Non-small cell lung cancer (NSCLC) can oftentimes be diagnosed at a later stage because there are few signs indicative of cancer when the disease first appears. However, by the time NSCLC becomes locally advanced – meaning it spread to the mediastinal nodes in the center of the chest – patients may start to experience symptoms, leading to their diagnosis, according to Beth Sandy, CRNP.
Standard of care still leaves much to be desired in the second-line setting for these patients. However, immunotherapy may be changing that.
Sandy, a nurse practitioner at the University of Pennsylvania Abramson Cancer Center, recently discussed treatment for locally advanced NSCLC at the 4th Annual
School of Nursing Oncology Live, Interactive Webcast.1
“Once those lymph nodes get big … you start to have symptoms like shortness of breath,” Sandy said.
Experts are currently debating whether or not it is appropriate to conduct surgery on stage III locally advanced NSCLC, according to Sandy, who noted that the potential survival advantage of surgery could come with more adverse events.
“So it appears the concurrent chemo radiation is the better way to go,” Sandy said. “The median progression-free survival (PFS) is only about 8 to 10 months, meaning that patients often are going to recur in that first year after chemo radiation, if they’re going to recur.”
Sandy outlined 3 common drug regimens given with radiation:
- Paclitaxel/carboplatin, given at a low dose once a week
- Pemetrexed/carboplatin or cisplatin, given at a full dose every 3 weeks
- Etoposide/cisplatin, with etoposide given on days 1 through 5 and cisplatin given on day 1 and day 8, repeating for 28 days
“Paclitaxel and carboplatin is probably the most common, as it’s the easiest to tolerate,” she said. “With pemetrexed and platinum cisplatin or carboplatin, the good thing about that regimen is that it’s full-dose… but it can be more toxic with full-dose chemo. Then, etoposide and cisplatin is kind of a middle-of-the road dose.”
After chemoradiation, there traditionally was no further treatment for patients with locally advanced NSCLC. However, the immunotherapy agent durvalumab (Imfinzi) has been showing benefit.
Immunotherapy Shows Promise
Findings from a randomized, phase 3 clinical trial (NCT02125461) showed that durvalumab (Imfinzi) improved outcomes in patients with stage III, locally advanced, unresectable NSCLC who have not progressed after 2 or more platinum-based chemotherapy/radiation treatments.2
Durvalumab bested placebo in median PFS (16.8 months versus 5.6 months, respectively), as well as 12- (55.9% versus 35.3%) and 18-month PFS (44.2% versus 27.0%).
“With PFS, we had significant improvement [with durvalumab],” Sandy said. “
The immunotherapy agent was better than placebo in overall survival, too. In fact, at the 36-month mark, 57.0% of participants on the durvalumab arm were alive, compared to 43.5% on the placebo arm.
“You can see that there is a significant number of more patients alive at the 3-year mark. This is really exciting,” Sandy said. “Once we get to that 5-year overall survival, we can then look and see not only an overall survival, but also maybe that they’re never relapsing…our cure rates may be improving.”
- Sandy B. Lung Cancer: Essentials for Oncology Nurses. Presented at: 4th Annual School of Nursing Oncology Live, Interactive Webcast. July 31-August 1, 2020.
- Dennis P. A Global Study to Assess the Effects of MEDI4736 Following Concurrent Chemoradiation in Patients With Stage III Unresectable Non-Small Cell Lung Cancer (PACIFIC). Updated March 19, 2020.