Mark A. Socinski, MD: Standards of care have continued to evolve as we accumulate more data to support the use of immuno-oncology agents in advanced non—small cell lung cancer. Oncologists have an expanding number of therapeutic options from which to choose when formulating a treatment plan for each patient. In this OncLive Peer Exchange® discussion, my colleagues and I will look at the challenges in finding the right systemic treatment for the right patient. We’ll talk about the data from the ASCO [American Society of Clinical Oncology] 2019 annual meeting and how it relates to the treatment of advanced disease. I’m Dr Mark Socinski, executive medical director of the AdventHealth Cancer Institute in Orlando, Florida.

Joining me today on this distinguished panel are: Dr Kristin Higgins, an associate professor in the Department of Radiation Oncology at Emory University School of Medicine, and medical director of radiation oncology at the Emory Clinic in Atlanta, Georgia; Dr Corey Langer, director of thoracic oncology and professor of medicine at the Hospital of the University of Pennsylvania, in Philadelphia; Dr Ticiana Leal, assistant professor in the Department of Medicine, Division of Hematology/Oncology, at the University of Wisconsin School of Medicine and Public Health in Madison; Dr Paul Paik, clinical director of the Thoracic Oncology Service at Memorial Sloan Kettering Cancer Center in New York City, New York; and Dr Heather Wakelee, professor of medicine in the Division of Oncology at the Stanford University Medical Center, and faculty director of the Stanford Cancer Clinical Trials Office in Stanford, California. Thank you, let’s begin.

Corey, I’m going to start with you. We’re going to start with stage III disease. There are 2 things that I’ve said to Fellows over the years, and to residents that we train. There are 2 things you absolutely have to get right in every cancer patient, particularly lung cancer, and that’s the diagnosis and stage. So I want to talk about stage III disease and staging, and what your typical work-up is, and what your thoughts and concerns are in the initial approach to making sure you really have a stage III patient.

Corey J. Langer, MD: Sure, Mark. The standard staging includes a CT [computed tomography] scan, of course—a CT of the chest. For most stage III patients, a bronchoscopy and EBUS [endobronchial ultrasound] are used to establish a nodal architecture, a nodal involvement, which makes a world of difference between IIIa and ipsilateral nodes versus contralateral. And in this day and age, particularly in developed countries, a PET [positron emission tomography] scan is routinely used. And just from the get-go, taking a patient who otherwise might have stage III disease, based on CT alone, anywhere from 15% to 20% are likely to be upstaged to stage IV with PET on the basis of otherwise occult metastatic disease. So those folks, in the past, would have been treated with a combined modality. And frankly, we’re not doing them any favors.

Mark A. Socinski, MD: In the brain?

Corey J. Langer, MD: Brain scan as well. MRI [magnetic resonance imaging] of the brain, routinely. And that, too, is a shift from the past. We’re old-timers. I’m a little bit older than you, but there was a time when we just did CT scans. We didn’t have MRI. And needless to say, probably another 15% to 20% were upstaged.

Mark A. Socinski, MD: And often, clinical trials would say, “If clinically indicated.”

Corey J. Langer, MD: Right. Pretty much in our clinic, it’s always indicated.

Mark A. Socinski, MD: Right. So I think you made a good point about the pathologic confirmation of the mediastinal nodes. I think that’s an important aspect of staging, to make sure that what you see on CT, and what you see on PET is actually a confirmation of disease.

Ticiana, your thoughts? Often what can happen, and I think we all experience this, is that sometimes it takes patients a while to get to us. And so, you’re sitting there. Someone may have done a CT scan, or may not have done a PET, or maybe did do a PET, and it’s from 3 months ago. When do you think that it’s appropriate to rethink the staging in that situation?

Ticiana A. Leal, MD: Certainly the timeliness in lung cancer care is something that we always think about. There really are no set and defined timelines that are most appropriate. But occasionally, when you have that patient who comes in and they’ve had a PET outside and it’s just taking them a while to get to your clinic, and now they’re 3 months out, they certainly need to be restaged. So a repeat PET scan is certainly indicated in that situation. When is sort of the cutoff? I think that’s the most challenging question. A lot of times, especially with our radiation oncologists, we have that discussion. I would say that clinically, it’s about 4 to 6 weeks for which we start to feel uncomfortable and worry that, perhaps, things have changed. There aren’t great data to support that, but I think it’s a clinical call at that point.

Mark A. Socinski, MD: It should be driven by whether patients are becoming, perhaps, more symptomatic or have new symptoms.

Ticiana A. Leal, MD: Right. I think that would be something that would be an easy call to do if somebody has symptoms that are suggestive of advancing disease. But I think also patients who are not having advancing disease; you can have progression of nodal disease, or progression of their disease even without symptoms. And I certainly would worry that patient might need a change in their care if we identify something new at that point.

Mark A. Socinski, MD: Kristin, from your perspective, as a radiation oncologist, what are your thoughts about staging? What do you think through?

Kristin Higgins, MD: The timing of the PET is really critically important for the design of optimal radiation treatment volumes. Many times, as a patient is progressing through their disease, the parenchymal primary tumor can grow. The extent of nodal disease can grow. We really only cover PET-positive disease. So having an accurate PET is really important when you’re designing your radiation volumes. We try to keep our radiation treatment volumes as reasonable as possible, as to not increase toxicity. We don’t want to make them larger if we don’t have to. So that updated PET information can be really important and helpful.

Mark A. Socinski, MD: Exactly. So are you along the same timelines in terms of repeating?

Kristin Higgins, MD: Yes, absolutely—4 to 6 weeks.

Mark A. Socinski, MD: Is PET kind of a standard now, in terms of radiation planning? Would you agree with that?

Kristin Higgins, MD: Yes.

Transcript Edited for Clarity