Navigating the Evolving Treatment Landscape in Small Cell Lung Cancer: A Payer Perspective on Pathways, Sequencing, and Coverage

And, you know, I think it's important that we, you and I, continue to highlight how payers need to evaluate the role of optimized first-line strategies and really the implications it may have for downstream treatment sequencing.

And so I think the case that you discussed and we discussed really highlights why maintenance optimization is critical.

I think it's over something like 60% of extensive stage small cell lung cancer patients never received that second line therapy.

You mentioned that.

Making the first line maintenance window that primary opportunity to really extend survival.

And while, you know, lorbanectin might be good for some providers and might not be for others, when we look at the Forte trial, we did see that lorbanectin added to atezolizumab did more than double the median progression-free survival and improved overall survival with patients about 66% of survival time without symptoms or toxicity versus just 50% of atezo alone.

So there is value, right, if patients are durable, if they can handle the toxicity of considering that treatment option.

However, you know, this intensifies maintenance does carry a caveat and you've kind of hinted at this, right? Is that lurbanectin and using the maintenance cannot be used as retreatment in these subsequent lines, which affects that downstream treatment planning.

So Dr. Sands, based on, you know, what you've discussed already and some of the things that we mentioned, how would you weigh the safety profiles of the PD-L1 based first line of maintenance regimens in this patient specifically? You kind of talked about it already and what monitoring and supportive care uh would be important given the potential for immune related toxicity some of the myelosuppression you talked about or even pre-existing hypothyroidism that we saw in the patient case

well we don't have much details about the hypothyroidism but i suspect that that's the kind of thing that's going to make it a non-issue if the patient is already on a thyroid replacement therapy and tsh is being monitored then there's not so much a risk of developing hypothyroidism on active PD-L1 directed therapy.

But things like colitis, rash, and those would be, those obviously still exist.

We monitor kidney liver labs, pneumonitis, and then rare things like cardiac or brain events.

For the vast majority of people, steroids really resolve that, but sometimes we do have to use some other treatments for that.

But continuing to monitor for toxicities is, of course, important and, you know, certainly comes up with more treatment.

We saw from mForte, there was a higher rate of atezolizumab-related adverse events that required corticosteroids on the lurbanectadine plus atezolizumab arm, which is a little confusing at first because it doesn't seem like adding lurbanectadine would increase AEs from atezo until you recognize that, well, they got essentially double, twice as long on therapy.

I think it was just over four months instead of just over two months on the maintenance therapy.

And therefore, you had more AEs.

But still, the majority of patients don't have AEs.

and we would continue the PD-L1 inhibitor essentially for as long as we can.

I think when I have patients that have gone beyond two years on the PD-L1 inhibitors and they have some toxicity that comes up that would require holding drug, then I no longer try to reinitiate drug.

But if it's earlier on and they have some toxicities that resolve with steroids, I would still lean toward, okay, can we reinitiate that PD-L1 inhibitor in that setting? Sometimes there's something so severe that we don't, but the majority of patients can.

If they've had something mild and it resolves with steroids, then I might try again, depending upon the circumstances, and I try to give that for longer.