Session Content References

Immunotherapy has become standard of care for all stages of NSCLC. However, there is a gap in knowledge on how to select patients for neoadjuvant immunotherapy followed by surgical resection. In addition, neoadjuvant immunotherapy may pose new challenges in technique aspect of surgical resection. For patients who received adjuvant immunotherapy following concurrent chemoradiation therapy, or stage IV patients who received first line chemoimmunotherapy, many patients develop required resistance to therapy. This section intends to discuss these challenges in practice and future direction.

It is imperative that the clinicians treating lung cancer patients understand the new trend and challenges in immunotherapy and direction of future in this area. This educational session will provide attendees the opportunity to gain exposure to the latest information in combination of immunotherapy in NSCLC and challenges in clinical practice.

Attendees need to determine when and how the latest science will affect their day-to-day practice, and thus be able to narrow competency gaps across the various stages of NSCLC most commonly treated with immunotherapy.

Potential Challenges/Barriers to Change:

1. Lack of knowledge
2. Lack of new treatment options
3. Lack of understanding of resistance mechanism

Expected Results:

• Give learners an opportunity to increase their level of knowledge and skills.
• When appropriate, apply new strategies and make practice modifications.

Upon completion of this live activity, attendees should be able to do the following:

1. Discuss outcomes and challenges of immunotherapy in all stages of NSCLC.
2. Use the knowledge in their practice for patient care decision making.

References:

1. The Landscape of Immunotherapy Resistance in NSCLC. Front. Oncol., 20 April 2022
   Sec. Thoracic Oncology Volume 12 - 2022 | https://doi.org/10.3389/fonc.2022.817548
2. Overcoming immunotherapy resistance in non-small cell lung cancer (NSCLC) - novel approaches and future outlook.  Horvath et al. Molecular Cancer (2020) 19:141 https://doi.org/10.1186/s12943-020-01260-z
3. Neoadjuvant immunotherapy with resectable non-small cell lung cancer: recent advances and future challenges. J Thorac Dis. 2020 Apr; 12(4): 1615–1620. doi: 10.21037/jtd.2020.03.44

Advances in medical oncology, radiation oncology and thoracic surgery have made advanced treatments available to older and more frail patients. A better understanding the interaction of patient frailty and comorbidities to evolving interventions and outcomes is needed.

This session will involve three lectures given by a thoracic surgeon, medical oncologist and radiation oncologist to explore individual patient variables that may influence complications related to treatment. Some of these variables may be well understood (such as poor lung function, renal failure) and some may be less well defined and less well understood, such as patient frailty, exercise capacity or body muscle mass.

Potential Challenges/Barriers to Change:

1. There can be a lack of knowledge with defined comorbidities and less well defined comorbidities (i.e., "frailty") and their association with complications following treatments for lung cancer.
2. There can be limited educational resources available to clinicians to understand these topics.

Expected Results:

• Give learners an opportunity to increase their level of knowledge and skills.
• When appropriate, apply new strategies and make practice modifications.

Upon completion of this live activity, attendees should be able to do the following:

1. Better assess important variables in determining risk of lung resection for lung cancer.
2. Better understand determinants of complications in radiation treatments for lung cancer.
3. Better understand determinants of complications following treatment with chemotherapy, targeted therapy and immunotherapy for lung cancer.

References:

1. Gulack BC. A Risk score to assist selecting lobectomy versus sublobar resection for early stage NSCLC. Ann Thorac Surg 2016; 102:1814.
2. Jean RA. Analyzing risk factors for morbidity and mortality after lung resection for lung cancer using the NSQIP database. J Am Coll Surg 2016;222:992.

The role of multidisciplinary care for small cell lung cancer has never been more important. Novel insights into subclassification of small cell lung cancer may unlock novel therapies that may be effective for each subtype. Emerging use of stereotactic radiosurgery for brain metastases in small cell lung cancer may reduce toxicities while maintaining efficacy. Finally, novel combinations of radiation therapy with immunotherapy and other novel systemic agents in limited stage small cell lung cancer may improve outcomes for these patients.

There are many ongoing advances in the treatment of limited stage and extensive stage small cell lung cancer. Failure to stay informed leads to potentially delivering suboptimal quality of care by practicing physicians.

It is imperative that practicing clinician stay current in the developing subclassification for small cell lung cancer, novel systemic treatment options in second and third line therapies, novel radiation delivery approaches and combinations with systemic agents, as well as current approaches to address brain metastases in small cell lung cancer.

Potential Challenges/Barriers to Change:

1. Perceived limited advances in small cell lung cancer research.
2. Lack of knowledge in novel advances in small cell lung cancer.
3. Lack of access to experts in rural areas

 Expected Results:

• Give learners an opportunity to increase their level of knowledge and skills.
• When appropriate, apply new strategies and make practice modifications.

 Upon completion of this live activity, attendees should be able to do the following:

1. Understand the emerging subclassifications for small cell lung cancer that may lead to different effective therapies.
2. Determine which small cell lung cancer patients with brain metastases are appropriately treated with stereotactic radiosurgery.
3. Understand current trials combining radiation therapy and systemic therapies such as immunotherapies for both limited stage and extensive stage small cell lung cancer patients.

 References:

1. Gay CM, Stewart CA, Park EM, Diao L, Groves SM, Heeke S, Nabet BY, Fujimoto J, Solis LM, Lu W, Xi Y, Cardnell RJ, Wang Q, Fabbri G, Cargill KR, Vokes NI, Ramkumar K, Zhang B, Della Corte CM, Robson P, Swisher SG, Roth JA, Glisson BS, Shames DS, Wistuba II, Wang J, Quaranta V, Minna J, Heymach JV, Byers LA. Patterns of transcription factor programs and immune pathway activation define four major subtypes of SCLC with distinct therapeutic vulnerabilities. Cancer Cell. 2021 Mar 8;39(3):346-360.e7. doi: 10.1016/j.ccell.2020.12.014. Epub 2021 Jan 21. PMID: 33482121; PMCID: PMC8143037.
2. Rusthoven CG, Staley AW, Gao D, Yomo S, Bernhardt D, Wandrey N, El Shafie R, Kraemer A, Padilla O, Chiang V, Faramand AM, Palmer JD, Zacharia BE, Wegner RE, Hattangadi-Gluth JA, Levy A, Bernstein K, Mathieu D, Cagney DN, Chan MD, Grills IS, Braunstein S, Lee CC, Sheehan JP, Kluwe C, Patel S, Halasz LM, Andratschke N, Deibert CP, Verma V, Trifiletti DM, Cifarelli CP, Debus J, Combs SE, Sato Y, Higuchi Y, Aoyagi K, Brown PD, Alami V, Niranjan A, Lunsford LD, Kondziolka D, Camidge DR, Kavanagh BD, Robin TP, Serizawa T, Yamamoto M. Comparison of first-line radiosurgery for small-cell and non-small cell lung cancer brain metastases (CROSS-FIRE). J Natl Cancer Inst. 2023 Aug 8;115(8):926-936. doi: 10.1093/jnci/djad073. PMID: 37142267; PMCID: PMC10407696.
3. Carlisle JW, Leal T. Advancing immunotherapy in small cell lung cancer. Cancer. 2023 Aug 21. doi: 10.1002/cncr.34977. Epub ahead of print. PMID: 37602492.