Patrick Forde, MBBCh: You could spend a long time talking about it. But I think the key for these patients really, it’s still going back to performance status and assuming the patient has a good performance status and not too significant comorbidities. The molecular data that Dr Dietrich mentioned is key. When I see a patient anymore, they may have a diagnosis of lung adenocarcinoma or squamous, but I can’t really tell them a treatment plan until I have this molecular data, and that’s PD-L1 and next-generation sequencing. For those patients who have a targetable alteration in the firstline setting, I think we’re up to 5 or 6 of those like EGFR, ALK, ROS1, we’re trying to go down one pathway with the targeted therapy up front. For those patients who don’t have one of those firstline targetable alterations, then we’re looking at the PD-L1 score and PD-L1–high disease. We’re talking generally either single-agent anti–PD-1, for example, pembrolizumab or PD-1 plus chemotherapy and our decision-making there. We don’t have really good data. But perhaps looking at the level of PD-L1 expression within that 50 to 100 range, the bulk of disease, is the patient very symptomatic or not? Is the patient a nonsmoker? Those are some things. More bulky disease, more symptomatic disease, nonsmoking might push you towards chemotherapy/PD-1. Less than 50%, essentially, it’s some combination of chemotherapy plus immunotherapy, and there is both chemotherapy/PD1 combinations and chemotherapy CTLC-4 PD-1s. Some of them look at the CTLA-4, PD-1 more and the PD-L1–low or negative disease because some of the data is encouraging there. But that’s broadly my firstline approach. Of course, we’d also sometimes think about radiation and stereotactic or treatment for metastatic disease where there’s some very good data as well from phase 2 studies.

David Carbone, MD, PhD: More and more, I would say that’s the rule rather than the exception, especially I would say with immunotherapy is if you have a single site of progression, the right thing to do is to ablate it and move on. In the old days, if a patient relapsed after surgery or after chemo-radiation, with metastatic disease, you just treat them like a first-line metastatic [patient]. But now that the chemotherapy-radiation patients are getting immunotherapy and the surgery patients are getting immunotherapy, Dr Forde, do you have a different treatment approach for those patients?

Patrick Forde, MBBCh: We don’t really have any good data to guide us. I think what I tend to do is if the patient has progression of their disease while on immunotherapy, so say for example, undervalue MAB or on adjuvant atezolizumab, I will tend to change course, if possible. If they have a second-line targeted option, for example, KRAS or perhaps consider chemo plus or minus immunotherapy, I wouldn’t tend to switch, for example, from durvalumab to pembrolizumab. I don’t think that makes a lot of sense. But again, we are kind of at the cutting edge of the field at the moment. Probably in 5 or 10 years’ time, we’d have a better idea of what to do for these patients more precisely. But at the moment, we have to use our judgment.

Transcript is AI generated and reviewed by an AJMC editor.