POLL: What Would You Do for a Patient With Metastatic NSCLC?
In the case of a woman with metastatic non–small cell lung cancer, answer question of what you would do in terms of treatment and management, as well as questions about your practice.
Share your perspective on a patient case with related polling questions about your practice and opinions on treatment in non–small cell lung cancer (NSCLC). All oncology practices see different patients and have their own protocols for treatment. In this case, chemoimmunotherapy regimens are considered from the phase 3 POSEIDON (NCT03164616), EMPOWER-Lung 3 (NCT03409614), KEYNOTE-407 (NCT02775435), and CheckMate 9LA(NCT03215706) trials.
CASE SUMMARY
- A 62-year-old woman presented to the emergency department with vague complaints of voice changes and cough. She had recent weight loss of 11 lb.
- Medical/family/social history:
- Hypertension, controlled with angiotensin-converting enzyme inhibitors 10 mg once daily by mouth
- Hyperlipidemia, treated with atorvastatin 20 mg once daily by mouth
- Chronic obstructive pulmonary disease, treated with maintenance fluticasone furoate, umeclidinium, and vilanterol (100/62.5/25 mcg oral inhalation once daily)
- Mother: deceased at 65 years-of-age from lung cancer
- Smoking: 10-15 pack-years, stopped 25 years ago
- Physical exam:
- Weight: 125 lb
- ECOG performance status: 1
- CT of thorax discovered a 4-cm nodule in left upper lobe.
- CT of abdomen also revealed metastases to the liver.
- MRI of brain was negative for brain metastases.
What percentage of patients do you treat with advanced stage or metastatic squamous NSCLC?
CASE CONTINUED
- Final pathology consistent with squamous cell carcinoma; metastatic stage IV
- PD-L1 expression by immunohistochemistry was 0%.
- Next-generation sequencing: no actionable mutations
Should patients with metastatic NSCLC without actionable driver mutations and PD-L1 greater than 50% receive chemoimmunotherapy?
Which combination therapy would you use for this patient?
CASE CONTINUED
- Treatment options were reviewed with the patient and family.
- Patient was initiated on nivolumab (Opdivo) plus ipilimumab (Yervoy) plus 2 cycles of chemotherapy.
Have you ever used nivolumab/ipilimumab plus 2 cycles of chemotherapy in practice?
CASE CONTINUED
- The 62-year-old patient began to experience grade 3 diarrhea while on treatment.
- She was seen in clinic to determine next steps.
For this patient with grade 3 diarrhea, your next step is to:
CASE CONTINUED
- Immunotherapy was held and infectious etiology ruled out.
- High dose steroids (1 mg/kg/day) were initiated, and the patient was eventually able to be rechallenged with treatment once steroid taper was completed.
