A Q&A with Jack West on Strategies for Personalizing NSCLC Therapy

As a lung cancer researcher and medical director of the Thoracic Oncology Program at the Swedish Cancer Institute in Seattle, Wash., Howard L. “Jack” West has made communicating with oncology specialists and patients part of his professional mission.

West founded the Global Resource for Advancing Cancer Education (GRACE), a nonprofit organization that grew out of an Internet-based information service that West founded in 2006. In an interview with OncologyLive, West discusses strategies for integrating emerging therapies into the treatment of patients with non-small cell lung cancer (NSCLC).

How do you form a personalized treatment plan for your patients with NSCLC?A Q&A with Jack West on Strategies for Personalizing NSCLC Therapy

You need to start with the stage of the cancer. Look at the histological subtype of the lung cancer, the bulk of it, the molecular features and whether there is a specific molecular marker that could change your treatment. Then, examine the characteristics of the patient: his or her health, goals and ability to tolerate aggressive treatment safely. There are a great many variables that affect and lead to individualization of the treatment path from one patient to another.

What is the importance of histological subtyping and molecular characterization in deciding to treat with conventional or targeted therapy?

In the setting of advanced-stage disease, there is an early branch point for whether a patient has squamous or nonsquamous histology, with molecular testing being less clearly valuable and indicated for squamous lung cancer. Particularly for nonsquamous disease, especially adenocarcinomas, the presence or absence of an activating mutation, which is most commonly an endothelial growth factor receptor (EGFR) mutation or an anaplastic lymphoma kinase (ALK) rearrangement, is going to lead to an immediate diversion of the treatment plan between recommending first-line chemotherapy-based treatment and recommending a pill-based targeted therapy as the treatment most likely to lead to a beneficial effect for the patient.

Which first-line conventional and targeted therapies are preferred?

There are many different doublet chemotherapy regimens—that is, a two-drug combination—and they have largely shown an efficacy that is more similar than different. There are subtle differences that would often lead us to favor one doublet regimen over another, depending on the histology. You can have a preferred chemotherapy regimen, but they really come out quite comparably.

In terms of targeted therapies, however, you have EGFR inhibitor-based treatment, such as erlotinib (Tarceva) or afatinib (Gilotrif), which are FDA approved and extremely appropriate for first-line treatment of patients with an EGFR mutation.

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