Today we discussed the case of a middle aged man with newly diagnosed metastatic non-small cell lung cancer; this is a hot area because there have been a lot of exciting new developments in this area over the past few years– particularly the development of several new targeted agents and immune therapy.
Here’s a diagram showing the approach for a patient with newly diagnosed NSCLC:
- There are a growing list of targeted therapies based on driver mutations for NSCLC, noted in the table below
- PD1 or PDL1 expression is important in determining the patient’s eligibility for immune therapy; 50% is the usual cut-off
- Note that metastatic lesions may have different PD1 or PDL1 expression than the primary tumor; the reason for this is unclear, but basically means that they may still be a candidate for immune therapy even if the originally biopsied tumor had low PD expression
- For EGFR positive patients that have disease progression on a 1st line agent like afatinib, you can get more tumor tissue and look for the T790M mutation which would make them a candidate for osimertinib (which per recent data is increasingly being used as a first line therapy for patients with EGFR exon 19 or 21 mutations)
- It is exceedingly rare for more than one driver mutation to occur in one patient; if that happens, it may mean there are two primary cancers which would also be unusual
- These targeted therapies don’t have the same adverse effects as standard chemo, so oncologists may have a lower threshold for giving them to patients with low performance status
Lastly, remember that there is a trial showing the survival benefit of early palliative care in NSCLC. Obviously this finding can be extended to other types of malignancies, but at least here at Penn is mostly limited by the availability of access to palliative care.
Temel J et al. Early Palliative Care for Patients with Metastatic Non-Small Cell Lung Cancer. NEJM 2010.