Lung cancer is the leading cause of cancer-related deaths in men and women in the United States, accounting for 27% of all cancer-related deaths. An estimated 222,500 new cases of lung cancer will occur in 2017, accounting for 14% of all new cancer cases, and an estimated 155,870 deaths will occur from lung cancer in 2017. Lung cancer is most commonly diagnosed among persons aged 65 to 74 years.
Of lung cancer cases, 85% to 90% are caused by smoking. Other risk factors include disease history, cancer history, family history of cancer, and other carcinogens. Non–small-cell lung cancer (NSCLC) comprises 85% to 90% of lung cancers, and 10% to 15% are small-cell lung cancer (SCLC).
Immunotherapy has dramatically improved survival in patients with metastatic NSCLC, and is rapidly becoming the standard of care in second-line treatment of metastatic NSCLC. The National Comprehensive Cancer Network panel recommends immune checkpoint inhibitors, including pembrolizumab and nivolumab, as preferred agents for second-line therapy.
SCLC is an aggressive subtype of lung cancer with a 5-year survival rate of 1% to 2% in patients with metastatic disease. Although up to 80% of patients respond to first-line therapy, most eventually relapse, decreasing their chance for survival. The rate of treatment response is low in second-line therapy, and there are no approved agents beyond second-line therapy.
Several studies have shown immune dysregulation in SCLC; however, clinical trials with antigenic targets, tumor vaccine, and adoptive cellular immunotherapy have yielded disappointing results. Clinical studies show that programmed death ligand 1 (PD-L1) expression does not correlate with tumor response; however, anti–PD-1 agents with or without anti–cytotoxic T-lymphocyte associated protein-4 agents may provide clinical activity in SCLC. The objective response rate (ORR) in this population is expected to be similar to response rates observed in second-line chemotherapy. Lastly, combined immunotherapeutic agents are expected to result in an ORR of 21%, compared with a 10% expected ORR with single immunotherapeutic agents.
With immune checkpoint inhibitors rapidly becoming the standard of care in second-line therapy for metastatic NSCLC, there is great expectation that these molecules will prove effective in SCLC. CheckMate-032 is a multicenter, open-label, phase 1/2 trial studying nivolumab alone and nivolumab plus ipilimumab in recurrent SCLC. This study has shown clinically meaningful activity and an acceptable safety profile, with limited/extensive SCLC after ≥1 platinum regimens. There are also ongoing phase 3 studies comparing nivolumab or nivolumab plus ipilimumab with placebo as maintenance therapy after first-line chemotherapy, or nivolumab versus single-agent chemotherapy as second-line therapy. A literature search was undertaken about the role of oncology nurses in the treatment of SCLC with novel immunotherapeutic agents. The search showed that several early-stage clinical trials demonstrated activity in SCLC; however, no studies examined the relationship between oncology nurses, SCLC, and immunotherapy. Outpatient oncology nurses working with SCLC patients in the Thoracic Medical Oncology Clinic were surveyed and interviewed. Data analysis indicates that outpatient oncology nurses desire additional educational material on immunotherapeutic options for SCLC and the management of common and rare side effects of immunotherapy agents.
This is an incredibly exciting, yet challenging period for oncology nurses as they are bombarded with multiple resources and channels for patient education and advocacy. In this dynamic and rapidly evolving landscape, it is imperative that oncology nurses are up to date on immunotherapeutic agents that can improve patient outcomes and their own understanding of this complex disease state. Oncology nurses must also be familiar with immune-related adverse events, including pneumonitis, hepatitis, pancreatitis, enterocolitis, thyroiditis, dermatitis, hypophysitis, adrenal insufficiency, neuropathy, arthritis, and the average time to onset for common immune toxicities. In addition, oncology nurses must continue patient follow-up for several months after cessation of treatment due to delayed toxicities.
Oishi K, et al. ONS Abstract 186.