Roman Perez-Soler, MD, chairman, Department of Oncology, chief, Division of Medical Oncology, Montefiore Medical Center, and professor of medicine and molecular pharmacology, Albert Einstein College of Medicine, discusses the utility of liquid biopsy in lung cancer.

Liquid biopsy allows for detection of molecular abnormalities by sequencing circulating tumor DNA (ctDNA) without an invasive procedure, explains Perez-Soler. Despite some controversy surrounding liquid biopsy, 70% to 80% of tests provide viable results, says Perez-Soler.

Tumor biopsy may be recommended for the 20% to 30% of cases where not enough ctDNA was present in the peripheral blood. However, because tumor biopsy is testing the DNA in a single lesion, the results may differ from peripheral blood testing, which encompasses DNA from all metastatic sites, explains Perez-Soler.

As such, Perez-Soler advises both liquid biopsy and tumor biopsy be performed when possible to provide complementary results.

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Roman Perez-Soler, MD, discusses the utility of liquid biopsy in lung cancer.
 

Dr. Perez-Soler on the Utility of Liquid Biopsy in Lung Cancer

Roman Perez-Soler, MD, chairman of the Department of Oncology and chief of the Division of Medical Oncology at Montefiore Medical Center, discusses the improved outlook for patients with lung cancer.

Twenty years ago, when patients were told that they had lung cancer it meant that they would probably succumb to their disease within a few months. Patients would receive toxic chemotherapy while dealing with symptomatic disease. Today, there are several effective treatment options available, particularly in the stage IV metastatic setting. These new therapies not only provide a physical benefit to patients, but have also helped improve the psychological outlook for patients with the disease. Since there has been so much rapid advancement in the space, the new mentality is that it is worth it to fight the disease; patients know that even more progress is inevitable.

Lung cancer is no longer a disease where oncologists simply don’t know what to do for their patients. There is a renewed interest in conducting research in this space, because investigators are starting to realize that the disease is not as complicated as originally believed. With more science driving research in lung cancer, even more effective therapies could be coming down the pike.

Dr. Perez-Soler on Improved Outlook for Patients With Lung Cancer

Roman Perez-Soler, MD, chairman of the Department of Oncology and chief of the Division of Medical Oncology at Montefiore Medical Center, discusses recent advances made in immunotherapy for the treatment of patients with small cell lung cancer (SCLC).

Up until a few months ago, the field had gone about 20 years without any progress made, says Perez-Soler, but it seems that 2018 was the breakthrough year for SCLC. The first positive data was seen with the frontline combination of the checkpoint inhibitor atezolizumab (Tecentriq) and chemotherapy; these data are of great historical impact, notes Perez-Soler, because they are first to show any survival advantage over the standard chemotherapy for frontline treatment.

Additionally, if immunotherapy is not given frontline, there is opportunity for nivolumab (Opdivo) in the third-line. It is universal that patients will progress on topotecan, and nivolumab has shown to result in overall response rates of about 10% to 12%; these responses have proven to be durable—lasting for about 1 year&mdash;which is exceptional in SCLC, according to Perez-Soler. Based on this data, in August 2018, the FDA granted accelerated approval to nivolumab for patients with metastatic SCLC with progression after platinum-based chemotherapy and at least 1 other line of therapy.

Roman Perez-Soler, MD, chairman of the Department of Oncology and chief of the Division of Medical Oncology at Montefiore Medical Center, discusses recent advances in immunotherapy for the treatment of patients with small cell lung cancer.

Dr. Perez-Soler on Immunotherapy Advances in SCLC

Roman Perez-Soler, MD, chairman of the Department of Oncology and chief of the Division of Medical Oncology at Montefiore Medical Center, discusses the current status of biomarkers in small cell lung cancer (SCLC).

PD-L1 expression and tumor mutational burden (TMB) are the most prominent biomarkers for immune response in lung cancer. However, although both have merit, Perez-Soler says they are not as reliable as researchers would hope. In the case of PD-L1, just because a patient is considered PD-L1—positive, does not necessarily mean that they will derive benefit from immunotherapy.

PD-L1 negativity has been suggested as a biomarker for immune resistance, but some of these patients might still benefit from treatment, Perez-Soler says, and, as such, he would give a checkpoint inhibitor regardless.

Perez-Soler notes that physicians should give the “benefit of the doubt” when assessing their patients for these biomarkers. Just because a patient’s biopsy shows up as PD-L1—negative does not necessarily mean that their entire tumor is negative; therefore, to decline treatment based off of the current biomarkers might be too drastic of a decision.

Roman Perez-Soler, MD, chairman of the Department of Oncology and chief of the Division of Medical Oncology at Montefiore Medical Center, discusses the current status of biomarkers of small cell lung cancer.

Dr. Perez-Soler on Current Status of Biomarkers in SCLC

Roman Perez-Soler, MD, chairman of the Department of Oncology and chief of the Division of Medical Oncology at Montefiore Medical Center, discusses the efficiency of next-generation sequencing (NGS) in lung cancer.

NGS testing is something that should be done in all patients with lung cancer, Perez-Soler stresses. Drug prices continue to rise in oncology and this is creating a lot of concern. However, the reality is that NGS could be a significant cost-effective solution. NGS will soon be as prominent as PET-CT scans. As soon as a patient is diagnosed, the next step should be NGS before any additional questions, he says.

There are some very rare abnormalities that can be picked up by NGS. Payers need to be convinced to cover this type of practice, and community oncologists need to understand that this should be part of routine practice. If NGS leads to the right treatment for a patient, it is a cost-effective strategy because it will eliminate the need for unnecessary hospitalization and other expensive factors.

Roman Perez-Soler, MD, chairman of the Department of Oncology and chief of the Division of Medical Oncology at Montefiore Medical Center, discusses the efficiency of next-generation sequencing in lung cancer.

Dr. Perez-Soler on Efficiency of NGS in Lung Cancer

Roman Perez-Soler, MD, chairman of the Department of Oncology and chief of the Division of Medical Oncology at Montefiore Medical Center, Albert Einstein College of Medicine of Yeshiva University, discusses the impact of osimertinib (Tagrisso) on patients with 

-positive non—small cell lung cancer (NSCLC).

Osimertinib, a third-generation EGFR tyrosine kinase inhibitor, has had a significant impact on the landscape since its FDA approval, Perez-Soler explains. This agent is able to target the significant number of patients who develop acquired 

Additionally, osimertinib is not associated with some of the toxicities frequently reported with EGFR inhibitors, including rash. Perez-Soler also explains that osimertinib has demonstrated higher levels of efficacy than gefinitib (Iressa), erlotinib (Tarceva), and afatinib (Gilotrif). Patient quality of life is also significantly improved on this agent, he says.

View more from the 2016 New York Lung Cancer Symposium

Roman Perez-Soler, MD, chairman of the Department of Oncology and chief of the Division of Medical Oncology at Montefiore Medical Center, Albert Einstein College of Medicine of Yeshiva University, discusses the impact of osimertinib (Tagrisso) on patients with T790M-positive non–small cell lung cancer (NSCLC).

Dr. Perez-Soler on Impact of Osimertinib on Field of NSCLC

Roman Perez-Soler, MD, chairman of the Department of Oncology and chief of the Division of Medical Oncology at Montefiore Medical Center, discusses the correlation between overall survival (OS) and the appearance of cutaneous toxicity following treatment with erlotinib (Tarceva) for patients with non-small cell lung cancer (NSCLC).

At the 2011 ASCO Annual Meeting, results from the SATURN trial showed trends towards a connection between OS and the development of skin rash for patients receiving maintenance erlotinib. Moreover, two studies presented at the 2012 ASCO Annual Meeting, the BR.21 and EURTAC trials, confirmed the correlation between OS and the development of skin toxicity, both in 

-mutated and non-mutated patients with NSCLC.

Perez-Soler believes these findings should be conveyed to patients who are struggling with skin toxicity while receiving erlotinib, since it may help improve their outlook on the side effect.

Dr. Roman Perez-Soler, from the Montefiore Medical Center, on the Correlation Between Erlotinib-Induced Skin Rash and Overall Survival

Dr. Perez-Soler on Erlotinib-Induced Skin Rash and Survival

Roman Perez-Soler, MD, Chairman, Department of Oncology, Montefiore Medical Center, Albert Einstein College of Medicine of Yeshiva University, discusses the desire to find targeted therapies and new driver mutations for smaller molecular subsets of non-small cell lung cancer (NSCLC).

Genetic subtypes of NSCLC, such as those containing mutations in 

, have been uncovered and successfully targeted. However, important groups still require the concentration of researchers. Areas of potential focus include tumors that contain identifiable alterations but do not have associated targeted pharmaceuticals, subtypes without an identifiable driver mutation, and multiple aberrations implicated in a single tumor.

Perez-Soler labels the mutations currently being targeted as low-hanging fruit and the beginnings of a complex journey to a more desirable location. This journey will require research into complex strategies and new tumor pathways that focus on reaching a more desirable overall prognosis.

A cure for patients with advanced NSCLC may not be possible, notes Perez-Soler. A more plausible goal and approach for future inquiries may be to convert the disease into a manageable chronic disorder.

Dr. Roman Perez-Soler, from Albert Einstein College of Medicine, on the Future of Lung Cancer Therapies

Dr. Perez-Soler on the Future of Lung Cancer Therapies

Roman Perez-Soler, MD, Chairman, Department of Oncology, Montefiore Medical Center, Albert Einstein College of Medicine of Yeshiva University, talks about the recent advances in treatment options for non-small cell lung cancer (NSCLC).

Perez-Soler states that targeted agents represent the most dramatic changes in the treatment of NSCLC. New agents are available that target subgroups with molecular alterations in EGFR and ALK. These alterations are driver mutations in tumor cells and as a result render high response rates.

Despite the initial response to a medication most tumors will eventually develop resistance. The next step for research is to understand how these tumors develop these resistance mechanisms.

Dr. Roman Perez-Soler, from Montefiore Medical Center, on Treatment Options for NSCLC

Roman Perez-Soler, MD

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