Radiation for Patients With Stage 3 Lung Cancer
Drew Moghanaki, MD, MPH, University of California, Los Angeles, discusses whether patients with resectable lung cancer should be offered a chemo-radiation approach.
At the Great Debates in Solid Tumors meeting in Miami, Florida, Dr Moghanaki argued for the use of radiation in stage 3 lung cancer, debating Jamie Chaft, MD, Memorial Sloan Kettering, New York City, New York, who argued for the use of surgery in this population.
Transcript:
My name is Drew Moghanaki and I'm a professor and Chief of Thoracic Oncology in the UCLA Department of Radiation Oncology. I just got finished with a really nice debate with Dr Jamie Chaft from Memorial Sloan Kettering whose wit and knowledge is very hard to top. She presented some information about how we're seeing extraordinary outcomes with a drugs and surgery management approach, either in the preoperative or perioperative setting. However, I leveraged Dr Chaft's last slide, which basically shows that people who are undergoing a drugs and surgery approach are fitter, have less disease overall, are destined to do better rather than those who undergo my radiation pathway, which introduced my debate, which is how would the patients do if they were resectable and actually got radiation therapy instead.
We've seen extraordinary results with the PACIFIC regimen. However, that population was very much a lot of N3 disease, [Stage] IIIB patients, and we're seeing more and more patients now with lower burden of disease who are at least considering chemo-RT [radiotherapy] as an alternative, which basically forms the question of our debate: should resectable, operable patients be offered a chemo-radiation approach?
In our debate, we both emphasized basically the paucity of data comparing radiation versus surgery. We're still going back to inter-group study data from nearly 2 decades ago at this time where we see that patients who could just undergo a lobectomy probably are going to do better with a surgical approach, but we're just not seeing good outcomes with pneumonectomy patients. Neither then nor now, where we're seeing, unfortunately, a lot of patients are actually succumbing to the procedure itself and we're very glad to discuss that in this study, like the AEGEAN trial, pneumonectomy were prohibited and we really think that in general practice today, we have to be very careful on patients who might need a pneumonectomy following a neoadjuvant approach.
Another topic that we emphasize in the debate is that when you go down to perioperative or neoadjuvant approach, you're getting all 3 drugs. That's a platinum-doublet plus immunotherapy at the same time, and we know we have very good efficacy with a triplet drug regimen approach. We've been trying to do that in addition to radiation therapy, but for some reason the concurrent administration of radiation during triplet, which now gets you to a quadruplet treatment regimen, is not panning out the way we would like it to.
We finished our debate, led by really thoughtful questions by Drs Eddie Garon and Corey Langer, that it's time to look at this idea of triplet chemo-immunotherapy before radiation therapy, and there are some studies being designed and we're very excited that both the cooperatives group and industry are looking at seeing if we can do a neoadjuvant triplet chemo-immunotherapy before radiation therapy in the future. The data are pretty clear today, we would turn off the immunotherapy during the chemo-radiation portion.
