Dr. Patel: This is a very interesting case. The fact is that almost half [50%] of our patients are over 70 [years of age], and there are unique treatment considerations for these patients.
Clearly, this patient was well enough to get about four cycles with a very nice response. He now has recurrence of a mild effusion. So we have a lot of treatment options, assuming that his performance status is well-preserved. I think that we could consider single-agent docetaxel, single-agent pemetrexed, or erlotinib—if he is quite well, doesn’t have a lot of lingering toxicity from the [first-line] therapy, and he's had responsive disease, that second-line therapy would provide not only a survival advantage, but probably a clinical benefit by keeping the effusion from returning.
If he had disease that was easily accessible through a biopsy, I would very much advocate for repeat biopsy. I would be more likely to do this if he had a modest or never-smoking history. I know we can't select [for] mutations clinically, but if my pretest suspicion is that he has an EGFR mutation in the second-line setting, I'd probably do the biopsy. This has relevance in terms of prognostic significance, and would help us plan and certainly personalize therapy.
So, if he had an [EGFR] mutation, the answer is easy: I'd treat him with erlotinib. Particularly in the elderly who have sensitizing mutations, treatment with tyrosine kinase inhibitors [TKIs] can have a dramatic response.1 If the tissue was more difficult to assess, then in all likelihood, I would treat this patient with single-agent pemetrexed until he had significant toxicity or progression of disease. So, pemetrexed every three weeks, with imaging every two or three cycles, again, until toxicities precluded further therapy.
There are some investigational therapies that many of us are interested in [some of which I will briefly outline here]. In this gentleman with adenocarcinoma, statistically he's got a 30% chance of having a [K-]ras mutation. We will have some data from recent clinical trials looking at MET inhibition with TKIs in this disease,2 and a more interesting “golden grail” is whether this gentleman would benefit from immunotherapy, looking at agents that target programmed death:
Narrator: Ipilimumab is not an approved treatment option for NSCLC.
Dr. Patel: Most trials in 2013 may require the correlation of tissue to help predict response to certain drugs and to help us better understand the biology. So that, alone, might push me to rebiopsy this patient, to really tailor even a clinical trial option [that would be] in his best interest