Accurately Diagnosing Unresectable Stage 3 NSCLC

Heather Wakelee, MD:When a patient presents with a stage 3 lung cancer that has been newly diagnosed, there are a few key things we want to make sure are happening. One is to really be thorough with the staging. In the United States, we’re almost always getting a PET scan. Usually, we’ll get a brain MRI and may consider doing endobronchial evaluation or mediastinoscopy.

You really want to determine whether those mediastinal nodes are involved and be clear that it’s truly stage 3 and not a more advanced cancer. Also, you need to really ask that question around surgical feasibility. That really should be done in the context of the multidisciplinary tumor board. With this particular case, that has all been done. They did all the right imaging. He was evaluated in a multidisciplinary group, and then they took it a couple of extra steps beyond.

It’s not necessarily standard of care to do mutational analysis forEGFRandALKin a patient who’s going through concurrent chemoradiation, but having that information is helpful to better understand the tumor, predict some of the behaviors, and also to help a little bit with guidance on therapy. It’s not going to change the chemotherapy. You’re still going to pick chemotherapy and do that concurrently with your radiation. And it turns out that it’s not really going to change your choice about whether or not to give durvalumab. That ended up not being significant in the PACIFIC trial. Patients who had mutations seemed to benefit—maybe not quite as much, but they certainly benefited from their durvalumab as others did. So, knowing that information is really more to know it. It is not treatment changing. But having that whole package (all the imaging, knowing the mutation status, knowing the PD-L1 status)—all those things are somewhat useful.

He is still actively smoking. We need to consider smoking cessation. We do know that patients who are actively smoking don’t do as well during concurrent chemoradiation. In the long term, they’re at higher risk for some infections and complications during the chemoradiation. And obviously, their risk of recurrence and of having other complications is higher if they don’t quit. I want to emphasize that.

Transcript edited for clarity.

• A 64-year-old man presented with shortness of breath and persistent cough of 18 months’ duration; recently, he has experienced chest pain, fatigue, and blood in his sputum. After consulting with his primary care physician, he was referred for oncology evaluation
• Patient history includes
  • Current smoker (1/2 pack day)
  • Hypertension
  • Acute MI at age 60
• Evaluation and follow up testing reveal
  • Non-small cell lung cancer in left lung and 2 lymph nodes (Stage IIIa)
  • WHO performance status: 1
  • Histology: adenocarcinoma
  • EFGR, BRAF,andALK/ROS1mutation status: wild-type
  • PD-L1 status: ≥25%
• He underwent multidisciplinary evaluation and was not a candidate for surgery; he was treated with chemoradiotherapy:
  • Concurrent carboplatin-paclitaxel doublet chemotherapy and radiotherapy (60 Gy)
  • Achieved partial response
• He had no disease progression 20 days after his last radiotherapy treatment, and began treatment with durvalumab