Angel Qin, MD, clinical assistant professor, Medical Oncology, Internal Medicine, Rogel Cancer Center, University of Michigan Health, discusses several areas of active investigation in non–small cell lung cancer (NSCLC), and highlights questions necessitating future research in this disease space.

The treatment of lung cancer has evolved in recent years, with the addition of insights on tumor biology helping to improve disease management, Qin begins. One such development is the increasing knowledge of driver mutations in both the first- and second-line settings. This has expanded the number of available agents associated with each of these drivers and has engendered insights into the acquisition of resistance mutations, thereby shedding light on the challenges faced in lung cancer management, Qin explains.

Another area of ongoing discussion in the lung cancer space is the sequencing of targeted therapies, particularly for drivers such as 

, where immunotherapy has demonstrated limited efficacy, she continues. Qin states that the explanation for this is not yet understood. In the meantime, efforts are underway to elucidate the role of immunotherapy in cases involving other driver mutations, Qin reports.

The use of perioperative therapy has been another substantial advancement in NSCLC, Qin states. This includes neoadjuvant chemoimmunotherapy, adjuvant immunotherapy, and more recently, perioperative chemoimmunotherapy and immunotherapy, she adds. Assessment of these strategies are being conducted to determine whether they offer equivalent benefit for patients with NSCLC, and to identify specific patient populations that would benefit most from a given approach, Qin details.

There is also heightened interest in neoadjuvant and adjuvant approaches using targeted therapies for molecularly-driven patients subsets in NSCLC, Qin says. These efforts are bolstered by studies such as the phase 3 ADAURA trial (NCT02511106), in which adjuvant osimertinib (Lynparza) produced a significant overall survival benefit in patients with completely resected, EGFR-mutated, stage IB to IIIA disease, Qin concludes.

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Angel Qin, MD,  discusses several areas of active investigation in non–small cell lung cancer, and highlights questions necessitating future research in this disease space.

Dr Qin on Areas of Active and Future Investigation in NSCLC

Angel Qin, MD, clinical assistant professor, Medical Oncology, Internal Medicine, Rogel Cancer Center, University of Michigan Health, discusses her process when choosing between targetable agents for patients with 

® State of the Science Summit™, Qin and colleagues from Rogel Cancer Center each gave presentations on topics spanning lung cancer treatment. Qin presented information about targeting 

exon 20 in lung cancer, highlighting the use of both amivantamab-vmjw (Rybrevant) and mobocertinib (Exkivity). The superiority of 1 of these agents above the other is currently unknown, she emphasizes.

 as the first approved treatment for adult patients with non–small cell lung cancer (NSCLC) whose disease harbors an 

 exon 20 insertion mutation. This approval was supported by findings from the phase 1 multicenter, non-randomized, open label, multicohort CHRYSALIS trial (NCT02609776). 

Mobocertinib was approved by the FDA in September 2021

 for the treatment of adult patients with locally advanced or metastatic NSCLC with 

 exon 20 insertion mutations whose disease has progressed on or after platinum-based chemotherapy. This regulatory decision was supported by the results of a phase 1/2 trial (NCT02716116).

Qin emphasizes that the decision between amivantamab and mobocertinib should be made following a discussion with the patient. Treatment aspects to consider include whether the patient would prefer intravenous infusions vs a pill, as well as the adverse effect (AE) profile of each agent, Qin explains. There are specific AEs associated with each targeted agent, including more rash and infusion reactions with amivantamab vs more diarrhea with mobocertinib, she notes.

Although patient preferences and AEs are important considerations, oncologists still do not have appropriate data to support the use of 1 agent instead of the other in patients who had either prior chemotherapy or prior chemoimmunotherapy in the frontline setting, Qin continues. However, Qin believes it remains important to understand the toxicities that patients may have experienced with their prior treatments, as these may influence the decision to choose amivantamab or mobocertinib, Qin concludes.

Angel Qin, MD, discusses her process when choosing between targetable agents for patients with EGFR exon 20–mutated lung cancer.


Dr Qin on Choosing Between Targetable Agents in EGFR Exon 20–Mutated Lung Cancer

Angel Qin, MD, clinical assistant professor, University of Michigan Health, medical oncologist, Rogel Cancer Center, Michigan Medicine, discusses treatment considerations for immunotherapy in patients with newly diagnosed non–small cell lung cancer.

To make therapeutic decisions, it is necessary to know the staging of the patient, according to Qin. Brain imaging must also be done due to the high propensity for brain metastases, Qin says. Understanding a patient’s molecular testing and PD-1 expression status is needed to inform clinical decisions with immunotherapy, Qin explains. Currently, there are 9 alterations for which FDA-approved targeted therapies are available, and more are under exploration in ongoing trials, Qin explains. 

Furthermore, it is important to understand a patient’s individual goal for treatment, such as whether they want to use a more aggressive approach or focus more on quality of life, Qin adds. It is possible to have both, but because of differing toxicity profiles, 1 therapeutic regimen may prove to be more favorable based on patient preferences, Qin adds. Finally, understanding a patient’s performance status is important and sometimes overlooked. Clinical trials often enroll patients with excellent performance status, and this is not always reflective of the patients who are seen in the clinic, Qin concludes.

Angel Qin, MD, discusses treatment considerations for immunotherapy in patients with newly diagnosed non–small cell lung cancer.

Dr. Qin on Treatment Considerations for Immunotherapy in NSCLC

Angel Qin, MD, clinical assistant professor, University of Michigan Health, medical oncologist, Rogel Cancer Center, Michigan Medicine, discusses selecting between single-agent immunotherapy or combination chemoimmunotherapy in non–small cell lung cancer (NSCLC).

The PD-L1 expression level of a patient with NSCLC largely determines whether the patient should receive single-agent immunotherapy or combination chemoimmunotherapy, Qin explains. For example, patients with PD-L1 expression at least 50% can be considered for single-agent immunotherapy. However, if the patient has significant tumor burden or is on the verge of visceral crisis from disease burden, chemotherapy may be added to immunotherapy for cytotoxic reduction, Qin says. In these situations, the full course of chemotherapy may not be required, Qin adds. 

For patients with PD-L1 expression between 1% and 49%, performance status guides treatment decisions, Qin says. Although single-agent pembrolizumab (Keytruda) is approved for use in this patient population, patients may not derive a sufficient response without chemotherapy. However, altering the treatment regimen to introduce histology-specific chemotherapy later after platinum-based chemotherapy and pembrolizumab may be beneficial for patients. 

Additionally, some patients have strong aversions to chemotherapy, so single-agent pembrolizumab can be considered based on patient preference as well, Qin concludes.

Angel Qin, MD, discusses selecting between single-agent immunotherapy or combination chemoimmunotherapy in non–small cell lung cancer. 



Angel Qin, MD

Articles

Dr Qin on Areas of Active and Future Investigation in NSCLC

Dr Qin on Choosing Between Targetable Agents in EGFR Exon 20–Mutated Lung Cancer

Dr. Qin on Treatment Considerations for Immunotherapy in NSCLC

Dr. Qin on Selecting Single-Agent Immunotherapy or Chemoimmunotherapy in NSCLC