Early integration of palliative care has been shown to improve the quality of life and decrease aggressive end-of-life measures for patients with cancer. However, data is limited in patients receiving immunotherapy who experience treatment-related complications. This single-center retrospective cohort study examined the effect of palliative care evaluation among all lung cancer patients who received at least one dose of immune checkpoint inhibitor between 6/1/18 and 2/1/20 (n=210) and who were subsequently hospitalized and started on steroids (n=97). We evaluated the rates of ICU admissions, intubation, CPR, hospice referrals and code status changes. In our high-risk cohort of 97 patients, median follow-up was 23 months with progression in 54 patients (56%) at median 11 months (IQR 6-26) and death in 67 patients (69%) at median 14mo (IQR 9-29). Primary outcomes are described in Table 1. Thirty-one patients (32%) were referred and 25 (26%) were seen by palliative care. Patients who initially presented with cancer as an incidental, asymptomatic finding were less likely to be referred to palliative care (OR 0.07, 95% CI 0.01-0.55). Patients who were first seen by palliative care as an outpatient (n=9) were seen earlier in their disease course at median 146 days (IQR 104-469) compared to those who were first seen while hospitalized (n=15) at median 610 days (IQR 287-944, p 0.03). Involvement of palliative care was associated with a lower rate of ICU admission and increased rate of referral to hospice for end of life care. Code status changes were not associated with palliative care consultation. Intubation and CPR were uncommon events even in this high-risk cohort. Prospective evaluation is needed for validation of these findings.

Small cell lung cancer (SCLC) represents a particularly aggressive neuroendocrine tumor with poor prognosis in the advanced stage and limited treatment options following progression with first line therapy. There is a particular need for novel therapeutic approaches within the refractory extensive stage population. Immunotherapy has seen relatively recent approval for treatment of relapsed or refractory SCLC, but overall response rates remain low. One approach to improve response rates is with the addition of cytotoxic chemotherapy to immune checkpoint inhibitors.

potential benefit in selecting candidates for PD-1/PDL-1 targeted immunotherapy in metastatic NSCLC and in this limited dataset were associated with the development of some autoimmune adverse events.Further studies are ongoing.

Lymphangitic carcinomatosis is a difficult to treat disease entity and usually portends a poor prognosis given the advanced state in which it is often diagnosed. Treatment is usually based on standard therapy of the primary malignancy, but in most cases, is palliative in nature. This case highlights the potential for PD-1 immunotherapy as both a rapid and durable treatment for lymphangitic carcinomatosis.

The optimal treatment paradigm for patients with oligometastatic non-small cell lung cancer (NSCLC) remains controversial. While primary systemic therapy is essential to maintain disease control, the role for subsequent local therapy is less well-defined. This prospective, multi-institutional phase II study was conducted to evaluate the potential survival benefit of radiotherapy to the chest and/or sites of oligometastatic disease after first-line chemotherapy. Twenty-six patients with metastatic NSCLC and ≤5 total lesions underwent a median 4 (range 3-6) cycles of first-line chemotherapy. Patients with partial response or stable disease by RECIST criteria were eligible. This was followed by radiotherapy to the primary tumor (if not previously treated) and/or up to 3 additional extracranial sites. No maintenance chemotherapy was administered. Eleven patients (42%) had brain metastases previously treated with surgery or stereotactic radiosurgery with or without whole brain radiotherapy followed by confirmation of intracranial disease control prior to registration. Radiotherapy techniques included stereotactic body radiotherapy (SBRT) or conventionally fractionated radiotherapy to the primary (median 60 Gy, range 50-70.2 Gy) and/or metastatic sites (median 50 Gy, range 27-60). The trial was closed early due to slow accrual; herein we report the results of patients enrolled prior to study closure. Progression-free survival (PFS) and overall survival (OS) were evaluated using Kaplan-Meier method. Mean age was 65 years (range 42-83). Primary histology was adenocarcinoma in 16 (62%) and squamous cell carcinoma in 6 (23%). The median number of lesions treated was 2 (range 1-4), including the primary site (89%), non-primary lung (27%), bone (15%), adrenal (12%), spine/paraspinal (12%), liver (8%), and other (12%). Median progression-free survival was 11 months (95% CI 7.4-15.9) and 5-year PFS was 29%. Of the 21 (81%) patients that experienced disease progression, the site of progression was identified in 18. Site of initial failure was distant in 9 (35%) patients, intracranial in 6 (23%), both local and distant in 2 (8%) and local alone in 1 (4%). Seven (27%) patients were alive at last follow-up. Median overall survival was 22.2 months (95% CI 13.3-45.8) and 5-year OS was 29%. In this prospective, phase II study, patients receiving consolidative/ablative radiotherapy after first-line chemotherapy for oligometastatic NSCLC demonstrated favorable disease-free and overall survival outcomes. Further prospective study evaluating more aggressive local therapies to carefully selected patients is warranted.