Dr. Rami Manochakian Breaks Down the Evolving Treatment Landscape for NSCLC

As the treatment landscape for non-small cell lung cancer (NSCLC) evolves, it’s critical for community oncologists to understand the implications of all the new information that comes out of meetings such as the American Society of Clinical Oncology Annual Meeting.

Advancements in Oncology, hosted by The Oncology Brothers during the annual meeting, helped disseminate this information to community oncologists by breaking down how to apply the results of new research to clinical practice.

The event, held on Saturday, June 1, featured panelists speaking about new updates in lung, breast, gastrointestinal, and genitourinary cancers.

Rahul Gosain, MD, MBA, and Rohit Gosain, MD, known collectively as The Oncology Brothers, sat down with panelist Rami Manochakian, MD, FASCO, of the Mayo Clinic, Florida, to share what community oncologists should know about the latest in NSCLC treatment.

The panel kicked off with a discussion of the current treatment landscape for NSCLC, the role of surgery and stereotactic body radiation therapy (SBRT), and how the situation is evolving.

“The current landscape when it comes to stage I is surgery, SBRT in the right settings, but then stage IB, IIIA, and IIIB—because with [the Eighth Edition of the American Joint Committee on Cancer Stating Manual] the staging is also changing—the perioperative treatment has changed completely over the last month,” Dr. Rahul Gosain said.

The Oncology Brothers and Dr. Manochakian discussed multiple treatment pathways that can be used in stage IB through stage IIIB NSCLC.

“We have what I would like to call very good problems. We have multiple options,” Dr. Manochakian said.

One potential treatment pathway begins with surgery, followed by platinum-based chemotherapy, then diverges based on the specific features of the disease. For example, osimertinib is an option for those with classical EGFR mutations, while atezolizumab is an option for those with stage II-IIA disease with PD-L1 ≥1%.

Another pathway for these patients is presurgical platinum-based chemotherapy plus nivolumab, or starting with cisplatin-based chemotherapy plus pembrolizumab, followed by optional chemotherapy plus or minus radiotherapy, and pembrolizumab.

He explained that input is needed from medical, surgical, and radiation oncologists, as well pulmonary specialists and the patient. The path taken depends on the specific patient, their characteristics, and their needs, Dr. Manochakian said.

“There are a lot of factors that need to be taken [into account] to decide if a patient should undergo surgery or not. Are they a good candidate for surgery? The good news is, right now, there is nothing major that would rule out surgery like the old days, even for bulky disease, even for others,” he said. “But [consider] the patient’s fitness. Can they tolerate surgery? [We’re] giving them the options, right? Do you want to go under for an operation? Would they need a pneumonectomy? Would they have enough reserve volume? There are so many factors, but again, we can’t tell them right now that the chemotherapy route followed by [immuno-oncology] is going to be better or vice versa. Maybe for some areas, and that’s why a lot of these future studies now are looking into some factors and biomarkers to try to tell us.”

Dr. Manochakian explained what he does in his own clinical practice when determining the treatment pathway in this setting.

“If I give the patients the option, I’ll tell them [about the] surgical route and the nonsurgical route,” he said. “If we go for a surgical route, I’m personally slightly in favor of the peri-[operative] where I feel, scientifically, each one of them, without going through much detail, is adding something of prepping before and then after.”

With multiple treatment options, there are remaining questions about determining the best approach for individual patients and the factors that should inform the treatment course. It is critical to employ a multidisciplinary approach and gain an understanding of each patient’s wishes, because the “patient’s input is going to be very important,” Dr. Manochakian said.