Checkpoint Inhibitors: Sooner Than Later in Lung Cancer?

Mark G. Kris, MD


September 14, 2020

This transcript has been edited for clarity.

Hello. This is Mark Kris from Memorial Sloan Kettering Cancer Center.

Today I would like to reprise a session presented at the recent American Society of Clinical Oncology educational session. I was privileged to be part of a panel with Stephen Swisher from the University of Texas MD Anderson Cancer Center and Corinne Faivre-Finn from the University of Manchester and the Christie NHS Foundation Trust in England.

In this session, we were charged with looking at using checkpoint inhibitors in the care of patients with early-stage lung cancer to see if they might achieve the benefits seen in stage IV patients, where some have become disease-free or disease-controlled for years. Even now, the outcomes in patients at 5 years give us the hope that those with earlier-stage lung cancer who receive checkpoint inhibitors can achieve not only longer times of being cancer-free but also cure.

We were also greatly encouraged by the results of the durvalumab trial, where durvalumab followed concurrent chemotherapy and radiation. Dr Faivre-Finn talked about the importance of that trial and how it not only improved survival but also improved the chance of cure.

Checkpoint inhibitors provide us with a unique opportunity. They are already part of the care in stage IIIB patients getting concurrent chemotherapy and radiation, and need to be moved up. We talked about how early data on giving checkpoint inhibitors in the neoadjuvant setting show strong hints of benefit. We also talked about trials going on in the adjuvant setting.

It's absolutely critical, though, to know what the real issue is here: We are not curing these patients now because they die of systemic disease. We have to think of additional systemic therapies.

I would urge us to rethink our approach to these patients. For the nearly 80,000 Americans every year who have locally advanced lung cancers, our goal of care is to cure them. We need to put our heads together and use all of the different modalities that we have to try to see if we can improve the cure rate.

The other important point in caring for these patients is that the risk-benefit equation, if you will, is somewhat different here. We're not talking about pushing out a progression-free survival by a matter of months; we're talking about the chance for cure. And where cure is the goal of therapy, we have a whole different metric on what would be an acceptable toxicity. I think we have that here and we need to think about that.

We also have to rethink what we consider a good prognosis. It's our best stage; tiny tumors, less than 1 cm, have a 5-year survival rate of 92%. That is excellent. But in other diseases, breast cancer in particular, people would be thinking about adjuvant therapies. We need to think that way too. I put it to you. For every single patient, we need to think about what can be done, using all the tools we have, to try to increase that rate of cure.

We have a greater number of tools and improvements in our individual modalities — radiation, surgery, systemic therapies — and we need to work a lot harder here. We need to choose the best modality. We need to choose the sequence of modalities and whether these modalities should be given sequentially or simultaneously.

Our work is much more difficult, but the rewards are much greater.

Mark G. Kris, MD, is chief of the thoracic oncology service and the William and Joy Ruane Chair in Thoracic Oncology at Memorial Sloan Kettering Cancer Center in New York City. His research interests include targeted therapies for lung cancer, multimodality therapy, the development of new anticancer drugs, and symptom management with a focus on preventing emesis.

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