Ask Dr. Charu Aggarwal About the Management of Lung Cancer

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The Personalized Medicine Foundation and Cancer Connect are pleased to provide patients and caregivers the opportunity to ask questions about the management of lung cancer and about the COVID-19 pandemic with Dr. Charu Aggarwal, MD FACP Assistant Professor for Lung Cancer Excellence Perelman School of Medicine at the University of Pennsylvania. Dr. Aggarwal is an expert on the use of precision cancer medicines and immunotherapy for the treatment of lung cancers.

Please submit your questions using the form below and you will be notified when the responses are posted.

Click here to submit your question to Dr. Aggarwal.

Answers to Submitted Questions About Advanced Lung Cancer (pending)

I am in remission for NSCLC and tested positive for COVID-19. Once you’ve had COVID-19 can you get it again?

We are actively learning about covid19. At this time, data are very limited, it would depend on the level of immunity generated by the initial infection.

I have Stage IV NSCLC, Adenocarcinoma, PDL 1 of 75%. Currently on DPX Survivac clinical Trial receiving Keytruda since Feb 14. My scans show progression of my lung tumors and lymph nodes though bone mets are shrinking. My doctor wants to start chemo. Today is my one year “cancerversary”.

  • Is it possible that there is another gene mutation?
  • Should I get tested for any other biomarkers? I am -negative for EGFR, ALK, ROS1.
  • Is there another immunotherapy drug that could be used instead of resorting to chemotherapy?

The question for NGS testing for other markers would be better answered in the context of what kind of testing was performed at the time of initial diagnosis. What kind of panel was tested? Were other clinical mutations tested- including KRAS G12C? If a limited panel was performed for only the three listed genes, then it would be good to test for the other treatable mutations, namely KRAS, NTRK, MET, and BRAF.

There are other immunotherapy drugs that are in clinical trials that are being evaluated, which can be considered before proceeding with chemotherapy. There are many different clinical trials, so it would be best to speak with your physician about them.

I am 71 years old and have stage 4 EGFR positive NSCLC diagnosed 1/18. I took Iressa for 17 months before progression and switched to Tagrisso 80 mg 11/2019. It made me very sick, I could not eat and my doctor stopped if for 15 days, then restarted on 40 mg. I am not sure how effective the 40 will be but if I have progression but can I gradually increase the dose back toward 80? Do you have other dosing or treatment recommendations if I fail Tagrisso?

It is important to understand the reasons for a dose reduction. The most common side effects of diarrhea and acneiform rash can and do respond well to treatment holds. In most cases, we are able to restart Tagrisso at 80 mg with supportive measures such as anti-diarrheals, and measures for rash/dermatitis. If patients can tolerate 40 mg, consideration should be made to increase dosing to 80 mg. In cases, where full dose is infeasible to administer due to side effects, it is reasonable to consider a dose reduction to 40 mg. While a large body of literature on efficacy of reduced dosing does not exist, retrospective reports demonstrate equivalent efficacy to the full dose.

Ongoing clinical trials are evaluating next generation tyrosine kinase inhibitors, either alone, or in combination with Tagrisso. Radiation may be another reasonable alternative, in case of isolated area of progression.

Chemotherapy remains a viable option in case Tagrisso stops working

I am taking Crizotinib and Tagrisso. I recently started the combination of both drugs. I am having a hard time with diarrhea, nausea and vision problems. I am taking Crizotinib twice a day (250 mg each time), and Tagrisso (80mg) once a day. Are these common side effects?

Although not traditional, there are certain instances, where we combine crizotinib with CAD risk so. This is especially true for patients that have an EGFR mutation, and then developed a met mutation. There is no doubt that combination therapy with 2 drugs is more challenging than 1 drug alone. Crizotinib is usually associated with vision changes, and some cases of nausea have been reported. Diarrhea can be seen with osimertinib. These are common side effects, and are very expected. When we use these drugs in combination, we recommend monitoring, dose adjustments for toxicity such as excess diarrhea and evaluation on an as needed basis. Nausea is usually managed with supportive medications.

I have been on Keytruda for advanced non-cell Lung cancer stage four, how long should I stay on treatment and how long does it usually extend someone’s life?

For metastatic Non-Small Cell Lung Cancer, we recommend use of Keytruda for as long as there is clinical benefit for up to 2 years. Keytruda when administered alone or in combination with chemotherapy has shown a survival advantage of about 16 months in addition to what we would achieve with chemotherapy alone.

I am on Gilotrif and the skin rash is horrible can Accutane be used to treeat a TKI rash? Doxycycline didn’t work for me.

Rash is a common side effect of these therapies. These rashes usually appear on the face, and the trunk. Sometimes the scalp can also be involved. We usually use topical antibiotics, and steroids for control of these symptoms. If in case the rash becomes worse, oral antibiotics can be used. If doxycycline is not effective, other antibiotics like minocycline can be used. Accutane is not very effective, and other oral antibiotics like minocycline should be tried.

I am 64 and pretty healty and was just diagnosed with Stage IV NSCLC. One doctor recommended Keytruda, the other Keytruda plus chemotherapy. Is there any advantage to getting chemo in addition to the Keytruda?

Chemo immunotherapy, and immunotherapy with Keytruda alone are both currently recommended for the treatment of stage IV non-small cell lung cancer. At this time, we base decisions on the results of a protein receptor called PDL1. If PDL1 is greater than 50%, there is an advantage to use immunotherapy alone, and avoid the side effects from chemotherapy. If however PDL1 is less than 50%, we usually combine chemotherapy with Keytruda. In certain circumstances, even for patients with PDL1 greater than 50%, we recommended a combination of chemo immunotherapy, this is usually true for case of patients that have a lot of symptoms, or disease involving more than two organs.

I am stage IV NSCLC on Tagrisso 80, I am wondering if adding Metformin would provide additional benefit?

There have been at least 2 studies that have been reported with the use of metformin in combination with Tagrisso, one of which showed an advantage, and the other one did not. Currently there is no evidence that metformin improves the efficacy of Tagrisso. We do know that it can add side effects such as diarrhea, and nausea. At this time, we are not routinely adding metformin to standard of care in patients that are receiving tagrisso, but can be entertained in the setting of a clinical trial.

Is it ok to proceed to surgery for stage III NSCLC following 2 months of chemo given the current pandemic? I am 78 and have lost a bit of weight so far.

During this pandemic, decisions regarding surgery, and use of chemotherapy prior to surgery are being made on an individualized case by case basis. Without going into further details regarding your surgery, or planned chemotherapy-- we would state that in general terms, it would be reasonable to consider chemotherapy in advance of surgery.

The Ask The Expert Series is made possible by support from The Personalized Medicine Foundation, Lilly Oncology and CancerConnect.

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