How I Treat: Incorporating Tumor Treating Fields in the Management of mNSCLC After Platinum Progression

Dr Eshan Patel shares his approach to managing a patient with metastatic non-small cell lung cancer (NSCLC) who experienced disease progression after platinum-based therapy. He outlines key decision points and highlights practical management strategies.

Dr Eshan Patel: Hello, everyone. My name is Dr Eshan Patel. I'm thoracic oncologist practicing at Robert Wood Johnson University Hospital Somerset. I'm also assistant professor at Rutgers Cancer Institute of New Jersey. Today, I'll be sharing a real-world case that highlights how Optune Lua can be integrated into the management of metastatic non-small cell lung cancer following progression on a platinum-based regimen. 

So let's begin with the clinical scenario. My patient, 70-year-old female with metastatic lung adenocarcinoma, stage 4 at diagnosis, with comorbidities including hypertension, type 2 diabetes, and pre-existing peripheral neuropathy from her diabetes. She was initially treated with combination of carboplatin, pemetrexed, and pembrolizumab. She had a good response initially. Later she was maintained on pemetrexed and pembrolizumab maintenance. Pemetrexed started causing some issues with her bone marrow, which was later dropped, and patient was continued on pembrolizumab maintenance. 

After 9 months, patient had surveillance imaging showing 2 to 3 new bone lesions, signifying progression. At the time of progression, her performance status remained acceptable. She was ambulatory, independent with her daily activities, had minimal symptoms burden, mostly fatigue and some neuropathic discomfort from her diabetic neuropathy. Importantly, she was very cognitively intact, highly engaged in her care and very motivated, and a strong desire to continue treatment that will not worsen her quality of life and give her some benefit in terms of her survival. 

Given her neuropathy and her concern about side effects, she was not interested in transitioning to our typical second-line regimen, which we use docetaxel. We discussed options extensively. I have discussed option of docetaxel single agent or docetaxel plus ramucirumab or other single-agent chemotherapy. Patient was not very excited about hearing the side effects from adding multiple other chemotherapy to her regimen. 

After discussion of multiple different options and taking a lot of other clinical factors in mind, such as oligoprogression, which might be controlled with radiation, stable systemic disease, otherwise with a strong motivated patient to avoid chemotherapy-related toxicity and wants to continue her immunotherapy, I took this opportunity to introduce Optune Lua to her care. Just to frame in context, Optune Lua is FDA-approved for use in patients with metastatic non-small cell lung cancer after progression on or after platinum-based regimen in a combination with either or PD-1 or PD-L1 inhibitor or docetaxel. 

After going over the data with the patient in terms of patients who used Optune Lua along with PD-L1 inhibitor had survival benefit with very minimal systemic toxicity, our goals were clear. Patient wanted disease control with a non-cytotoxic strategy and also preserve her independence and daily function without having much of toxicity from chemotherapy. And most of all, she wanted to avoid all other factors that could have exacerbated her neuropathy, such as docetaxel chemotherapy. 

When introducing Optune Lua to the patient, we always focus on approach and we want to make sure a patient understands what are the goals of the therapy. Optune Lua is a non-invasive adjunctive therapy that can be integrated with her immunotherapy. 

And we also discussed in terms of goals for how long she needs to wear throughout the day for how much amount of hour she needs to wear Optune Lua. Per trial, at least patient wore it for more than 12 hours. And I told patient that as long as you wear more than 12 hours, there has been seen some benefits. 

I also discussed with patient to probably wear device after dinner. Then they can sleep through it. And in the morning, they can wear it while they're having their breakfast and until early morning, then they can discontinue the device, and they can do their daily activities and then can be reconnected at evening time. By doing this, at least sleeping throughout with their device, do get them most of the hours of the day that they need. 

Patient’s adherence to the treatment was excellent. We moved along with the immunotherapy maintenance, and patient wore the device on average 12 to 14 hours a day with extended wear overnight. Patient had very minimal to mild skin issues, which were expected. With the guidance from our care team, she used topical steroid at time and also she used some protective water-soluble-based barriers, which was, give her easily managed skin issues and did not disrupt the treatment. 

In reflection, with treatment provided and how well this patient did, Optune Lua has earned a place in my treatment algorithm for selected patient. Patients especially who have metastatic non-small lung cancer, post-platinum showed either oligometastatic disease that can be locally controlled with radiation or patients who have low disease burden, asymptomatic patient with a very favorable performance status and highly motivated to continue immunotherapy along with looking for something that might enhance their immunotherapy; I think Optune Lua is a perfect tool in my toolbox that I can add at that time, of course alongside with other treatment options such as SBRT for oligomet control or patients who are asymptomatic, lung-only mets that we are planning to continue to observe. I think at the time, we can add Optune Lua to those patients for enhancement of immunotherapy.