Healthcare Unfiltered Express
Healthcare Unfiltered Express curates quick-hit conversations between Dr. Chadi Nabhan and his guests on hot-button topics in the healthcare world today.
Healthcare Unfiltered Express
Episode 59: ASCO 2026 Lung Cancer Updates
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Dr. Bruna Pellini of Baptist Health Miami Cancer Institute joins Healthcare Unfiltered EXPRESS to break down the most important lung cancer data presented at ASCO 2026. Together, we discuss the trials most likely to influence clinical practice, what they mean for patients today, and how they may reshape future treatment decisions. Watch on YouTube, subscribe, share, review, and join the conversation.
Welcome to the Healthcare Unfiltered Express, where I conduct short video interviews back with relevant and timely information that you cannot miss. So sit back and enjoy the show. Well, folks, I'm very excited because uh first of all, we have a first timer on the Healthcare Unfiltered Express, and I promised Dr. Polini that we're gonna take 15 to 17 minutes only of our valuable time. Welcome, Bruna, to the show.
SPEAKER_00Thank you, Chaddy, for the invitation. Super happy to be talking to you finally in your podcast.
SPEAKER_01I know, and uh, we are tipping in June. I mean, it's gonna air in a couple of weeks, but uh I mentioned that because we're tipping as the World Cup is happening and no Italy.
SPEAKER_00Yes, I know, but you know, there's some underdogs they're doing great. I as a Brazilian, I love soccer, obviously. Uh, and Miami is crazy uh with all the fans, but it's so much fun. The energy is palpable.
SPEAKER_01So you think Brazil is gonna take it all?
SPEAKER_00I wish, but you know, I'm from the era where we had Ronaldinho, Ronaldo. I saw Brazil win uh so many times, and now I don't think the players that are at the same level, unfortunately.
SPEAKER_01And I my favorite team was 1982, Socrates and Zico. I mean, I'll never forget that that team. All right, but we're gonna talk about lung cancer. We just finished a few weeks ago the crazy ASCO 2026 meeting, but a lot of information on lung cancer that may be shaping practice. So I thought we'll get together for 10 to 15 minutes and talk about top five to six abstracts that you think oncologists need to be aware of that may either inform their practice or change their practice.
SPEAKER_00Yes. So I think uh thinking about precision medicine first, and this was a plenary session abstract, Libreto 432. Um, so basically the study uh was a phase three global study. Uh patients that had stage 1B through 3A that had a rat fusion, they were offered uh supercatenib after uh surgery, and some patients did get chemotherapy as well. The hazard ratio was impressive, it was 0.17, and the median EFS was not even reached. I loved uh Dr. Lovely's discussion on the topic, and the main thing that stuck with me was her question regarding whould we just wait and run trials for every single rare genomic alteration to show that that's the way we need to treat patients when we have trials over and over showing consistent results that this benefits patients.
SPEAKER_01I love that question, Bruna. And um I agree it's a tough. It's a it's it's a like realistically, you would think no, but we could always think of studies that were also negative sometimes, right? Like, you know, I mean, uh, so it's uh I recall um it's not the same, it's not really a targeted therapy, but I believe there were some studies looking at avastin. Um it's not target, it's different in adjuvant therapy for colorectals was negative. But um great question. So this is changing practice right now, right?
SPEAKER_00Absolutely. So now if we see patients that have red fusions, they have receptable non-small cell lung cancer, we should absolutely be giving them cell percatenin.
SPEAKER_01What's the percent of lung cancer that are red positive?
SPEAKER_00Uh, it's probably around, I'd say three to five percent. I think that's the right range.
SPEAKER_01It's not do we need chemo?
SPEAKER_00Uh I'm not sure. Uh some patients did get chemo in the study. And I think uh if we look at, for instance, Adora, 60% of the patients did get chemo, but 40% didn't. And then if we look at studies that patients got a lact nib in the adjuvant setting, those patients didn't get chemo, right? So I don't think the field knows the right answer to this question. I will say this. Um, I think there's a biomarker um that was published, a study was published last year regarding this uh biomarker that looks at 14 genes expression after surgery to see if patients would benefit from chemotherapy determining their risk. Uh, it's called risk review. The trial was aim high, and that was for early stage non-small cell. I think that could be something that we could potentially use to try to answer this question. But again, they didn't have a good representation of patients with actionable genomic alterations. So, how much can you really extrapolate? But the bottom line is if there was a way to determine which patients do need chemos and uh chemotherapy and the ones that do not, that would be the ideal scenario.
SPEAKER_01Okay. Abstract number two.
SPEAKER_00Abstract number two. I will have to talk about harmony six. This is again a plenary uh session um abstract. And I understand that the study was conducted in China, and but still it was focusing in patients with squamous non-small cell line cancer. We have to pause there because that's a very hard-to-treat disease. The outcomes are always inferior than non-squamous, and we clearly see a median OS benefit. It was, I believe, 23 versus 27 months, almost 29, 28 months, giving Ivanesimab with chemotherapy, comparing chemotherapy with immunotherapy. And I think as a community, we need to understand that the studies that we so-called global, they don't have very even representations from every single country. And uh I do also understand that studies conducted in a very homogeneous patient population may have different outcomes, but I also don't think we should discard and ignore the benefit of a therapy because our gold standard is median OS in a study with a lot of patients that's showing the overall uh survival benefit. So the hazard ratio was always very also very good. I think it was 0.66. So do we really think this is not gonna be significant in an other patient population? I'd say probably not. Um I what are your thoughts on this?
SPEAKER_01Well, I I mean the I think uh as a non-thoracic oncologist, I'm fully aware of the difficulty with squamous cell uh versus adenocarcinoma just histologically. And I do think that um we haven't made as much progress in the squamous uh versus adenocarcinoma. I have heard of the trial, I've seen the difference. I think one of the uh I have no issues in general about global uh conceptually having trials done globally, we should. But I do think that uh we need to have additional representation from US patients uh because I am a believer that some of the differences in outcomes could be could be pharmacogenomics. I mean, it could be that uh people in China metabolize drugs or these drugs a bit differently than here. That field is, you know, so so it's hard to uh sometimes uh translate. It's also impossible to do every single trial in every single patient population. It is not possible. So I think companies should discuss with the FDA if there's a goal to get something approved and say, this is what we are thinking. What percent of our patient population in the trial should be from the US for us to get an approval? And I believe these kinds of dialogues do take place between sponsors and the FDA.
SPEAKER_00Yes, that's a very thoughtful answer. And and I agree, uh, we need that global trial, but I would be surprised if it's a negative trial with all the data that we've been seeing building up on Ivan SMEB.
SPEAKER_01Yeah, so we have to, we do we can we shouldn't replicate every study, but we should look at some of them. Okay, abstract number three.
SPEAKER_00Uh I would say optitrope lung O5. So that was Sassetismab uh plus Pembroke in PDL1 positive, uh non-small cell line cancer versus Pembro alone. So there was a very uh obvious benefit. I think the hazard ratio was 0.35 uh versus Pembroke alone. A few thoughts though. Uh it was for patients that had a PDA1 of at least 1%. So that makes me pause uh because there were other studies that were done this way, and people questioned if the comparison arm was the fair comparison because why are you not using chemo and pembolism ab as the comparison? That's point number one. Point number two, and I think there was a very relevant theme during ASCO this year, is being mindful of toxicities. How much uh benefit it's outweighing the hindrance in quality of life for our patients. So I think the bottom line and the way I would answer this question is how can we select who actually needs the additional treatment and spare people that really don't need the additional toxicity and they will do just well with pembroly someabolone. So I think it's something that we should uh consider ADCs combined to immunotherapy, but I don't think one size fits all.
SPEAKER_01Yeah, it's always the tailoring therapy to whoever benefits is always the holy grail. And we'd love to have some biomarker that tells you this is the right thing to select versus not, right?
SPEAKER_00Mm-hmm. Exactly. Because the key issue is whether improved PFS, which was obviously demonstrated here, justifies adding all this hematological and non-hematological toxicity. That's the main question. Uh, and another thing that is a pet peeve of mine, uh Shari, is when we are presenting the data and there's obviously very high rates of grade three and four toxicity, and we say manageable toxicity. I'm sorry, unless you're the one dealing with the toxicity, you shouldn't say be saying that it's manageable. So I think we need to be careful.
SPEAKER_01That's a pet peep in grade two, by the way. I mean, I think we focus on grade three and four, and I would say grade two are very difficult.
SPEAKER_00Exactly. Uh, because that's another pet peep of mine. Uh when we report studies, many times we plump grade one and grade two together, and it's very different, as you and I know.
SPEAKER_01Yeah, yeah. Okay, what's next?
SPEAKER_00What's next? I think we should talk about crown. I I mean crown data. Let's talk about outpositive non-small cell lung cancer. So, first line lorlatanib uh showed that the medium PFS hasn't been reached with lorlatanib after seven years.
SPEAKER_01Amazing.
SPEAKER_00This is incredible. I I think I understand uh lorlatanib has a lot of toxicities and uh it wasn't compared, for instance, with brigatinib or electinib, it was chrisotinib. But if you look at all the data, cross-trial comparison, all of the other agents that are newer generation, electinib, brigatineb, the median PFS is around three years. Here we are with an agent that has a medium PFS not reached seven years. So I think it I cannot say it's better because there's no head-to-head comparison, but I can assume it's probably better because look at the numbers, right? Um, I think the main thing with lore latine, in my opinion, is that when we talk to many colleagues, most of us don't start patients at the full approved dose of 100 milligrams. A lot of us start patients at 75 milligrams and assess tolerability. And when you look at the data that was published initially, patients that received dose reduced lore latinib had the same outcomes as the ones that received 100 milligrams. So I'm questioning whether the 100 milligrams once a day is the right dose. That's my uh criticism. But I think it should be the choice for AUK inhibitor right now. I I don't think there's a justification for you not to choose lurlatinib with the data we have. You should be asking yourself, who should I not give lurlatinib? Not should, who should I give it to?
SPEAKER_01That's who are the patients, what is the patient population in the Crown study?
SPEAKER_00So it's stage four, uh non-small cell line cancer with alk fusions, first line.
SPEAKER_01You know why I asked this question. Because if I have an early stage disease with an alk positive fusion, I'm gonna be hard-pressed not to give low-latinate.
SPEAKER_00I know because we only have data with a lactinive. I hear you. And that goes back to the first point that we were talking about. Should we run a study for every single genomic?
SPEAKER_01I think you're gonna see people using low lattice. I think you're gonna see people if they get it paid for, I suspect they will use it. It's gonna be very difficult. I mean, you could make an argument. Is there a role for a study compared in lowlatinib versus electinib in the adjuvant setting?
SPEAKER_00That's a good point.
SPEAKER_01That would be really is there anything else from ESCO uh 2026 uh that you want to also share?
SPEAKER_00I think uh I want to just touchly uh uh briefly touch on two negative studies because I think we should talk about negative studies. So the ECOG Akron Alchemist trial that was assessing Ajuva Nivolumab after surgery and chemotherapy uh in patients with non-small cell and cancer with resectable disease. Uh, Nivolo Mab did not improve disease-free survival, and they had a follow-up that was over six years, uh, or right around six years. So I think uh it kind of raises the question about patient selection because we do have two other trials in the Ijuvant setting with other agents, uh Tizalism EB and Premieralism EB that were uh positive trials. And I think I have to pose the question, are all PD1 and PDL1 inhibitors the same? Or is it a patient selection issue? And clearly for targeted therapy, we treat them in like different drugs, different generations, but we don't do that with immunotherapy agents. And they're not necessarily made all the same way.
SPEAKER_01That's very true.
SPEAKER_00Uh and lastly, I think uh enough is enough uh with us trying to combine radiation with chemo and immunotherapy. It failed in non-small cell now. Uh I think was a leap-breaking abstract for extensive stage small cell, also negative, much more toxicity. So we should not be running any more trials, in my opinion, combining chemoimmunotherapy and radiation together.
SPEAKER_01Well, but in an extensive stage, do you use radiation?
SPEAKER_00So there was a previous study that showed that if you did consolidative radiation after the induction phase, you did improve disease control locally. So that's what motivated this study that was this phase three evaluating, giving the thoracic radiation integrated with concurrent chemo and immunotherapy. And then obviously it was negative. The study had to stop earlier because of toxicity.
SPEAKER_01So and I appreciate the fact that you bring uh negative trials. I do think we learn a lot from them. And as you just mentioned, um, you know, now we should abandon the idea of radiotherapy with chemoimmunotherapy in uh in uh small cell lung cancer. Look, uh, Bruno, we need to have you back more longer podcast, talk a lot about the evolving field of thoracic oncology. This was more of the express version where we get to know what happened at ASPA 2026. Thank you for an amazing summary. Is there anything else I should have asked you about from the meeting that I completely forgot?
SPEAKER_00No, I don't, I think there's way more abstracts that we could cover in a few minutes, but I think we touched on the plenary session ones and some negative ones and precision medicine. So I think that's a good summary for today.
SPEAKER_01Dr. Bruno Pellini from Baptist Health and Miami Cancer Institute. Thank you so much for coming on Healthcare Unfiltered Express. Thank you for listening to this edition of Healthcare Unfiltered Express. Until next time, take care.