Treatment Options and Unmet Need in Non-small Cell Lung Cancer

Alex Spira, MD, PhD, FACP, director of the Virginia Cancer Specialists Research Institute, medical director at US Oncology Network, provides an overview of currently available treatment options in non-small cell lung cancer, and describes the unmet need and challenges in treating this type of cancer.

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Welcome back to PopHealth Perspectives, a conversation with the Population Health Learning Network where we combine expert commentary and exclusive insight into key issues in population health management and more.

Today we are joined by Alex Spira, director of the Virginia Cancer Specialists Research Institute and medical director at US Oncology Network. He provides an overview of currently available treatment options in non-small cell lung cancer and describes the unmet need and challenges in treating this type of cancer. Dr Spira?

I'm Dr Alex Spira. I'm a medical oncologist with Virginia Cancer Specialists and US Oncology Research. I work out of an office in Fairfax, Virginia, right outside of Washington DC.

Can you tell us a bit about the unmet need in non-small cell lung cancer?

We have a huge unmet need in non-small cell lung cancer still. We’ve made a lot of headway, but there's a lot of unmet need, especially for second-line therapy across all patients, and especially for some new and targetable mutations as well.

We've made a lot of headway with immunotherapy and certain things over the last few years, but we're still not where we would like to be, which is more treatments for everybody.

What are some specific challenges for treating non-small cell lung cancer?

Non-small cell lung cancer has become relatively challenging over the last couple of years for many reasons. One of the big ones is that it's not one disease anymore. When I started this job around 18 years ago, non-small cell lung cancer was just that: non-small cell lung cancer.

Then, we started having some therapies by different sub-histologies. Now we have about, I lost track, but I think around 10 different, what we call targetable mutations. If you have a targetable mutation, it means there's a specific drug against a specific mutation that you can attack with that drug.

It's made it a lot more complicated. It's made clinical trials much harder to do. Instead of looking at 100 lung cancer patients, you're doing studies for a small subset of those.

However, it's great for our patients because we now have therapies specifically targeted toward their individualized lung cancer, which has been the holy grail for a long time.

Can you give us an overview of currently available treatment options?

The currently available treatment options for our patients, it really depends. It's still chemotherapy and immunotherapy, for most. There's about 8 to 10 targetable mutations. Osimertinib; Lumakras, which is sotorasib; a couple of new ones for the other KRAS G12C drugs.

There's c-MET drugs, called tepatinib and capmatinib. There's drugs against RET. There's a drug called alectinib against ALK. Amivantamab for c-MET exon 14, which is currently approved for exon 20 insertion mutations. a lot of different treatment today depends upon the subtype that you have.

As you just mentioned, there are a lot of different standards of care based on what type of cancer it is. At what point do providers typically change treatment regimens and for what reasons?

For most people, we start on a regimen. A typical reason you start on a new regimen is if there's what we would call progressive disease, ie, the treatments don't work.

That's when we typically talk about altering the treatment regimen accordingly. Every time there's a change in their tumors, ie, it grows, or no longer works, that's when we end up going to a new line of treatment.

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