A Case of Non-Driver Non-Small Cell Lung Cancer

Mark Socinski, MD:The case we’re going to discuss is a 72-year-old gentleman who was diagnosed with stage 4 squamous cell carcinoma. He did have the presence of 2 brain metastases at the time of diagnosis. Those were treated with stereotactic radiotherapy. He subsequently received a platinum doublet in the first-line setting. In this case, he received cisplatin and gemcitabine, which is perfectly appropriate, although there are a number of options that one could use in this particular setting. He received 4 cycles, and then approximately 6 months later, he became more symptomatic. At that point, he did not have evidence of disease progression in his brain. However, his CT scan of the chest did suggest new lesions in the lung as well as the liver. And at that point, he was transitioned to second-line immunotherapy, which was, in this case, atezolizumab.

The prognosis of these patients, I always explain to patients, like our patient today, is that they have a treatable but not a curable disease. The reality of treating stage 4 squamous carcinoma is a median survival measured in about a year. That means 50% of people die within the first year and 50% of people live longer than a year. I think one of the things that we need to be aware of is that there are multiple lines of therapy that are approved by the FDA in this situation. So, I think physicians have to think of a multiple-line strategy in terms of how you manage these patients and try to optimize the benefit of treatment, even though many patients will die relatively early.

Obviously, the challenge in lung cancer—particularly squamous, which is tightly linked to smoking—is that most patients with the diagnosis of squamous cell carcinoma do have a history of smoking. And in our case today, the average age of lung cancer is about 70 years old. Our patient today is 72. When you combine aging and smoking, you get a lot of comorbidities. One common one is COPD. Many of the symptoms related to the chest can be relatively nonspecific. And oftentimes, we see patients who have been symptomatic, and at the end, we attribute those symptoms to lung cancer. I’ve always been an advocate for getting a chest X-ray as early as possible. If a patient has a change in their symptoms, just get a plain old-fashioned X-ray that can detect lung cancer in many cases at an earlier stage. And I do think that earlier detection, even in stage 4 disease, is important because we want patients to retain a good performance status so they can optimally benefit from systemic therapy.

I think physicians need to be aware that COPD is often associated with smoking. I think physicians need to be, or are aware, that smoking increases the risk of lung cancer. But COPD also is an independent risk factor for the development of lung cancer. So, I think you have to have a heightened awareness in patients with a history of COPD, certainly with a history of smoking, and really be aggressive at investigating any change in symptoms, or new symptoms, because they might be the first indication of a cancer that has developed.

Transcript edited for clarity.

• A 72-year old male presented with dyspnea, weight loss, chronic cough, fatigue, and back pain
• PMH: current non-smoker for the past 10 years with 40-year (1-pack/day) smoking history, COPD, controlled on LABA/LAMA/ICS; hyperlipidemia controlled on atorvastatin
• Chest CT scan showed a 3.5-cm nodule in the upper lobe of the left lung
• MRI of the brain revealed lesions in the left cerebellum and left frontal lobe
• 99mTc bone scan showed increased uptake in the L1 vertebra and eighth rib
• ECOG PS=1
• Pathologic diagnosis of biopsy under bronchoscopy was squamous cell carcinoma
• IHC: PD-L1 expression in 0% of cells
• Patient was started on gemcitabine/cisplatin
• Brain metastases treated with stereotactic radiotherapy
• At 6 months, patient reported worsening fatigue
• Follow up MRI scan showed no evidence of new brain metastases
• CT scan showed new lesions in the right lung and liver
• Patient was started on atezolizumab; ICS medication for COPD was discontinued
• Patient reported decreased appetite, which resolved following implementation of self-management techniques