Edward S. Kim, MD

Question

After a patient is diagnosed with advanced nonsquamous non-small cell lung cancer, what are the treatment options you consider? What are the key patient factors that influence your decision making for initial therapy selection and treatment planning?

Answer

For any patient who is diagnosed with advanced nonsquamous non-small cell lung cancer, the first thing we do after seeing the patient is to assess their overall fitness. We certainly want to have patients that are in better shape, and many times after they are newly diagnosed that is the case, but it is always important to be mindful of their overall health because there are also patients who are very sick when they are diagnosed, which can make it more challenging to administer treatment. Once a patient is diagnosed, what is key, just like the assessment of a patient with breast cancer, is their molecular markers. This is a really big distinction between 10 years ago when we treated these patients and assessed them. Just as in breast cancer, where you have hormone markers and HER2 that’s very important to make a treatment decision, in patients with lung cancer we need to have a set of biomarkers performed and run and we need that information prior to starting therapy. The markers we need are EGFR mutation, ALK translocation, ROS1, BRAF, and PDL1. There are some other markers out there that are not yet FDA indicated for treatments and the list, I’m sure, will grow over the next year, but these are the basics. Once we have that determined, we’ll be able to stratify the patient to see if they are someone who can take a pill that matches up with one of these markers, whether they can take BRAF-directed therapy, or if they qualify for a single-agent immunotherapy, pembrolizumab, with a PDL1 score greater than 50%.

Question

For patients that do not have molecular biomarkers for which there are FDA-approved targeted therapies, what are the indicators that a patient is an appropriate candidate for maintenance therapy? What factors do you consider when determining the appropriate treatment for those patients?

Answer

If, however, a patient’s biomarkers are tested and they come back negative and the PDL1 is less than 50%, the patient is evaluated for fitness and tolerability and treated with a combination of chemotherapy (carboplatin and pemetrexed) with immunotherapy (pembrolizumab); that is the new standard of care for these patients. The only patients that would take a non-specific doublet therapy are those that don’t match up with any of these and also have a direct contradiction to receiving an immunotherapy, like an autoimmune disorder or if they have a high steroid utilization.

Question

What are some of the common side effects of treatment? Are there specific side effects associated with particular treatments that you look out for?

Answer

We are always mindful of side effects and if a patient is receiving one of the biologic TKIs then there are side effects, such as rash and diarrhea, that can occur. Overall these side effects are still much easier to tolerate than those associated with traditional chemotherapy.

If a patient is an appropriate candidate for immunotherapy treatment we watch for immune-related side effects, such as colitis or any of the other “-itis” that can occur. We have to follow patients receiving immunotherapy closely, those treatments have a different set of side effects and doctors are now learning how to better manage them.

If the patient is receiving chemotherapy, it is common to see some of the traditional side effects, such as watching blood counts, however, these days, patients being treated with chemotherapy are much easier to manage. Patients tend to tolerate pemetrexed and carboplatin very well and therefore it hasn’t been as big of a burden to treat them with these therapies, which has been a positive change in how we develop therapies and how patients can tolerate them.

There are many treatment options for patients, which I am excited about from the standpoint of a treating physician and I am able to give hope to patients that they can tolerate these therapies. These therapies are often geared toward the patient, and precision medicine is always our goal in trying to treat patients and give them the right opportunities.

Question

What are your strategies for managing these side effects and how do you counsel patients on what to expect?

Answer

It’s important to give patients extensive counseling on what they could expect, there is a lot of anxiety among patients because this is often the first time they are receiving this type of treatment and any time you do anything for the first time it can cause nervousness and anxiety. I tell patients how their treatment cycles will go and what types of side effects they might expect, we give patients a lot of training and counseling on that so that they realize what may or may not happen. We tell patients that each person is different and that it’s important to call us regarding what they are experiencing so that we can manage them individually. It really depends on the specific therapy that a patient is receiving, but we aim to give them as much education about their treatment and the associated side effects so that they are prepared.

Question

Is there any recent research may offer new treatment options for patients with nonsquamous non-small cell lung cancer? What are you looking forward to in terms of research in this area?

Answer

We will continue to look at all of the different genes in patients and we have to try to continue to investigate them. We are not always going to find the answer, but proactive research will help us to find new markers, which hopefully will translate into new therapies. We have already seen advances in squamous cell carcinoma — prior to these advances we would treat those patients with traditional doublet therapy and now we have options that include chemotherapy plus immunotherapy that are really going to change the standard of care for those patients. We are also excited about additional molecular markers that may uncover new therapies that we have not previously encountered, KRAS fusions is one that is being looked at promisingly, EGFR exon 20 insertion, perhaps even CMET. There is hope, and with that will come some ups and downs, but the goal is that in the end we will study them prospectively and in a thoughtful manner and that will help us to identify some new treatments for patients.