Round 3: Sequencing in the Real-World Setting

In the third round, panelists consider when TTFields should be introduced, balancing arguments for early integration against calls for careful patient selection and individualized sequencing. 

To hear arguments related to the optimal approach for patients with nNSCLC, see Round 1.

To hear arguments related to managing oligoprogression, see Round 2.

Beth Sandy: Our final round is sequencing in the real world. So obviously, we're all living in the real world, and some of the study data was not exactly where we are now. 

Dr Chun, you're going to be up first. Sequencing in a real-world setting. So earlier or later?

Dr Stephen Chun: So, as I mentioned, I am a community-based, satellite doctor. I treat everything from lung cancer to breast cancer to prostate to gastrointestinal cancers, etc. And whereas in something like prostate cancer and breast cancer, they often can do this watchful waiting approach, let's save this intervention until they progress or something. As we saw from the survival curves, this is a population where very few patients get even beyond 2 years. We do not have the luxury in this population to withhold things that we have level 1 evidence for, especially if we are offering things like local consolidative radiation for which there isn’t level 1 evidence for.  

Despite being a radiation oncologist, we offer radiation, as I mentioned, in spite of negative trials empirically, but this is not a population of patients where you have a time horizon of years. These are patients who have a time horizon of months, and especially in intervention, I understand with prostate cancer or something, where hey, we want to hold off on docetaxel’s use for prostate cancer, too. I understand, we want to hold off on using docetaxel until we have diffuse progression or something. I get it, because these patients, even on current androgen deprivation strategies, are going to live for years, if not decades. That is simply not what we're dealing with with stage 4 metastatic lung cancer, especially when we have an intervention that has a Grade 3 dermatologic adverse event rate of 5%.  

And by the way, it has nothing to do with the actual therapy, the electrical fields. It's purely just a reaction to the adhesive, which anyone can have to any medical adhesive. So, the potential benefit versus the risk of reaction to a medical adhesive in a population with this kind of short-term survival… I don't see a reason to be holding out on them.

Beth Sandy: So the dermatitis is not a burn from the actual electrical currents, it is an adhesive issue? 

Dr Stephen G. Chun: Correct, it is an allergic reaction to the adhesive.   

Beth Sandy: Got it. Dr Patel, earlier or later? 

Dr Eshan Patel: I think, I will say, again, the data is not very clear, and for the real-world implication, I think there’s a lot of other factors that goes in, right? And this is where I wanted to talk about having a limitation to only use it with IO plus docetaxel, right? What about the other therapies? 

And I think this is a point where we were making it earlier: ADCs are getting very popular, and they're going to most likely replace docetaxel in a second-line therapy, right? Patients with other mutations—KRAS, ERBB2, c-MET, and in the future, we'll probably have a more target-based second-line therapy as well.  

So I think, what are for those patients, right? And so, not clear answer. I think also patients who have diffuse mets, as we debated out in the first question, right? Those patients also, at what point will you introduce the Tumor Treating Field, right?  

And the quality of life, yes it does show quality of life was not, it was pretty much balanced, but still is a nuisance to wear it 18 hours a day, right? You still need a very motivated patient. You need patients who want or have some support also, right? Changing it, in terms of keeping control of the arrays, and keep helping them navigate through everything.  

So definitely I would like to consider for patients, especially I think asymptomatic oligomets patients, as we discussed in the second question. I think by all means, for those patients as early as I can. But I think the question is for in a real-world implications for a lot of the other subgroups I think is still very unclear. And where do we fit that in, right? And I think in the future, we will have to answer those questions where docetaxel might not be the perfect second-line option, and what do we do at that time then?