Traveling Through the Lung Cancer Treatment Paradigm: Oral Etoposide

In this fifth episode of OncChats: Traveling Through the Lung Cancer Treatment Paradigm, Aaron Franke, MD, of the University of Florida Health, discusses instances where oral etoposide could be utilized for patients with small cell lung cancer (SCLC).

"One alternative in the setting of SCLC is the idea of oral etoposide. This came about as [somewhat] of a pragmatic tool during the [COVID-19] pandemic—especially when I was in Tampa, FL, at the [VA Tampa Health Care]. We had a plethora of new [patients with] SCLC coming in, and we were really trying to limit both travel and clinic exposure to patients as much as we could. This was when we had the alternative dosing [guidance] for immune checkpoint inhibitors come out. This [was also] when we were trying to [use] alternative [approaches for] patients [with multiple myeloma], and really trying to mitigate how much patients had to come into clinic, which at the time was obviously our fear of their biggest risk of exposure to [COVID-19]. [In trying to find ways] to get crafty and limit bad patient outcomes, this was an area where we leveraged probably a less commonly utilized part of the SCLC treatment armamentarium, and that was the use of oral etoposide.

What data do we have to support this? There was a [phase 3] study done in [Japan in patients with] extensive-stage [SCLC] where they looked at irinotecan [plus carboplatin] vs etoposide and carboplatin, and irinotecan seemed to [result in] a little bit better of an outcome. Now, granted, they were using oral etoposide in this, but they also were using carboplatin at an area under the curve of 4. I think those 2 combined is where you saw a little bit more of a slight prolongation in overall survival and benefit of irinotecan, [at] 8.5 months vs 7.1 months. However, I don't think that's the bigger story to take away from it.

You know, there are data supporting oral etoposide. [Published] around 2004, this was a study that mostly looked at patients getting cisplatin with chemoradiation, and [they] got oral etoposide. I still think about this [for use] in patients who travel very far, where the logistics of traveling for 3 days in a row for chemotherapy is still an issue. I will sometimes offer patients the day 2 and 3 as oral etoposide. Now, remember, the dose is twice as much, so if you’re giving 80 mg/m2 intravenously [IV], you’re going to give 160 mg orally. Also, if this patient weighs over 70 kg to 80 kg, it’s usually going to be a split dosing based on the total mg per day. So, there are some dosing nuances to think about there, and again, giving patients prophylactic antiemetics so they do not throw up their pills [is another thing to remember].

One thing I counsel patients on, who opt for this therapy or [for whom] I find this [approach] to be pragmatically an easier fit than traveling 3 days in a row to the clinic, is the psychological burden that sometimes is put on [them] when they are in charge of their [treatment]. When I give all 3 days IV, I know that they’re getting the drug [and] they’re getting the full dose; there’s no, ‘if,’‘ands,’ or ‘buts’ about it. Giving them the luxury of [being able to take] it at home for their convenience also gives them the responsibility that they need to take their drug, they cannot throw it up, and they need to take it at a reasonable time, the way it's supposed to be taken—with or without food, with or without other drugs. Sometimes that extra anxiety really puts a lot [of pressure] on them. If they missed their dose, they lose their pill, they can’t get it from the pharmacy, they throw it up, or anything else happens, they really have a lot of extra anxiety [because] they may be compromising their own outcomes.

I try not to put any unnecessary angst on a patient who’s already going through a very anxiety-prone scenario. I [explain all] this to the patient up front, that this responsibility and this extra pressure is there. [I remind them] that we can obviously mitigate [this anxiety] by giving [the treatment] through the IV if traveling is not a concern; I think [this] is something to consider [when] traveling the 3 days really is a treatment-limiting factor in their ongoing treatment [journey]. If they can’t get treatment locally…, consider day 2 and 3 oral therapies with these nuances in mind."

Check back next Wednesday for the final episode in this series.