Thank you for joining us on January 10 for the Ask the Lung Cancer Experts webinar. A recording of the webinar is available if you'd like to re-watch it, and below are answers to the questions we were unable to get to during the webinar.
If you have medical questions or concerns about your particular situation, we advise you to discuss them with your own healthcare team.
Medical Oncology
Would you please discuss fourth-generation TKIs for EGFR and any other developments you're excited about? What is your expectation for FDA approval for these therapies for someone who progresses on Tagrisso?
There are several exciting fourth-generation TKIs in the pipeline for EGFR and ALK. They are all in early phases of development, so it will likely be a few years before FDA approval. If needed, talk to your doctor about potential clinical trials.
How do I get my tumor tissue to be tested for HER3 mutation since patritumab deruxtecan targets HER3 mutation?
Patritumab deruxtecan binds to the HER3 protein, but does not require a HER3 mutation or HER3 overexpression to work against cancer (as far as we know now).
What are some of the most interesting experimental treatments for the BRAF V600E mutation?
At the end of 2023 a new combination of RAF/MEK inhibitors was approved for this type of lung cancer (encorafenib/binimetinib).
Any new research on KRAS G12V?
Yes, new trials are looking at other KRAS mutations with pan-KRAS inhibitors, all early phase. If needed, talk to your doctor about potential clinical trials.
Please discuss the KRAS D gene abnormality and why there is no targeted therapy, and how is it different from the KRAS C abnormality, which just got a targeted therapy.
The currently approved drugs adagrasib and sotorasib specifically bind to the cysteine “C” residue in the G12C genotype, so they are not effective without that binding site. Excitingly, there a few drugs in clinical development for KRAS G12D. If needed, talk to your doctor about potential clinical trials.
Is amivantamab considered immunotherapy or target therapy?
Targeted therapy, but it has some properties that engage the immune system in its mechanism of action.
Until very recently, I had never heard of leptomeningeal disease related to lung cancer patients. Why are we hearing more about it now?
Leptomeningeal disease is a challenging type of lung cancer to diagnose and treat. Many of our standard approaches for lung cancer do not effectively work for leptomeningeal disease, so it is an area of great need where we are focused on new research.
Any advances in treatment for small cell lung cancer?
The addition of immunotherapy to first-line therapy and lurbinectedin as a second- or third-line therapy have been major advances in the past few years. In addition, multiple clinical trials are in progress to capitalize on better molecular understanding of SCLC and design new approaches to treatment.
For Tagrisso patients, do the GI side effects improve over time? Is there a way to mitigate the effects?
With Tagrisso, the GI side effects are improved over the first- and second-generation drugs, although diarrhea is listed as a potential side effect. In our clinic, we do not see patients having issues with diarrhea. However, if a patient experiences this side effect, they can use Imodium as needed. If a patient is already prone to diarrhea, they may want to start it daily. Please keep in mind that excessive use of Imodium can lead to constipation. Also, as always, discuss any concern with your primary oncology team (MD, NP, PA, RN) to ensure this is appropriate for you.
For those where targeted therapy stops being effective, what are the early signs and symptoms that are observed?
If a patient has clinical symptoms, an increase in shortness of breath that had previously resolved is possible, or the return of a cough that had previously resolved. Another possibility is an increase in fatigue and/or worsening oral intake. Again, these are broad symptoms and may not happen at all. Sometimes, there may not be any symptoms and the change is only noted on routine scans.
What is the next step if this occurs?
It depends on the amount of growth and progression. This will be discussed in a shared decision-making conversation with the oncologist. Some options could be continued targeted therapy, possibly with the addition of palliative radiation; or continued targeted therapy, since it is providing protection to the brain; or starting chemotherapy or participating in a clinical trial. Again, a patient’s care plan would be based on the shared discussion with the oncologist.
How do you determine if lung cancer is primary or metastasized?
This is based on the pathology results where there are certain markers to confirm that the primary cancer is in the lungs.
What are the side effects with ami & laz?
For amivatinamab, the common side effects (20% or more) are rash, infusion-related reaction (IRR), paronychia (infection of fingernails or toenails), musculoskeletal pain, dyspnea (shortness of breath), nausea, fatigue, edema, stomatitis, cough, constipation, and vomiting.
What can we do for neuropathy symptoms in the feet from immunotherapy…visit a neurologist?
Neuropathy is not a common side effect of immunotherapy, but chemotherapy can cause neuropathy. In this case, the delayed neuropathy could be from the previous chemotherapy. If this is not the case and the oncologist determines that the neuropathy is directly from the immunotherapy, a neurology referral may be warranted. As always, you should have a conversation with your oncology team.
For stage III lung cancer survivors with 4 years in remission, what percentage of individuals remain in remission after the 5-year mark?
This is a question for your oncologist, who will be able to give a more informed answer based on a more precise understanding of the staging of your cancer.
Why do oncologists differ on how frequently they use PET in place of CT scans for stable patients? Some say only use PET when first diagnosed and then again at progression, and others recommend them annually.
As an overview, PET scans are done initially to confirm other areas in the body that may have disease. Remember, a PET can light up on anything. The degree to which it lights up (the higher the number) can point in the direction of cancer. CT is used routinely in our practice for ongoing evaluation. PET is used again, typically only as follow-up to concerns noted on a CT, to confirm if an area truly heightens the concern for malignancy.
Radiation Oncology
How do you decide if someone is a candidate for proton therapy in advanced stage?
Someone is more likely to be a candidate for proton therapy if they do not have stage IV cancer, have received radiation therapy in the past, or have a large area of disease that cannot be safely treated with traditional radiation. In general, this is a patient-specific question.
Is there any way to connect whether radon caused one's EGFR cancer? Are certain mutations more indicative?
I am not aware of any studies that correlate radon exposure and specific EGFR mutations, but there are some small studies showing "possible" correlation between increased tumor mutation burden and increased radon exposure.
Can you give the name of the place to get the radon test for free? I wanted to get one but it was costly.
Here is a list from the Environmental Protection Agency (EPA) of state radon websites that will provide the test at a discount: EPA Map of Radon Zones and Supplemental Information | US EPA
When radiation is planned, should I be concerned with what kind of radiation my oncologist is planning to use?
It is a good idea to ask your radiation oncologist what kind of radiation they are using and why they are using it.
What is and when would cyberknife be utilized?
Cyberknife is the commercial name of a radiation delivery machine that does stereotactic ablative radiotherapy (SABR), also known as stereotactic body radiotherapy (SBRT). There are many other companies that also offer machines that deliver SABR/SBRT, and this is institution dependent.
Can you talk about radiation necrosis? How to diagnose or decipher if it's tumor or necrosis?
Radiation necrosis in the brain is difficult to definitively diagnose, and this commonly poses difficult clinical questions. We often will use characteristics of MRI (MR spectroscopy or perfusion sequences) to determine this, as well as serial MRI testing over time. The only way to truly identify necrosis vs. tumor is to perform surgery to obtain tissue.
What are side effects for early-stage patients treated with radiation alone?
The side effects of radiation for early-stage patients depend on the location of the tumor and the nearby anatomy. In general, side effects of radiation for early-stage cancers should be relatively limited in severity and duration. Most patients who, for example, receive stereotactic radiation for stage I lung cancer will usually have almost no side effects from their treatment—but again, this is patient-specific.
Is there a limit to how much radiation a patient can receive per year? Is there a cumulative cap over a period of years?
There are limits to how much radiation a patient can receive to each organ in their body. There is no time limitation necessarily, but the closer the radiation treatments are to each other over time, the more risk for side effects there will be (assuming that the radiation treatments are delivered to the same region).
Types of lung cancers, specifically NET/carcinoid tumors are rather rare, and not a lot of patients/cases for study. Is the area of RPT radiopharmaceutical therapy/PRRT under review, as well as the two main types under active study of ALPHA PRRT for treatment?
There are studies looking at radiopharmaceutical treatments for neuroendocrine/carcinoid cancers. Some have looked at, for example, lutetium-dotatate as a possible treatment for such cancers.
Can you discuss cardiotoxicity when it comes to SBRT? Are patients who receive radiation more likely to have heart issues such as an AMI?
The risk of cardiac toxicity from SBRT or radiation of any form depends on the proximity of the tumor/target to the heart. If the tumor is close to the heart, there may be an increase in risk of myocardial infarction or other cardiac toxicity. SBRT, because of its focused nature and the fact that it is usually not delivered if the tumor is directly adjacent to the heart, will generally not have significant risks of cardiac toxicity.
I developed neurological side effects due to radiation in my spine resulting in losing complete sensation from below body part. Is there any way to improve from the neurological issue?
I would defer this question to the oncologist and possibly to a neurologist, if the oncologist recommends a referral. There also could be a conversation with the oncologist/NP/PA to determine if there is any role for a palliative care referral to see if there are possible medications that could help.
Other Questions
Do you have recommendations to find nutritionists to help also change and improve our diet along with our treatment team?
Within Hopkins, you just need to ask your Oncology team to provide a referral to our dedicated nutritionist. Outside of Hopkins, you can look at the American Institute for Cancer Research (www.aicr.org), which is the leading organization conducting research related to cancer and nutrition. Life with Cancer in Northern Virginia offers nutrition consultations - contact at 703-206-5433 (LIFE) or [email protected]