Hi Naz,

Janine and Judy make good points. Typical treatment of stage IIIa NSCLC tends to be surgery and/or radiation, with chemotherapy often added. Using immunotherapy in place of chemo in this context would be experimental at this point: most oncologists would prefer to use chemo regimens that have been well-tested in stage IIIa combination therapy.

Another point regarding Judy's question about whether the plan would be to use immunotherapy prior to surgery, it should be noted that the benefit from immunotherapy tends not to become visible nearly as fast as with chemo. In addition, even with high PD-L1 expression, immunotherapy is only effective for a smaller percentage of patients than standard chemo (especially in the short term).

JimC
Forum moderator

Thanks for the clarifying information, Naz. It makes the situation much clearer.

Standard stage IIIa treatment is surgery or chemoradiation, with chemotherapy added to surgery at times, either pre- or post-surgery. After these therapies are complete, the usual course of action is to stop treatment and continue to monitor with periodic scans. Maintenance chemotherapy is not typically pursued, especially if a patient is NED.

So that would be the first question, whether maintenance is advisable. Certainly something to discuss with your oncologist. If you choose to pursue maintenance, chemotherapy would be the leading contender, although a good case could be made for immunotherapy given the high PD-L1 expression. It would be considered experimental, especially by your insurer, who might be unwilling to pay for it.

Good luck with further treatment, whether you opt for it now or later. Of course, we're all hoping the cancer never appears again and treatment remains unnecessary.

JimC
Forum moderator