COMMENTARY

'A Really Big Year' for Lung Cancer Treatment

Mark G. Kris, MD

Disclosures

July 30, 2019

This transcript has been edited for clarity.

Hello. It's Mark Kris from Memorial Sloan Kettering, speaking about many of the developments presented at the 2019 American Society of Clinical Oncology (ASCO) meeting in Chicago. People said it was not going to be a big year, but in truth, it was a very big year.

First, I'd like to talk about some of the presentations dealing with locally advanced lung cancers. Two presentations talked about using neoadjuvant therapy with nivolumab and with atezolizumab. The nivolumab presentation was by Tina Cascone from MD Anderson Cancer Center,[1] and the atezolizumab one was by David Kwiatkowski from the Lung Cancer Mutation Consortium (LCMC3).[2] I am part of LCMC3, so forgive the conflict of interest here.

Both groups have made a great contribution, demonstrating the ability to deliver immunotherapies before surgery and the safety of doing so, and also the truly unexpected benefit for these patients—out of proportion, really, to what we would expect for these drugs as single agents. Cascone presented preclinical data showing that when you have a more intact immune system, both with lymph nodes and the primary tumor, perhaps you can get a better result than when giving these kinds of therapies adjuvantly.

All of these concepts are moving forward. There are multiple randomized phase 3 trials looking at giving immunotherapeutics with chemotherapy to try to improve pathologic complete response rates even more. I think they showed the benefits of neoadjuvant therapy and how drugs can work better, be safely delivered, and provide additional options. The important thing is, once you give a neoadjuvant therapy, you know whether that drug worked in the patient. That is something that you just don't know with adjuvant therapy. These were important developments, and there will be more to come on that.

The second area of great note was in high-risk patients with stage I lung cancer. We still have this idea in the lung cancer community that if your 5-year survival is 80%, that is good enough. Of course, it's not good enough. We need to cure all of our patients, and other diseases in oncology with that degree of risk all receive neoadjuvant therapy. One way to move this field forward—other than my exhortations to treat people with adjuvant therapy—is to look for high-risk groups.

Tsutani and colleagues[3] showed that patients with tumors > 2 cm, invasion of visceral pleura, lymphatic permeation, or vessel invasion were high risk. There was a decrement with having these factors in [recurrence-free] survival from 96% down to 71%. And for overall survival, there was a reduction from 96% to 86%. Importantly, they also showed that if you gave adjuvant therapy to these patients, you improve both of these outcomes—relapse-free survival and overall survival—by about 10%. So smaller tumors should be treated, and this presentation gives the oncologist a comfort that for these high-risk groups, the benefits of chemotherapy are better. Yes, cisplatin therapy is really tough, but cure is the goal. The authors here gave us information on how to perhaps better select patients for adjuvant therapy.

I urge you to look at that abstract. And look carefully at the pathology reports of patients who are referred to you for adjuvant therapy; look for those with high risk, and think about treating them. I think the data are there that it helps. There are also data from the United States that there is a benefit from chemotherapy down to the tiniest tumors.

To cure more, we have to treat more, and ASCO this year gave us some strategies to do that in the adjuvant and neoadjuvant setting.

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