Mark A. Socinski, MD, discussed how the understanding of lung cancer has evolved over time, as well as how its heterogeneity impacts treatment strategies.
Mark A. Socinski, MD, executive director at AdventHealth Cancer Institute, explained how the understanding of lung cancer has evolved in recent years, as well as how the heterogeneity of the disease impacts treatment decisions.
Can you speak to the heterogeneity of lung cancer and why differentiation between subtypes is important?
Historically, if you go back 30 years or so ago, we divided lung cancer into 2 major groups: non–small cell and small cell. Non–small cell was a broad group of patients; we have now learned over the past decade or so that there are many subsets within the category of non–small cell lung cancer. These subsets are defined by either DNA mutations or fusions, as well as PD-L1 status. So, it is no longer true that one size fits all in terms of the treatment of lung cancer. You have to know the results from comprehensive genomic testing to see if the patient does have a specific mutation or a specific fusion in which there's an FDA-approved therapy. And the reason these targeted therapies—and we use the term targeted therapies because we think those DNA alterations and fusions and these sorts of things are our targets. These drugs are designed to inhibit the target, and we use the term targeted therapy.
You need to know that targeted therapies are much more highly effective than chemotherapy, and patients that have these DNA targets tend not to get the same benefit from immunotherapy. So, we want to get the right treatment to the right patient at the right time, and that really demands us knowing whether or not they have a target. The flip side of that is if you don't have a target, then PD-L1 status makes a difference. It makes a difference in the sense that it tells us how engaged the immune system might be, and it does predict for the option of using immunotherapy by itself without chemotherapy if there's very high PD-L1 expression.
We like to think that we're much more customized by delivering much more personalized treatment to patients based upon understanding that, again, one size doesn't fit all, and we need to know the comprehensive genomic information, the PD-L1 status, to say, "This is your diagnosis and this is the way that we should treat it initially."