Tarlatamab, a bispecific T-cell engager (BiTE), is a newer type of immunotherapy for patients with relapsed small cell lung cancer (SCLC). It can be a second-line treatment option when the cancer progresses after first-line chemotherapy and other immunotherapies. Cameron Oswalt, MD, Duke Cancer Institute thoracic oncologist, explains that Duke was involved in early tarlatamab clinical trials. 

“Clinical trials have demonstrated that tarlatamab significantly improved overall survival rates compared to chemotherapy alone, with more durable responses and a lower toxicity profile,” says Oswalt. “We have a great deal of experience with this treatment, and it’s a significant new option to help patients with advanced small cell lung cancer,” he adds.

Compared with other cell therapies, tarlatamab doesn’t require cell harvesting or testing for delta-like ligand 3 (DLL3), so it has fewer treatment barriers and can be initiated more quickly compared to other cell therapies. “Most patients considering second-line therapies are candidates, and we can usually start tarlatamab therapy within two weeks,” Oswalt says.

He adds, “We want our community physicians to know this could be an option for their patients, and we offer it with unique expertise at Duke. SCLC can be aggressive, and we don’t want patients to miss their window of opportunity. The earlier patients are referred to us, the more options we can offer, including tarlatamab or other clinical trials.”

Tarlatamab is administered IV and has a unique dosing schedule. Patients must receive the first doses inpatient at the present time. “The first two doses are administered one week apart and are each done inpatient while admitted to the hospital so we can closely monitor for side effects. If the patient does well, they can usually go home within 24 hours,” Oswalt explains. After a third weekly dose given as an outpatient, patients can then return every two weeks for continued infusions. 

According to Oswalt, caregiver support is important for patients on tarlatamab because it requires close observation and symptom monitoring. While effective, tarlatamab takes some time to show clinical benefits. “The results are not immediate, so we want to start this treatment without delay,” says Oswalt.

Because Oswalt and the thoracic oncology team at Duke have provided tarlatamab therapy for over two years, they’ve created streamlined processes to administer it and manage potential side effects, which typically present during earlier cycles. 

According to Oswalt, the two most common side effects of tarlatamab are cytokine release syndrome (CRS), characterized by fevers, low blood pressure, and trouble breathing, and immune effector cell-associated neurotoxicity syndrome (ICANS), which can cause mild symptoms to more severe neurologic changes like seizures, though severe toxicities are less common. “We have strategies to monitor for and manage CRS and ICANS. If either happens, we want to be able to act quickly,” says Oswalt.
Team approach to care

Duke’s team approach to care supports optimal delivery of therapy and the best possible patient outcomes with tarlatamab. Medical oncologists, radiation oncologists, and sometimes brain and spine metastasis experts are involved in case-based discussions, specifically when brain metastases are present, which can unfortunately be common with SCLC. “We see and discuss with each other every day in the clinic and review cases in weekly tumor board meetings,” says Oswalt. 

“We develop a plan for each patient before their admission, closely monitor for side effects, continue that communication with the patient and caregiver after discharge, and are in lock-step with the plan to continue the patient’s care moving forward,” he adds. 

Duke offers more treatment options for SCLC than ever before and continues to explore clinical trials that further improve options for patients. The team has examined different dosing approaches for tarlatamab and is exploring new treatments for SCLC. “While treatment options for SCLC were previously limited, there has been more enthusiasm recently toward developing new therapies for SCLC, and it’s one reason Duke is a special place. We’re always striving for better treatments and ultimately outcomes for our patients,” Oswalt concludes.