Panel Shares Management Considerations for Patients Undergoing NSCLC Treatment

A roundtable discussion, moderated by Millie Das, MD, covered challenges, advances, and future directions for the diagnosis, treatment, and management of non-small cell lung cancer (NSCLC), as well as critical clinical trial data and updates from the 2024 American Society of Clinical Oncology Annual Meeting. Dr. Das was joined by Ticiana Leal, MD, Martin Dietrich, MD, PhD, and Kent Shih, MD.

In the seventh segment of the roundtable series, the panel discusses how to manage and counsel patients about adverse events and toxicities related to treatment for NSCLC, as well as the importance of working with a multidisciplinary team.

In the next segment of the series, the panel discusses key lung cancer updates from 2024 American Society of Clinical Oncology Annual Meeting.

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Dr. Das: These drugs have now been around for almost a decade, and we’re all, I think, now accustomed to managing a lot of these immune-related adverse events, we’re co-managing with our disease specialists as well. But there are grade 5 toxicities, and I agree with you. I think that this is one of those areas that I really want to get some answers: Who are the patients who are going to have that grade 5 toxicity? Because obviously you would want to avoid these therapies in those patients.

Can we identify upfront which patients are going to have those toxicities? Can we do anything to proactively prevent them from occurring? And so, I think these are complex questions as we’re thinking about survivorship of our patients, as we’re thinking about counseling our patients, about the potential for toxicities, and I don’t know that we have clear answers here.

Dr. Leal: Unfortunately, we don’t have biomarkers to predict toxicity. And I think there’s a lot of work that can be done in that space. But I think that at this point it’s really important to have, especially in the metastatic setting where the goals are palliative, it’s an informed decision-making discussion with your patients and education on what to watch out for, when to call, when to come in, and it’s sort of continuous education of the patient and their family members or caregiver to make sure that they don’t delay coming in or calling so that we can catch some of these toxicities earlier on before they escalate. I think that’s really, really key.

The second thing I would say is making sure that you have a multi-[disciplinary] team. If it’s a [dermatologic] toxicity, if it’s a [gastrointestinal] toxicity, if it’s a [pulmonary] toxicity. For pneumonitis, it is extremely challenging sometimes to identify what is really happening: Is it progression? Is it infection? Is it pneumonitis? Or is something else that you’re still trying to figure out? I think getting pulmonary to weigh in has been very helpful. And having radiation oncology weigh in, in case the patient has had radiation as we’re trying to identify, okay, what is the next best approach? And then certainly having a low threshold to start steroids. If they need to be admitted, admit, and do an expedited workup.

Then sometimes, patients are going to have those really bad idiosyncratic reactions, where it’s myocarditis or something that is sometimes unfortunately a toxicity that, despite aggressive measures to try to reverse that, unfortunately patients can still die of these toxicities.

So again, not to be taken lightly. It’s really transformed how we treat patients and how patients live. When it goes well, it goes really well. And we all have those patients that have done extremely well, but it’s having those conversations, and they’re tough conversations. They happen sort of in my clinic at various time points. If they happen when we start the treatment, but they may also happen at points of when we’re reviewing scans or worried, [saying] “Oh, I see some changes on your scan. No breathing symptoms now.” But I’ve had a few patients where I see progressive radiographic changes that are clearly due to [immuno-oncology], but the patient is fine. It’s like grade 1 radiographic pneumonitis, but they’re grade 1 progressive radiographic changes, and then at some point we have to make the call with pulmonary: “We’re not comfortable to continue to treat. What do we do?”

These are asymptomatic patients with progressive radiographic changes, which is a really big challenge. Some patients end up getting chronic toxicities where after the acute event with pneumonitis, they have chronic fibrosis now. These are patients that we’re co-managing with pulmonary, trying to maximize, number 1, disease response, but number 2, making sure that quality of life is maintained, symptoms are under good control.

I’m a big proponent of early palliative care, a lot of my patients, I co-manage with palliative care. We saw today the data at the plenary from [the American Society of Clinical Oncology Annual Meeting] about telemedicine, palliative care, and in-person palliative medicine consultation. I think there’s a lot of value for the telemedicine palliative care. A lot of my patients feel burdened with too many appointments, too many tests. They want to spend time doing other things as well. I found the presentation really, really nice to sort of see that being validated, because we’re doing it. I think one of the things that we have been incorporating for patient convenience, and some of our patients live far, is the telemedicine to help check in and help make sure patients are okay and that their needs are being met.

Dr. Shih: We learned a lot from COVID, and fortunately, and unfortunately, in what we can do, what we can’t do. And I think particularly in research, I don’t know if you guys had probably the same obstacles, but we unfortunately… totally different conversation, I guess. But unfortunately, I think we’ve had to take a step back now from some of those standards that we were able to achieve during COVID.

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View the first segment of this roundtable series here.

View the second segment of this roundtable series here.

View the third segment of this roundtable series here.

View the fourth segment of this roundtable series here.

View the fifth segment of this roundtable series here.

View the sixth segment of this roundtable series here.