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Walter J. Curran, Jr., MD, FACR, associate vice president of cancer, Woodruff Health Sciences Center, executive director, Winship Cancer Institute, Lawrence W. Davis Chair of Radiation Oncology, Emory University, discusses radiation therapy dose for the treatment of patients with lung cancer. 


Radiation Therapy Dose for the Treatment of Patients With Lung Cancer

ASH 2024 Preview for Community Oncologists: The Show and After Show

The American Society of Hematology (ASH) Annual Meeting and Exposition aims to educate oncology providers across an array of hematologic malignancies, with a focus on novel agents, drugs across the FDA pipeline, and more.

, co-hosts Kristie L. Kahl and Andrew Svonavec offer a glimpse at some of the presentations guaranteed to spark one’s curiosity, spur debate, and enhance the field even further. Some key highlights include:

 Continued advancements in CAR T-cell therapy are expected to revolutionize the treatment of hematologic malignancies.

 Bispecific antibodies, such as Epcoritamab (Epkinly), offer a novel approach to target multiple antigens on cancer cells.

 The assessment of MRD is becoming increasingly important in predicting treatment response and overall survival.

Advances in Acute Lymphoblastic Leukemia (ALL)

Blinatumomab (Blincyto) in pediatric ALL:

 The addition of blinatumomab to chemotherapy has shown promise in improving disease-free survival in high-risk pediatric ALL. This combination therapy may offer a more effective treatment option for young patients.

Acalabrutinib (Calquence) in mantle cell lymphoma (MCL):

 The FDA is set to review the approval of acalabrutinib with bendamustine or rituximab (Rituxan) for previously untreated MCL, based on data from the phase 3 ECHO trial (NCT02972840).

Asciminib (Scemblix) in chronic phase chronic myelogenous leukemia (CML-CP):

 The FDA recently granted accelerated approval to asciminib for newly diagnosed CML-CP. This tyrosine kinase inhibitor has shown favorable safety and tolerability profiles.

 isn't just about data, as the duo also offers food recommendations, tourist attractions and fun activities to partake in, as well as interesting facts about San Diego.

This is just a taste of the wealth of information and inspiration waiting at the 2024 ASH Annual Meeting. Check back for future meeting previews with 

Targeted Oncology co-hosts Kristie L. Kahl and Andrew Svonavec highlight abstracts for community oncologists to look out for at the upcoming ASH Annual Meeting in San Diego, with some additional tidbits to round out the main event.

News

The biologics license application (BLA) of the subcutaneous formulation of nivolumab (Opdivo) coformulated with human hyaluronidase (rHuPH20) has been accepted by the FDA.

Findings from the CheckMate -67T (NCT04810078) support this BLA of subcutaneous nivolumab as the trial met its coprimary pharmacokinetic end points and key secondary end point of overall response rate (ORR) vs intravenous (IV) nivolumab in clear cell renal cell carcinoma.

The FDA has set a Prescription Drug User Fee Act (PDUFA) goal date for December 29, 2024.

The FDA has accepted the BLA of the subcutaneous formulation of nivolumab coformulated with rHuPH20, also known as subcutaneous nivolumab, for all previously approved adult solid tumor indications of nivolumab as a monotherapy, monotherapy maintenance following completion of the combination therapy with nivolumab plus ipilimumab (Yervoy), or in combination with chemotherapy or cabozantinib (Cabometyx).

Results from the phase 3 CheckMate -67T trial of subcutaneous nivolumab support this application. In the trial, experts sought to evaluate subcutaneous nivolumab vs its intravenous (IV) formulation.

 Here, the subcutaneous form demonstrated noninferior pharmacokinetics and efficacy, as well as consistent safety compared with the IV formulation of nivolumab among patients with advanced or metastatic clear cell renal cell carcinoma (ccRCC) who have received prior systemic therapy.

A PDUFA goal date has been set for December 29, 2024. With this, subcutaneous nivolumab shows promise to become the first and only subcutaneously administered PD-1 inhibitor.

“We believe subcutaneous nivolumab has the potential to make a significant difference in the lives of patients, which is reinforced by the FDA’s acceptance of our application,” said Gina Fusaro, PhD, vice president, global program lead, Bristol Myers Squibb, in a press release.

“[Nivolumab] is a foundational PD-1 inhibitor approved for many different types of cancer, and our continued investment in research that puts patients first remains a priority. If approved by the FDA, the subcutaneous administration of nivolumab would provide patients and their physicians with a new option that delivers the same well-known benefits as IV [nivolumab] but with the improved convenience of an injection administered in 3 to 5 minutes rather than a 30- to 60-minute infusion,” Fusaro continued.

The phase 3, randomized, open-label CheckMate -67T trial is exploring subcutaneous administration of nivolumab coformulated with rHuPH20 vs IV nivolumab for the treatment of patients with advanced or metastatic ccRCC who were previously treated with systemic therapy.

In the study, 495 patients were randomly assigned to receive either subcutaneous nivolumab or IV nivolumab. Enrollment was open to patients with a histological confirmation of ccRCC, advanced RCC not amenable to curative or radiation therapy, metastatic RCC, those who received no more than 2 prior systemic therapies, those with intolerance or progression after last treatment regimen within 6 months of randomization, and those with a Karnofsky performance score ≥ 70 at screening.

Experts assessed the coprimary end points of time-averaged serum concentration over 28 days and trough serum concentration at steady-state of subcutaneous nivolumab vs IV nivolumab. A key secondary end point of the trial was ORR.

The study met its coprimary pharmacokinetic end points and key secondary end point of ORR with subcutaneous nivolumab in this patient population.

 Subcutaneous nivolumab was noninferior in regard to time-averaged nivolumab serum concentration over 28 days and steady-state trough serum concentration vs treatment with IV nivolumab. Additionally, subcutaneous nivolumab also demonstrated a noninferior ORR compared with IV nivolumab.

1. U.S. Food and Drug Administration accepts Bristol Myers Squibb’s application for subcutaneous nivolumab (nivolumab and hyaluronidase). News release. Bristol Myers Squibb. May 6, 2024. Accessed May 6, 2024. 

2. Phase 3 Check-Mate -67T trial of subcutaneous nivolumab (nivolumab and hyaluranisade) meets co-primary end points in advanced or metastatic clear cell renal cell carcinoma. News release. Bristol Myers Squibb. October 19, 2024. Accessed May 6, 2024. 

3. A study of subcutaneous nivolumab versus intravenous nivolumab in participants with previously treated clear cell renal cell carcinoma that is advanced or has spread (CheckMate-67T). ClinicalTrials.gov. Updated October 12, 2023. Accessed May 6, 2024. 

https://www.clinicaltrials.gov/study/NCT04810078

The FDA is considering a subcutaneous nivolumab formulation for various solid tumors based on promising data from the phase 3 CheckMate -67T trial. A target action date has been set for December 29, 2024.

Clinical

FDA Accepts BLA for Subcutaneous Nivolumab Across Various Solid Tumors

In October 2016, a 57-year-old black man was referred to the urology department with a PSA (prostate-specific antigen) of 6.8 ng/mL. His medical history included seizures that were controlled with oxcarbazepine. His mother and sister had a history of breast cancer, and his brother had a history of pancreatic cancer. A multiparametric MRI scan showed a 58 cc index lesion to his left prostate zone, and prostate imaging reporting and data system showed it to be 4/5, 1.8 cm. 3 months later, he had a robotically assisted radical prostatectomy and extended lymph node dissection. 6 weeks post operation, the patient had a PSA of 0.15 ng/mL and baseline serum testosterone of 420 ng/mL.

Androgen deprivation therapy (ADT) was initiated with leuprolide depot at 45 mg. The patient returned in August 2019. His PSA doubling time (PSA-DT) was 8.6 months with a PSA of 1.2 ng/mL. In October 2019 he was restaged, and bone scans showed he was negative for metastatic disease with an ECOG performance status of 0. In October 2020, the patient’s PSA was 3.81 ng/mL.

Continue androgen deprivation therapy as monotherapy

How critical are quality-of-life issues in decision-making?

Why would you reach for a first-generation antiandrogen?

 I did pick a first-generation antiandrogen, and the reason for that is mainly pragmatic reasons.

In this nonmetastatic recurrent disease, you have a drug that is effective, it is inexpensive, and it has hardly any adverse events [AEs]. So, I tend to use that in these settings, and I [have success] with it for a year or 2. And then once they [progress], I go to the next generation, mainly because of the cost.

 So, you would use something like bicalutamide [Casodex] due to the [low] cost and not having a lot of AEs?

What factors influence your selection of a novel hormonal agent?​

 Which [novel hormonal agent] one would you select? Dr Jafari, let us say you used bicalutamide already and the PSA is still rising through [the treatment period], and you restage the patient. Still no metastases on CT or bone scan. Would you pick abiraterone [Zytiga], apalutamide [Erleada], darolutamide [Nubeqa], or enzalutamide [Xtandi] for this patient?

 I picked apalutamide because that is the first one to get approved for this specific indication of nonmetastatic castrate-resistant prostate cancer [nmCRPC].

 [I have] experience since I have been using it for the past year and more.

 I picked enzalutamide because I am familiar with it. That is the only reason.

 [Dr Agarwal’s reason] was that apalutamide was first to be approved in this setting…and enzalutamide was the first to be approved for metastatic CRPC, post-chemotherapy, and then pre-chemotherapy.

 I prefer darolutamide for a slightly better tolerability, and fewer interactions between this drug and others.

 I chose enzalutamide. I was between darolutamide and enzalutamide. Enzalutamide was more tolerable, and I have seen it more.

 [I chose abiraterone for] similar reasons to [Dr Sui]. I am familiar with the abiraterone in the metastatic setting. And I am familiar with the AE profile, so I think I can manage them.

 Yes. Does that affect your choices, Dr Wong?

 I do not have any clinical experience with it causing seizures, but supposedly enzalutamide can lower the seizure threshold.

 Yes, it is not high. It is [around] 0.6% to 0.9% in their early studies.

 Then subsequent earlier-stage studies are only 0.1%.

 But again, those trials excluded patients with a seizure history, and this patient already has a seizure disorder. Did you pick abiraterone, then?

 I picked darolutamide because although they were not directly compared, it seemed to have the lowest rate of AEs compared with placebo.

 Darolutamide has a different biochemical structure than enzalutamide or apalutamide, and there are data to show that there is less crossing in the blood-brain barrier with darolutamide.

 So, the interesting thing is that the darolutamide clinical trials did not exclude patients with seizure history or seizure risk.

 It is the only agent that does not have a contraindication [or warning] for patients with seizures.

Now, abiraterone does not have any issue with seizures either, but it is not an androgen receptor antagonist. Although there are great phase 2 data, there has not been a randomized phase 3 trial with abiraterone in this setting.

So I think you hit the nail on the head there. If you are looking for FDA-approved answers for a patient with a history of seizures, darolutamide would be the best agent for this patient.

 So, [the SPARTAN trial (NCT01946204) of] apalutamide also excluded patients with seizure history?

 Yes. Enzalutamide and apalutamide were created in the same lab. There is just a small change in the nitrogen side chain. So, they are essentially almost the same biochemical structure.

Abiraterone is not approved for treatment of nmCRPC. It is apalutamide, darolutamide, and enzalutamide [that are approved by the FDA].

For abiraterone, there is only the phase 2 [IMAAGEN] study [NCT01314118]. The data looked great. If they ran a phase 3 study, it probably would work as well. It is just that abiraterone went generic, so nobody was going to back a phase 3 study in this situation.

After shared decision-making, darolutamide was initiated.​

How would a PSA doubling rate of 15 months affect your choice?

What if the PSA doubling was not 8 months, but was 15 months? Does that change your decision making at all?

 Yes, I think that makes difference if the doubling time is 6 months, 8 months, or 12 months, it makes a difference. If it were 15 months, I would think about it. If, for example, the PSA went from 1 ng/mL to 2 ng/mL, with a doubling time of 15 months, I may not change the regimen.

 You might just watch them for a while. Alright, that sounds good. Dr Shao, what would you do if the PSA doubling time was 15 months here?

 [There are] 2 choices. Either we watch for a while, or we can continue the hormone that he is [receiving] right now.

 Dr Sun, would you treat this patient, or would you observe, still just on ADT?

 I would just continue the monotherapy. I wouldn't add another agent in this situation. Fifteen months doubling time can be monitored. Once the doubling time shortens you can initiate at that point.

 The most recent National Comprehensive Cancer Network guidelines [recommend that patients with] nmCRPC with rising PSA should continue ADT with leuprolide [Lupron]. And they break it down based on whether the PSA doubling time is less than or equal to 10 months, or greater than 10 months.

If the PSA doubling time is greater than 10 months, then observation is preferred, or other, secondary hormone therapy like bicalutamide. If it is less than or equal to 10 months, the preferred category 1 recommendations are apalutamide, darolutamide, or enzalutamide. But they say you can also use other secondary hormonal therapies as well.

1. FDA approves apalutamide for non-metastatic castration-resistant prostate cancer. FDA. Published February 14, 2018. Accessed February 15, 2022. https://bit.ly/3LGHvgc

During a live virtual event, Evan Yu, MD, discussed the choice of novel hormonal agent for a patient with nonmetastatic castration-resistant prostate cancer. 

Walter J. Curran, Jr., MD, FACR

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