10 Commonly Asked Lung Cancer Questions With Dr. Jyoti Malhotra

Following a lung cancer diagnosis, many patients wonder what the next steps are — from treatment options, next-generation sequencing, surveillance and more.

To ensure patients can always best advocate for themselves in their treatment journey and beyond, CURE® spoke with Dr. Jyoti Malhotra, director of thoracic medical oncology at City of Hope and a presenter at the Educated Patient® Lung Cancer Summit held on June 15, to answer the 10 most commonly asked patient questions in the lung cancer space. Malhotra focused on post-treatment monitoring, emerging treatment options and managing potential side effects.

After five years of surveillance and no evidence of disease, what monitoring is appropriate long term?

Malhotra: After five years, guidelines recommend continuing with annual surveillance scans. This may be more frequent if there are radiological findings that are being monitored on the scan.

Can you explain, how and if RNA sequencing is a part of next-generation sequencing in lung cancer?

RNA sequencing is preferred and recommended in addition to DNA sequencing for next-generation sequencing for lung cancer. This is because some of the genomic changes, such as fusions, are more effectively detected by RNA sequencing.

Are there any advanced treatments for interstitial nephritis that persist after treatment ends, other than just steroids? What is the best steroid to use?

Currently, the recommended treatment for interstitial nephritis is steroids as well as consultation and regular follow-up with a nephrologist for additional work-up and treatment. The most commonly used steroid in the outpatient setting is prednisone.

Can any therapies get into the brain? Does radiation open the blood-brain barrier to allow treatment in?

We know that some targeted therapies such as new-generation EGFR and ALK inhibitors (Tagrisso [osimertinib], Lorbrena [lorlatinib] and Alecensa [alectinib], for example) have good penetration across the blood-brain barrier. We do not have a good understanding of the degree to which other therapies are able to get into the brain. We do not have clear data to support that radiation opens the blood-brain barrier to other therapies.

How do you treat patients who experience pneumonitis (inflamed lung tissue)?

Pneumonitis is treated by holding the drug treatment and starting high-dose steroids. It is important to treat with steroids for more than four weeks followed by a gradual taper of dose. Patients who don’t respond to steroids or have severe pneumonitis are admitted to the hospital for additional supportive care and management.

For advanced/metastatic EGFR non-small cell lung cancer (NSCLC), when is chemotherapy combined with Tagrisso, versus Tagrisso alone, or versus chemotherapy and/or immunotherapy?

For advanced/metastatic EGFR-mutated NSCLC, both chemotherapy combined with Tagrisso and Tagrisso alone, are approved regimens. As the approval for chemotherapy plus Tagrisso is recent, so we are still trying to understand when to use the combination therapy rather than monotherapy with Tagrisso. We still do not have survival data for chemotherapy plus Tagrisso from the trial (the phase 3 FLAURA2 trial), but we should have it in the next few years and this will also help answer this question.

LEARN MORE: Combining Drugs, Radiation Is ‘Practice-Changing’ for Some Lung Cancer Subsets

What is the timeline for post-radiation cloudiness to clear?

This is variable and depends on multiple factors. There is significant variability between patients.

Can you discuss what determines dose adjustments; for example, under what condition a patient can go from 80 milligrams (mg) of Tagrisso to 40 mg?

The recommended dose of Tagrisso is 80 mg. A lower dose of 40 mg is only used if the 80 mg dose is associated with significant side effects and is not tolerable. We do not know if the 40-mg dose will work as well as the 80-mg dose.

Can you discuss any updated treatment options for multifocal adenocarcinoma lung cancer?

This depends on the presentation and extent of the cancer. So it is important to form an individualized treatment plan for each patient with input from a multidisciplinary clinical team. This would include surgery, radiation oncology as well as medical oncology.

Can you discuss treatment options for patients with oligometastatic lung cancer?

The treatment for oligometastatic lung cancer is similar to the treatment for metastatic lung cancer in general. Many physicians do consider more definitive therapies such as radiation for oligometastatic cancer in addition to systemic therapy. But this approach is still under investigation in ongoing clinical trials.

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