Data from Adam Jeffery - Curated by EPG Health - Last updated 14 February 2019
At the recent ELCC, held from 11‒14 April 2018, several hundred abstracts were presented detailing the latest cutting-edge research in lung cancer treatment and care. Brief summaries of some of the key abstracts are found below.
Further evidence that immunotherapy provides a long-term survival benefit for lung cancer patients
Researchers from a multinational study, led by Dr Julien Mazières of Toulouse University Hospital, France, presented three-year survival results from the phase II POPLAR clinical trial which investigated atezolizumab vs docetaxel in patients with previously treated NSCLC. Atezolizumab is a monoclonal antibody against the protein PD-L1 which plays a role in cancer’s ability to evade the immune system.
Over 30% of patients who were taking atezolizumab were alive after two years, almost double the number of those in the docetaxel group, and 18% were still alive after three years, compared to 10% in the docetaxel group. The median duration of response for atezolizumab was also significantly longer, at 22.3 months compared to docetaxel’s 7.2 months.
Generally, atezolizumab was well tolerated and could be continuously administered for several years. Dr Mazières said, "Some of my patients who were in the atezolizumab treatment group are now long-term survivors with lung cancer. They are not cured, but they have survived, have a good quality of life, and have returned to work. With immunotherapy we now have a new type of patient: long-term survivors with lung cancer who can go back to a normal life."
Professor Solange Peters, Head of Medical Oncology at Centre Hospitalier Universitaire Vaudois, Switzerland, commented saying, "Before immunotherapy, the long-term survival of NSCLC patients was close to 0%. POPLAR supports the concept that long-term survival is possible with immunotherapy. These latest results are exciting because unlike the previous two trials, POPLAR was a large, randomised trial and provides convincing proof that long-term survival now exists in lung cancer."
Peters went on to state that every patient with advanced NSCLC should receive immunotherapy, "We should offer all patients this one in six chance of five-year survival. However, this poses a financial challenge for healthcare systems." She advocates patient screening in order to identify patients that will not benefit from immunotherapy, helping to keep costs down and make the programme sustainable in the long term.
"That would enable us to treat only the patients with a high chance of long-term survival with immunotherapy. POPLAR shows that PD-L1 is not a useful biomarker to exclude patients from immunotherapy since some patients with very low expression had an overall survival benefit. Rather than a single biomarker, I think it will be a signature of many biomarkers including tumour mutation burden that identifies the patients who should not be treated."
Alectinib provides longer symptom improvement than crizotinib in ALK-positive lung cancer
At this year’s ELCC, patient reported outcomes from the phase III ALEX trial were presented for the first time. The trial is comparing the next generation TKI alectinib and the current standard TKI used, crizotinib, in patients with ALK-positive NSCLC, which affects around 4% of NSCLC patients leaving them at a high risk of CNS metastases.
The EORTC QLQ-C30 questionnaire was used to ascertain HRQoL and the EORTC QLQ-LC13 questionnaire was used to assess lung cancer related symptoms. Patients completed the questionnaires at baseline, every four weeks during treatment, within four weeks after they withdrew from the study, and after disease progression.
Patients in both groups had a clinically significant improvement in HRQoL, however, the duration of improvement was longer in the alectinib group (88 weeks) compared to crizotinib (68 weeks). With regard to symptoms, again, both groups showed meaningful improvement but the duration of improvement was longer in the alectinib group (cough, 96 versus 84 weeks; chest pain, 96 versus 80 weeks; fatigue, 96 versus 68 weeks; pain in other parts, 96 versus 68 weeks). Fewer patients in the alectinib group also described detrimental side effects.
Lead author, Dr Maurice Pérol, medical oncologist at the Centre Léon Bérard, said, "The patient-reported outcome data is consistent with the main results of the study. The primary analysis showed a similar response rate for crizotinib and alectinib, but a longer duration of response with alectinib. This is consistent with the improvements in health-related quality of life and lung cancer symptoms, which were of similar magnitude in both groups but lasted longer with alectinib. The patient-reported outcome data supports the use of alectinib as a new standard of care in the frontline treatment of patients with ALK-positive lung cancer."
Dr Fiona Blackhall, Honorary Consultant in Medical Oncology, The Christie NHS Foundation Trust, UK, commented on the study, "The ALEX trial was a practice-changing study that firmly placed alectinib as a first-line palliative treatment for ALK-positive non-small cell lung cancer patients. This secondary analysis strengthens the rationale for alectinib as the standard of care in first-line treatment."
She goes on to emphasise the importance of patient-reported outcomes, especially in diseases like lung cancer where palliative care is essential. "In this context of palliating advanced lung cancer, living better is as important, if arguably not more important, than living longer. And for this reason, patient-reported outcomes and health-related quality of life are crucial to assess and analyse."
With regard to the ALEX study, she states, "The time to deterioration in common and difficult to palliate lung cancer symptoms including cough, dyspnoea, and chest pain was comparable between alectinib and crizotinib. However, alectinib prolonged the improvement in those symptoms. That fits in with the previously reported improvement in progression-free survival and favourable tolerability with alectinib."
Coordinating nurses can improve cancer patients’ quality of life and satisfaction during treatment
In Quebec, Canada, a dedicated medical role was created called the Pivot Nurse in Oncology (PNO), however, until now very little data had been collected on the impact of this initiative. A new study aims to determine whether the implementation of these new nurses has produced a noticeable benefit to lung cancer patients.
As lung cancer treatment has progressed and survival rates have improved, care has become more complex and potentially toxic, leading to the accelerated deterioration of QoL and a greater discontent with care due to delays, misinformation and distress about treatment.
"At the CHUM, patients who enjoy continuity of care have a treating pivot nurse in addition to their treating physician. Each pivot nurse cares for 50 to 60 patients, who all have his or her direct phone number," explains Elie Kassouf, haematologist and medical oncologist at Centre Hospitalier de Lanaudière. "The PNO has the patients’ files and can take care of scheduling follow-up appointments with their physician as soon as they receive new test results. If a patient calls to report worrying symptoms, the nurse will also speak directly to their doctor, who may then see that person on short notice without the latter having to go through the regular emergency system."
65 patients were recruited at the CHUM three months after their treatment. 12 of these patients, who had not had access to a PNO since starting treatment, were assigned to the usual care cohort, with the remainder assigned to the continuous care cohort, where a PNO was present throughout treatment.
"The Princess Margaret Hospital Patient Satisfaction with Doctor Questionnaire (PMH/PSQ-D) that we used in the study covers four dimensions of a patient’s relationship with his physician: interpersonal skills, empathy, information exchange and quality of time," said Kassouf. "The score difference we saw between the two cohorts was huge across the board: not because the usual care group scored poorly – their results were similar to those found in other studies based on the same questionnaire – but because the continuous care cohort produced exceptionally high scores."
A large majority of the patients stated that they had a better understanding of their disease and treatment course when provided with a PDO, giving them more strength to fight the cancer. However, due to the small size and localised nature of the study, it is difficult to draw concrete conclusions.
Anja Kröner, oncology nurse and member of the management team at the Comprehensive Cancer Centre in Zurich, commented, "Despite the small number of patients involved, which means we must be cautious with the results, this work shows a clear tendency of continuity of care improving when there is an established role similar to that of the pivot nurse on a patient’s medical team," she said. "In Europe, too, we have seen promising signals. Several clinics in Germany, for example, found it was beneficial to assign a case manager to cancer patients."
She goes on to underline the importance of regular assessment of patient adherence to prevent breaks in the care process, "It would be interesting to take the research further by framing patient satisfaction more broadly, as well as considering other outcomes alongside quality of life, such as patients’ ability to carry their own weight, or to work, throughout the process," she added. "In light of the financial pressure faced by many healthcare systems today, it would also be worth exploring whether pivot nurses can reduce the cost of cancer, as another study has already suggested."
Resources & further reading
Mazières J, et al. 3-year survival and duration of response in randomized phase II study of atezolizumab (atezo) vs docetaxel (doc) in 2L+ NSCLC (POPLAR). Journal of Thoracic Oncology. 2018;13(4):S79
Perol M, et al. Patient-reported outcomes (PROs) in ALEX: A phase III study of alectinib (ALEC) vs crizotinib (CRIZ) in non-small-cell lung cancer (NSCLC). Journal of Thoracic Oncology. 2018;13(4):S80‒S81
Kassouf E, et al. Impact of the continuity of nursing care delivered by a pivot nurse in oncology on improving satisfaction and quality of life of patients with advanced lung cancer. Journal of Thoracic Oncology. 2018;13(4):S138