Locally ablative therapy, which consists of surgery, radiation, and other definitive treatments at all sites of metastasis, has shown efficacy in oligometastatic non-small cell lung cancer (NSCLC). Given that immunotherapy has also shown efficacy in NSCLC, Joshua Bauml, MD, and colleagues at the University of Pennsylvania's Perelman School of Medicine investigated the combination of locally ablative therapy with pembrolizumab (Keytruda®, Merck). The investigators found that adding pembrolizumab after locally ablative therapy improves median progression-free survival compared with historical data on locally ablative therapy alone. In this interview with i3 Health, Dr. Bauml discusses the importance of his study's results.
Can you comment on the significance of your study's findings concerning the efficacy of pembrolizumab after locally ablative therapy for oligometastatic NSCLC?
Oligometastatic NSCLC represents approximately 7% of all NSCLC cases. Emerging data have indicated that the use of locally ablative therapy for such patients seems to improve outcomes, but there are no data to guide the use of systemic therapy after such treatments. Given the hypothesized synergy between ablative treatments such as radiotherapy and immunotherapy, we tried giving immunotherapy using pembrolizumab to patients who had completed locally ablative therapy. We found that the addition of pembrolizumab was associated with an impressive progression-free survival of 19.1 months.
How does pembrolizumab compare with other options being used to treat oligometastatic NSCLC after locally ablative therapy?
To date, ours was one of the only studies that formally evaluated the addition of systemic therapy to locally ablative therapy in oligometastatic NSCLC.
What additional research advances are on the horizon for oligometastatic NSCLC?
The clear next step from our study's findings would be to perform a randomized trial in oligometastatic NSCLC comparing locally ablative therapy followed by pembrolizumab versus locally ablative therapy alone.
Do you have any words of advice for community oncologists who are treating patients with oligometastatic NSCLC?
The definition of oligometastatic disease remains very complex; each trial has used a different definition. For a community oncologist, it is important to think about this in terms of balance. In order to consider locally ablative therapy for oligometastatic disease, one must remember that not all patients with metastatic disease are the same. However, I don't think that we should advocate widespread use of locally ablative therapy for patients with too disseminated disease outside the confines of a clinical trial. When in doubt, I would reach out to colleagues doing this type of research to help identify the best patients for locally ablative therapy.
About Dr. Bauml
Joshua Bauml, MD, is an Assistant Professor of Medicine in the Division of Hematology-Oncology at the University of Pennsylvania's Perelman School of Medicine. His academic and clinical work focus on improving outcomes for patients with lung and head/neck cancers through clinical research.
For More Information
Bauml JM, Mick R, Ciunci C, et al (2019). Pembrolizumab after completion of locally ablative therapy for oligometastatic non-small cell lung cancer: a phase 2 trial. JAMA Oncol. [Epub ahead of print] DOI:10.1001/jamaoncol.2019.1449
Transcript edited for clarity. Any views expressed above are the speaker's own and do not necessarily represent those of i3 Health.
Image courtesy of Penn Medicine.