Notes on ESMO17: Metastatic lung cancer

Clinical Brief – September 20th

ESMO, or the European Society of Medical Oncology Congress, is an annual gathering of cancer experts and patient advocates. Here are some studies from this year’s ESMO that may be of use.

“Hyper-progressive disease is frequent in non-small cell lung cancer after treatment with anti-PD-1/PD-L1 immunotherapy,” reports a study led by researchers at Gustave Roussy, France.

Hyper-progression refers to cases where the tumor grows rapidly after treatment instead of shrinking.

Here, researchers looked through records of about 240 patients with non-small cell lung cancer who were treated with an anti-PD-1/PD-L1 immunotherapy. Over 90% of patients received immunotherapy after at least one previous treatment has failed.

The trial didn’t mention which immunotherapies were involved. Anti-PD-1/PD-L1 immunotherapies approved or currently in development include atezolizumab (Tecentriq), avelumab (Bavencio), durvalumab (Imfinzi), nivolumab (Opdivo), and pembrolizumab (Keytruda).

Compared to before treatment, tumor growth slowed in 64% of patients, but a little under 1 in 6 patients developed hyper-progressive disease.

As would be expected, patients whose tumors grew rapidly had shorter survival vs those whose tumors did not (median overall survival 3.4 vs 17 months).

Abstract #1306PD

Patients on corticosteroids before receiving anti-PD-1/PD-L1 immunotherapy for lung cancer may experience significantly less benefit vs those who weren’t on steroids.

Researchers look through records of about 240 patients with non-small cell lung cancer. About a quarter of patients were on prednisone, a corticosteroid, before starting treatment with an anti-PD-1/PD-L1 immunotherapy.

Prednisone was most often used to manage difficulty breathing and brain metastasis. About a third of those on prednisone at baseline were taking it at over 20 mg/day.

Patients who were taking over 20 mg/day of prednisone before immunotherapy treatment had significantly shorter survival vs those who didn’t need prednisone (median overall survival 3 vs 10 months).

Abstract #1323P

About 7 in 10 patients with lung cancer may be barred from Phase III trials with immunotherapies.

A study by Korean researchers looked through the inclusion/exclusion criteria of three prominent Phase III trials with nivolumab (Opdivo) and pembrolizumab (Keytruda).

They then hypothetically applied these criteria to patients with non-small cell lung cancer at their own hospital, and also compared it to patients who were treated as part of their routine practice.

Of over 700 patients diagnosed at their own hospital between 2011 and 2013, 70% would be barred from these Phase III trials. The top five reasons for being ineligible were:

  1. Not previously treated with platinum doublet chemotherapy
  2. Lack of tissue for analysis
  3. Poor physical fitness (as measured by ECOG >1, a standard scale used in many trials)
  4. Being on corticosteroids
  5. Having active metastasis in the brain or spinal cord

Of the 53 patients who were treated with nivolumab or pembrolizumab at their practice, 68% wouldn’t have qualified for these Phase III trials.

“These findings suggest that [there’s] a huge gap between the practice-changing Phase III trials and real-world [lung cancer] patients.”

– Yoo SH, et al.

Abstract #1325P

Response to erlotinib (Tarceva) may not depend on how much drug is in the blood.

Researchers in Japan treated 70 patients with non-small cell lung cancer with a flat dose of erlotinib 150 mg/day and measured the level of drug in their blood to see how much they were actually getting.

They found no significant relationship between the amount of drug in their blood and their tumor response or progression-free survival.

“The approved dose of erlotinib is sufficient…even with dose reduction due to toxicities.”

– Kenmotsu H, et al.

This also reminds me of a study last year where researchers neutralized a potential drug interaction with erlotinib using Coca-Cola. #RealStudy

Abstract #1357P

For more presentations from #ESMO17, take a look at my hand-curated Twitter moment 🤓.

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