Thread by @ShrutiPatelMD

@TumorBoardTues 1/17 #TumorBoardTuesday #LungCancer #OncTwitter
72y 👩🏻with 58 pk-yr 🚬hx
Chest pain
PMH: diabetes
CT: 3 cm LLL nodule & left pleural effusion with 5mm nodule in LUL
PET: GGO in LLL SUV 4.5
💉thora with cytology
🔬Stage IVA (T4N0M1a) 🫁 adenoCa

🤨What systemic tx would YOU give?

@TumorBoardTues 2/17 #TumorBoardTuesday #LungCancer

🔪 🫁 tissue tested
🦠 Tissue NGS and IHC was sent 🧬
🔬 NGS: no actionable mutations
🔬 PD-L1 62%

@TumorBoardTues 3/17 #TumorBoardTuesday #LungCancer
👩🏽‍🏫Mini tweetorial 1👩🏽‍🏫

@NCCN based guideline for #NSCLC biomarker negative, PDL1 >50% ⤵️

CATEGORY 1 RECOMMENDATIONS:
📍 Pembro, atezo, and cemiplimab
📍 ipi/nivo considered in certain circumstances

@TumorBoardTues @NCCN @jillfeldman4 @FawziAbuRous @ADesaiMD @OncBrothers @visheshkhanna @esinghimd @GlopesMd @CharuAggarwalMD @AnaVManana @DevikaDasMD 4/17 #TumorBoardTuesday #NSCLC
👩🏽‍🏫Mini tweetorial 2👩🏽‍🏫

✨KEYNOTE-042 ✨

♦️305 pts randomized 1:1 pembro:platinum-doublet
♦️HR 0.60 (95% CI, 0.41-0.89)
♦️Median OS 17.2 months
♦️44% serious AR with 10% discontinue 2/2 AR

@TumorBoardTues @NCCN @jillfeldman4 @FawziAbuRous @ADesaiMD @OncBrothers @visheshkhanna @esinghimd @GlopesMd @CharuAggarwalMD @AnaVManana @DevikaDasMD @manalipatelmd @IbiayiMD @CBelaniMD @DasMillie11 @DivyaGuptaMD @Surbhi_Singhal2 @COlazagasti 5/17 #TumorBoardTuesday
👩🏽‍🏫Mini tweetorial 3👩🏽‍🏫

✨IMPOWER 110 ✨

♦️205 pts randomized 1:1 atezo:platinum-doublet
♦️HR 0.59 (95% CI, 0.40-0.89)
♦️Median OS 20.2 months
♦️30% with grade 3-4 ARs with 6% discontinue 2/2 AR

@TumorBoardTues @NCCN @jillfeldman4 @FawziAbuRous @ADesaiMD @OncBrothers @visheshkhanna @esinghimd @GlopesMd @CharuAggarwalMD @AnaVManana @DevikaDasMD @manalipatelmd @IbiayiMD @CBelaniMD @DasMillie11 @DivyaGuptaMD @Surbhi_Singhal2 @COlazagasti @NarjustFlorezMD @HwakeleeMD 6/17 #TumorBoardTuesday #lungcancer
👩🏽‍🏫Mini tweetorial 4👩🏽‍🏫

✨CheckMate 227 ✨

♦️205 pts randomized 1:1:1 ipi/nivo:nivo:platinum-doublet
♦️Median OS 21.2 months
♦️32% with grade 3-4 ARs with 18.1% discontinue 2/2 AR

@TumorBoardTues @NCCN @jillfeldman4 @FawziAbuRous @ADesaiMD @OncBrothers @visheshkhanna @esinghimd @GlopesMd @CharuAggarwalMD @AnaVManana @DevikaDasMD @manalipatelmd @IbiayiMD @CBelaniMD @DasMillie11 @DivyaGuptaMD @Surbhi_Singhal2 @COlazagasti @NarjustFlorezMD @HwakeleeMD @drtclay @DrAnnaMcGuire @ksivaprasadk @letswinpc @LungAssociation @LungCancerDr 7/17 #TumorBoardTuesday #LungCancer
👩🏽‍🏫Mini tweetorial 5👩🏽‍🏫

✨ EMPOWER-Lung01 ✨

♦️710 pts randomized 1:1 cemiplimab:platinum-doublet
♦️HR 0.68 (95% CI, 0.53-0.87)
♦️Median OS 22.1 months
♦️36% with grade 3-4 ARs with 6% discontinue 2/2 AR

@TumorBoardTues @NCCN @jillfeldman4 @FawziAbuRous @ADesaiMD @OncBrothers @visheshkhanna @esinghimd @GlopesMd @CharuAggarwalMD @AnaVManana @DevikaDasMD @manalipatelmd @IbiayiMD @CBelaniMD @DasMillie11 @DivyaGuptaMD @Surbhi_Singhal2 @COlazagasti @NarjustFlorezMD @HwakeleeMD @drtclay @DrAnnaMcGuire @ksivaprasadk @letswinpc @LungAssociation @LungCancerDr 8/17 #TumorBoardTuesday #LungCancer
👩🏽‍🏫Mini tweetorial 6👩🏽‍🏫

🤨Things to consider between IO options🤨

⏳Frequency of infusions
💊Adverse Events
💸Cost
🌍Access ⬇️ income countries

@TumorBoardTues @NCCN @jillfeldman4 @FawziAbuRous @ADesaiMD @OncBrothers @visheshkhanna @esinghimd @GlopesMd @CharuAggarwalMD @AnaVManana @DevikaDasMD @manalipatelmd @IbiayiMD @CBelaniMD @DasMillie11 @DivyaGuptaMD @Surbhi_Singhal2 @COlazagasti @NarjustFlorezMD @HwakeleeMD @drtclay @DrAnnaMcGuire @ksivaprasadk @letswinpc @LungAssociation @LungCancerDr 9/17 #TumorBoardTuesday
👩🏽‍🏫Mini tweetorial 7👩🏽‍🏫

📍No head-to-head comparison
📍Pt population differs across trials

@TumorBoardTues @NCCN @jillfeldman4 @FawziAbuRous @ADesaiMD @OncBrothers @visheshkhanna @esinghimd @GlopesMd @CharuAggarwalMD @AnaVManana @DevikaDasMD @manalipatelmd @IbiayiMD @CBelaniMD @DasMillie11 @DivyaGuptaMD @Surbhi_Singhal2 @COlazagasti @NarjustFlorezMD @HwakeleeMD @drtclay @DrAnnaMcGuire @ksivaprasadk @letswinpc @LungAssociation @LungCancerDr @SeastedtMD @StephenVLiu @JoelNealMD @JackWestMD 10/17 #TumorBoardTuesday
Cost effectiveness w recent approval of cemiplimab @Regeneron
📍associated w ⬆️ in budget for 1L tx
📍cemiplimab <pembro
📍🤏🏽cost⬆️maybe d/t tx length- longer PFS
⚡️Exciting data but limited - each clinical scenario differs
📚 ascopubs.org/doi/abs/10.120…

@TumorBoardTues @NCCN @jillfeldman4 @FawziAbuRous @ADesaiMD @OncBrothers @visheshkhanna @esinghimd @GlopesMd @CharuAggarwalMD @AnaVManana @DevikaDasMD @manalipatelmd @IbiayiMD @CBelaniMD @DasMillie11 @DivyaGuptaMD @Surbhi_Singhal2 @COlazagasti @NarjustFlorezMD @HwakeleeMD @drtclay @DrAnnaMcGuire @ksivaprasadk @letswinpc @LungAssociation @LungCancerDr @SeastedtMD @StephenVLiu @JoelNealMD @JackWestMD @Regeneron 11/17 #TumorBoardTuesday
If squamous hx with PDL1 express >50%...

📍Cemiplimab trial ~60:40 split adeno:squam - 74% larger crossover
📍Atezo/Pembro trials ~80:20 split adeno:squam
💰tox (insurance)
Big dz burden & 🚫candidate for chemo - cemi may be 👍🏽 or ipi/nivo vs others

@TumorBoardTues @NCCN @jillfeldman4 @FawziAbuRous @ADesaiMD @OncBrothers @visheshkhanna @esinghimd @GlopesMd @CharuAggarwalMD @AnaVManana @DevikaDasMD @manalipatelmd @IbiayiMD @CBelaniMD @DasMillie11 @DivyaGuptaMD @Surbhi_Singhal2 @COlazagasti @NarjustFlorezMD @HwakeleeMD @drtclay @DrAnnaMcGuire @ksivaprasadk @letswinpc @LungAssociation @LungCancerDr @SeastedtMD @StephenVLiu @JoelNealMD @JackWestMD @Regeneron 12/17 #TumorBoardTuesday #LCSM

🤨 How would you change management if our patient 👩🏻 with lung adenocarcinoma had < 50% PDL-1 expression and without 🎯target mutations?

@TumorBoardTues @NCCN @jillfeldman4 @FawziAbuRous @ADesaiMD @OncBrothers @visheshkhanna @esinghimd @GlopesMd @CharuAggarwalMD @AnaVManana @DevikaDasMD @manalipatelmd @IbiayiMD @CBelaniMD @DasMillie11 @DivyaGuptaMD @Surbhi_Singhal2 @COlazagasti @NarjustFlorezMD @HwakeleeMD @drtclay @DrAnnaMcGuire @ksivaprasadk @letswinpc @LungAssociation @LungCancerDr @SeastedtMD @StephenVLiu @JoelNealMD @JackWestMD @Regeneron 13/17 #TumorBoardTuesday #LCSM
Back to our case 🔎

👩🏻Patient returns to clinic to discuss systemic treatment options
💭Discuss IO monotherapy vs chemo/IO
🏃🏼ECOG 1

D/t histologic type, dz burden, comorbidities & insurance, pt started Cemiplimab monotx

@TumorBoardTues @NCCN @jillfeldman4 @FawziAbuRous @ADesaiMD @OncBrothers @visheshkhanna @esinghimd @GlopesMd @CharuAggarwalMD @AnaVManana @DevikaDasMD @manalipatelmd @IbiayiMD @CBelaniMD @DasMillie11 @DivyaGuptaMD @Surbhi_Singhal2 @COlazagasti @NarjustFlorezMD @HwakeleeMD @drtclay @DrAnnaMcGuire @ksivaprasadk @letswinpc @LungAssociation @LungCancerDr @SeastedtMD @StephenVLiu @JoelNealMD @JackWestMD @Regeneron 14/17 #TumorBoardTuesday #LCSM
Pembro vs cemiplimab

📌Things to think about:
🏋🏻‍♀️Disease burden
🔋Performance Status
😷Autoimmune disease history
💰Financial toxicity
🔬Histologic type

@TumorBoardTues @NCCN @jillfeldman4 @FawziAbuRous @ADesaiMD @OncBrothers @visheshkhanna @esinghimd @GlopesMd @CharuAggarwalMD @AnaVManana @DevikaDasMD @manalipatelmd @IbiayiMD @CBelaniMD @DasMillie11 @DivyaGuptaMD @Surbhi_Singhal2 @COlazagasti @NarjustFlorezMD @HwakeleeMD @drtclay @DrAnnaMcGuire @ksivaprasadk @letswinpc @LungAssociation @LungCancerDr @SeastedtMD @StephenVLiu @JoelNealMD @JackWestMD @Regeneron 15/17 #TumorBoardTuesday #LungCancer #LCSM

🔋Performance Status Matter?

📍​​~40% of pts with advanced #NSCLC have ECOG >=2
📍 >20% of pts on pembro alone have an ECOG >=2
📍ECOG PS >=2 on IO had (down arrow) OS compared with ECOG 0/1 (23.2 vs 4.1 months)

@TumorBoardTues @NCCN @jillfeldman4 @FawziAbuRous @ADesaiMD @OncBrothers @visheshkhanna @esinghimd @GlopesMd @CharuAggarwalMD @AnaVManana @DevikaDasMD @manalipatelmd @IbiayiMD @CBelaniMD @DasMillie11 @DivyaGuptaMD @Surbhi_Singhal2 @COlazagasti @NarjustFlorezMD @HwakeleeMD @drtclay @DrAnnaMcGuire @ksivaprasadk @letswinpc @LungAssociation @LungCancerDr @SeastedtMD @StephenVLiu @JoelNealMD @JackWestMD @Regeneron @arkhaki @AMansfieldMD 16/17 #TumorBoardTuesday
Back to our case🔎
🏥pt returns for 3 month follow up

🚨IO SE - THINGS TO MONITOR FOR 🚨

👺Rash
💩Diarrhea
🫀Myocarditis
🦋Endocrinopathies
💉Infusion Reactions
🫁Pneumonitis

@TumorBoardTues @NCCN @jillfeldman4 @FawziAbuRous @ADesaiMD @OncBrothers @visheshkhanna @esinghimd @GlopesMd @CharuAggarwalMD @AnaVManana @DevikaDasMD @manalipatelmd @IbiayiMD @CBelaniMD @DasMillie11 @DivyaGuptaMD @Surbhi_Singhal2 @COlazagasti @NarjustFlorezMD @HwakeleeMD @drtclay @DrAnnaMcGuire @ksivaprasadk @letswinpc @LungAssociation @LungCancerDr @SeastedtMD @StephenVLiu @JoelNealMD @JackWestMD @Regeneron @arkhaki @AMansfieldMD 17/17 #TumorBoardTuesday

🫁🫁Case outcome 🫁🫁

Fast forward 9 months

👩🏻 Patient: on Cemiplimab monotherapy
🙏🏽 No new SE or dose adjustments
🎉 scans: NED 🙌🏽

🧑‍💻Thoracic oncologists: remain questioning best PDL-1 inhibitor

@TumorBoardTues @NCCN @jillfeldman4 @FawziAbuRous @ADesaiMD @OncBrothers @visheshkhanna @esinghimd @GlopesMd @CharuAggarwalMD @AnaVManana @DevikaDasMD @manalipatelmd @IbiayiMD @CBelaniMD @DasMillie11 @DivyaGuptaMD @Surbhi_Singhal2 @COlazagasti @NarjustFlorezMD @HwakeleeMD @drtclay @DrAnnaMcGuire @ksivaprasadk @letswinpc @LungAssociation @SeastedtMD @StephenVLiu @JoelNealMD @JackWestMD @Regeneron @arkhaki @AMansfieldMD @DrSteveMartin #PostTest Q1️⃣ #TumorBoardTuesday
👉🏽CME Eval 🔗integrityce.com/tbtEval
🤔@NarjustFlorezMD @ShrutiPatelMD taught 1L #NSCLC differentiate PD1/PDL1, test your 🧠 with 4❓

🧐What 1L would YOU pick for a metastatic #NSCLC (adenoca) pt with neg action molecule bio & 54% PDL1 express?

@TumorBoardTues @NCCN @jillfeldman4 @FawziAbuRous @ADesaiMD @OncBrothers @visheshkhanna @esinghimd @GlopesMd @CharuAggarwalMD @AnaVManana @DevikaDasMD @manalipatelmd @IbiayiMD @CBelaniMD @DasMillie11 @DivyaGuptaMD @Surbhi_Singhal2 @COlazagasti @NarjustFlorezMD @HwakeleeMD @drtclay @DrAnnaMcGuire @ksivaprasadk @letswinpc @LungAssociation @SeastedtMD @StephenVLiu @JoelNealMD @JackWestMD @Regeneron @arkhaki @AMansfieldMD @DrSteveMartin #PostTest Q2️⃣ #CME #TumorBoardTuesday
Free CME🔗: integrityce.com/tbt
👉🏽CME Eval 🔗: integrityce.com/tbtEval

🤔In what scenario would you opt for systemic rather than continuation maintenance therapy in a patient who received 1L IO for the txt of metastatic #NSCLC? 🫁