DR BLUMENSCHEIN: Okay. Sure. So this is actually a gentleman who came to us after receiving carboplatin/paclitaxel. He was being treated at an outside facility. Completed treatment in May of 2016. And then got his repeat imaging about 2 months later and presented with progression of disease. So we talked about the options. And, as you know, nivolumab is approved for the treatment of refractory squamous cell and nonsquamous cell non-small cell lung cancer. So we reviewed this option with him. He didn’t have any contraindications, ie, he had no autoimmune illnesses, and he began therapy with this. And he’s actually tolerating it quite well, not having any signs of side effects at all.

DR LOVE: And how long has he been on treatment now?

DR BLUMENSCHEIN: He’s been on treatment for approximately 2 months now. And so he’s coming up on his first set of scans. But he remains asymptomatic. And he feels much better having been off chemotherapy. It’ll be interesting to see how his scans are supportive of this. I’m hoping he’s responding.

DR LOVE: So I want to go back through a few things about this case and in squamous cell carcinoma in general. And the first is up-front therapy, in first-line therapy of metastatic disease. We’ve seen, when we poll general oncologists, kind of a split between 3 kinds of doublets, either gemcitabine/paclitaxel or nab paclitaxel. How do you approach, again, selection of first-line therapy outside a trial setting? And again, there’s also the issue of cisplatin versus carbo, but also the issue of necitumumab.

DR BLUMENSCHEIN: So in my practice, the majority of our patients come from outside of the city where I practice. And we usually do a q3week regimen, either with paclitaxel or docetaxel. Patients who have underlying neuropathy, I’ll give gemcitabine with carboplatin. And those are my general approaches. I haven’t used much in the way of nab paclitaxel. I’ve made recommendations for that and has been used by the local oncologists if the patient lives at a distance.

DR LOVE: We have heard people talking about nab paclitaxel, particularly in squamous cell and in older patients, where I guess some of the subset data suggested an advantage. Any thoughts about that?

DR BLUMENSCHEIN: No. I think the subset data looks interesting. And it is, head to head, probably a better tolerated drug. But the issue for us is that the schedule is a little more labor intensive for the patients, and so we end up doing mostly q3week therapies for that reason.

DR LOVE: And then again, there is now an anti-EGFR antibody approved in non-small cell, necitumumab.

Can you talk a little bit about the data that underlies that approval? And also, what your thoughts about it are in terms of using it in clinical practice.

DR BLUMENSCHEIN: So, funny you should mention that. I tried to utilize it about a week ago, but not with the cisplatin backbone. I was treating with gemcitabine/carboplatin, and the FDA indication is with cisplatin. So it was denied. And the patient couldn’t take cisplatin, so we didn’t utilize it. I mean, I think it offers a modest benefit, but non-small cell lung cancer needs whatever modest benefit we can get. So I think it’s a reasonable option for patients.

It does enhance toxicity in terms of some of the neutropenia. But on the whole, I think it’s a reasonable addition in the appropriate patient.

DR LOVE: What was the patient’s situation where you wanted to use it? And sometimes people talk about younger patients, people who are more motivated who want every possible advantage. Was that the situation, or something else?

DR BLUMENSCHEIN: No. It was a younger patient who we thought — we discussed the options with the patient, and it’s a little more involved for the patient in terms of the number of times they come in. But it was something we discussed. They were interested. And then they had insurance issues vis-à-vis that particular drug.

DR LOVE: Interesting. Have you used the drug, and any thoughts or information about dermatologic toxicity?

DR BLUMENSCHEIN: I’ve used infrequently at best, so I haven’t seen much in the way of skin toxicity. Those are class effects with EGFR monoclonal antibodies. We saw that with cetuximab. But it hasn’t been an issue for us yet.

DR LOVE: So another issue here in this patient who’s currently on a PD-1 antibody is, what are you going to do if the patient, like most people, actually has disease progression, unfortunately? Hopefully he won’t fit into that category. But if he were to develop disease progression and, for example, found on imaging but he was still stable clinically, what would you be thinking about third-line therapy? And what kinds of trial options might you be thinking about?

DR BLUMENSCHEIN: So if I was in practice without a clinical trial option, given that he’d had paclitaxel, carboplatin and now nivolumab, the options available would include docetaxel with or without the addition of ramucirumab. And then there’s gemcitabine and vinorelbine. So those would be the choices off study I think available to him.

DR LOVE: I guess another issue, you mentioned the potential, outside a trial setting, of using ramucirumab, another anti-angiogenic. Obviously approved and utilized a lot in gastric cancer. What’s your thinking? Are you generally offering it to patients in this situation? Are you recommending it?

DR BLUMENSCHEIN: So it is approved in squamous cell carcinoma of the lung, and so that’s a discussion point that we have. And then I’m very cognizant of discussing the pros and cons of the therapy with the patients. Now, with ramucirumab, in addition to docetaxel, you saw about a 5- to 6-week improvement in overall survival. Which, again, modest, but it’s an improvement and some patients do better than that. And the nice thing about these regimens is we can always stop something if the patient runs into toxicity.