Real-World Treatment Sequencing, Toxicities, Health Utilities, and Survival Outcomes in Patients with Advanced ALK-Rearranged Non-Small-Cell Lung Cancer

Delayed Bronchopleural Fistula Formation Following Salvage Surgery of Stage IV Anaplastic Lymphoma Kinase-Positive Non-Small-Cell Lung Cancer

This case report highlights the management of a delayed bronchopleural fistula (BPF) following salvage pulmonary resection to achieve local control and no radiographic evidence of disease in a patient treated with serial tyrosine kinase inhibitors (TKIs) for stage IV anaplastic lymphoma kinase (ALK)-positive non-small-cell lung cancer (NSCLC). The initial pulmonary resection was complicated by dense adhesions and an abnormally torturous pulmonary artery. Six weeks after the index surgery, the patient presented with a delayed BPF requiring decortication, repair of airway, and coverage of the bronchial stump with a serratus anterior muscle flap.

Real-World Creatinine-Based Estimates of Acute and Chronic Kidney Dysfunction in Patients with Advanced ALK-Rearranged Non-Small-Cell Lung Cancer Receiving Tyrosine Kinase Inhibitors

BACKGROUND

Anaplastic lymphoma kinase inhibitors (ALKi) are a mainstay of therapy for patients with advanced non-small cell lung cancers (NSCLC). ALKi are associated with increased serum creatinine, which may represent reduced renal tubular creatinine secretion and/or true acute kidney injury (AKI).

METHODS

We performed a retrospective study of patients who received ALKi for NSCLC (2013-2022). The primary outcomes were incidence of AKI within 90 days of ALKi start and chronic kidney disease (CKD) within 1-year. AKI and CKD were defined via KDIGO criteria, using the CKD-EPI equation with creatinine (and cystatin C in a subcohort). We performed logistic regression for AKI risk factors and Kaplan-Meier analysis for overall survival (OS). Spline curves were generated for eGFR means over time.

RESULTS

Among 114 NSCLC patients, median age 61 years; 53% were female; 191 ALKi treatments were initiated: Alectinib (n = 91), Crizotinib (n = 33), Ceritinib (n = 27), Brigatinib (n = 21) and Lorlatinib (n = 19). There were 20 (10%) AKI events within 90 days after ALKi initiation, with 4 treatment changes attributed to AKI. Twenty-eight (14%) patients developed CKD, with 10 treatment changes; none requiring dialysis. In multivariate analysis, hypertension and male sex were associated with AKI. OS did not differ by AKI status.

CONCLUSION

AKI/CKD events were frequent post-ALKi initiation (using creatinine-based eGFR), with a minority resulting in treatment change. Mean eGFR declined in the 90-days post-ALKi start. Most patients had mild CKD, with eGFR recovering postdrug cessation. AKI did not impact OS. Our findings suggest that most patients may continue ALKi therapy despite creatinine-based eGFR changes.

Brief Report: Real-World Treatment Patterns and Clinical Outcomes for Patients With Advanced ALK-Rearranged NSCLC in British Columbia

Introduction

EML4-ALK rearrangements represent an oncogenic driver alteration in 5% of NSCLC cases. We aim to better understand real-world treatment patterns and outcomes of ALK fusion-positive (ALK+) patients with advanced-stage NSCLC.

Methods

We performed a retrospective population-based chart review of ALK+ patients with locally advanced or metastatic NSCLC in British Columbia (BC), Canada. Patients diagnosed from January 2014 to May 2023 were identified through the BC Cancer Genetics Laboratory database, and data were collected up to December 2023.

Results

A total of 216 patients with stage IIIB, IIIC, or IV ALK+ lung NSCLC were identified. Median age was 60 (range: 24-91) years, 151 (68.9%) had never smoked, and 95 (43.9%) were Asian. The median overall survival was 49.4 months with median follow-up time of 55.4 months. Majority of the cohort (n = 198, 91.7%) received palliative systemic therapy, all of which included at least one ALK tyrosine kinase inhibitor (TKI). The most common first-line regimen was alectinib (n = 97, 49.0%) followed by crizotinib (n = 84, 42.4%); only four and one patient received lorlatinib and brigatinib first line, respectively. Alectinib was frequently prescribed overall, with 80.3% of patients receiving it in any treatment line. Time to treatment discontinuation was significantly longer (p < 0.0001) on first-line alectinib at 22.9 months as compared with 10.9 months for crizotinib.

Conclusions

Patients with ALK+ advanced NSCLC in BC have durable responses to ALK TKIs. Despite approval of all ALK TKIs for first-line use since 2021, alectinib is largely the favored agent in BC. Further real-world investigations can refine treatment strategies and shape policies around ALK TKIs for patients with ALK+ NSCLC.

Survivability prognosis of lung cancer patients with comorbidities-a Gaussian Bayesian network model

Comorbidities are influencing factors that cause lung cancer. An accurate survivability prediction model is required considering these confounding factors (a variety of comorbidities and treatments). The study developed a conditional Gaussian Bayesian network (CGBN) model to predict the related survival time with likelihood under various conditions. The lung cancer patients were collected from the National Health Insurance Research Database in Taiwan. Six major chronic diseases (i.e., pulmonary tuberculosis, COPD, kidney failure, diabetes mellitus, stroke, and liver disease) are investigated. A total of 2875 lung cancer cases with key comorbidities were selected. This study examined three types of lung cancer treatment: surgery, chemotherapy, and targeted therapy. The study outcomes provided the likelihood of survival time occurrences. Survival analysis indicates that diabetes mellitus and liver disease are significantly riskier than the other comorbidities for lung cancer patients. The proposed CGBN model achieved high accuracy as compared to the existing literature. The proposed CGBN model is advantageous for modeling the relationship between numerical and categorical influencing factors and response variables for lung cancer with comorbidities. The proposed model facilitates the flexible and accurate estimation of various lung cancer-related queries.

Cardiovascular toxicity of anaplastic lymphoma kinase inhibitors for patients with non-small cell lung cancer: a network meta-analysis

Aim: We conducted network meta-analysis to assess cardiovascular toxicity of anaplastic lymphoma kinase-tyrosine kinase inhibitors (ALK-TKIs).Materials & methods: Eleven articles involving 2855 patients and six interventions including crizotinib, alectinib, ceritinib, lorlatinib, brigatinib and chemotherapy were analyzed.Results: No significant difference was observed in overall cardiovascular risk among ALK-TKIs. Subgroup analysis showed that for cardiac toxicity, crizotinib and alectinib were more likely to cause myocardial rhythm abnormalities. Crizotinib and ceritinib had a higher risk of Q-T prolongation than chemotherapy. For vascular toxicity, crizotinib and ceritinib had a higher risk of thrombotic events than brigatinib. Crizotinib and lorlatinib were more likely to cause blood pressure abnormalities.Conclusion: Clinicians should carefully monitoring cardiovascular events when ALK-TKIs used in NSCLCs patients with baseline cardiovascular diseases.

Brain metastases and mortality in patients with ALK + metastatic non-small cell lung cancer treated with second-generation ALK tyrosine kinase inhibitors as first-line targeted therapies: An observational cohort study

BACKGROUND

Brain metastases (BM) are common in patients with ALK + metastatic non-small cell lung cancer (mNSCLC). Limited contemporary real-world evidence exists on the burden of BM in these patients. This study estimated the cumulative incidence of BM in patients with ALK + mNSCLC treated with second-generation ALK tyrosine kinase inhibitors (TKI) as first-line (1L) targeted therapies and assessed the association between BM and mortality.

MATERIALS AND METHODS

Using a 100 % sample of Medicare fee-for-service and Advantage beneficiaries from 2017 to 2022, patients > 65 years with ALK + mNSCLC (index date = 1L alectinib/brigatinib following lung cancer diagnosis) were identified. The cumulative incidence of BM was calculated, accounting for competing risk of death, overall and by age and race/ethnicity. To assess the association between BM and death, a time-varying Cox proportional hazards model compared the risk of death in those with incident, and baseline BM, separately, to those without BM, adjusting for confounders.

RESULTS

In 1040 patients, 289 (28 %) had baseline BM. In 751 patients without baseline BM, the cumulative incidence of BM was 20 % after 5 years. After 4 years, the cumulative incidence of BM was highest in patients ≥ 85 years (25 %) and in non-White patients (23 %). Patients with incident BM had 2.6 times the risk of mortality compared to patients without BM (hazard ratio (HR): 2.59, 95 % confidence interval (CI): 1.98-3.38), while patients with baseline BM had 1.5 times the risk of mortality compared to patients without BM (HR: 1.46, 95 % CI: 1.20-1.77).

CONCLUSIONS

Patients with ALK + mNSCLC treated with second-generation ALK TKIs as 1L targeted therapies faced a high burden of BM. Incident BM were associated with increased mortality risk to a greater extent than baseline BM. Efforts are needed to provide safe and efficacious approaches to prevention and treatment of BM, including additional monitoring as required, in patients with ALK + mNSCLC.

Adaptive Universal Principles for Real-world Observational Studies (AUPROS): an approach to designing real-world observational studies for clinical, epidemiologic, and precision oncology research

The field of precision oncology has witnessed several advances that stimulated the development of new clinical trial designs and the emergence of real-world data (RWD) as an important resource for evidence generation in healthcare decision-making. Here, we highlight our experience with an innovative approach to a set of Adaptive, Universal Principles for Real-world Observational Studies (AUPROS). To demonstrate the utility of these principles, we used a mixed-methods approach to assess three studies that follow AUPROS at Princess Margaret Cancer Centre: (1) Molecular Epidemiology of ThorAcic Lesions (METAL), (2) Translational Head And NecK Study (THANKS), and (3) CAnadian CAncers With Rare Molecular Alterations (CARMA; NCT04151342). We performed resource assessments, stakeholder-directed surveys and discussions, analysis of funding, research output, collaborations, and a Strengths-Weaknesses-Opportunities-Threats (SWOT) analysis. Based on these analyses, AUPROS is an approach that is applicable to a wide range of observational study designs. The universality of AUPROS allows for multi-purpose analyses of various RWD, and the adaptive nature creates opportunities for multi-source funding and collaborations. Following AUPROS can offer cost and logistical benefits and may lead to increased research productivity. Several challenges were identified pertinent to ethics approvals, sustainability, complex coordination, and data quality that require local adaptation of these principles.

Taiwan Nationwide Study of First-Line ALK-TKI Therapy in ALK-Positive Lung Adenocarcinoma

BACKGROUND

The clinical outcomes of patients with anaplastic lymphoma kinase-positive (ALK+) advanced lung adenocarcinoma vary according to real-world data.

OBJECTIVE

In this study, we aimed to investigate the treatment discontinuation (TTD) and overall survival (OS) of patients with ALK+ advanced lung adenocarcinoma treated with first-line ALK-TKIs in Taiwan.

PATIENTS AND METHODS

This retrospective study evaluated all advanced lung adenocarcinoma patients registered in the National Taiwan Cancer Registry from 2017 to 2020 who had ALK rearrangement and received ALK-TKI treatment, using data from Taiwan's National Health Insurance Research Database (NHIRD). The TKI treatment sequences were classified into first generation (G1: crizotinib), second generation (G2: ceritinib, alectinib, brigatinib), and third generation (G3: lorlatinib).

RESULTS

A total of 587 patients were analyzed, with a median age of 60.0 years, 91 (15.5%) aged ≥ 74 years, 293 (49.9%) female, 397 (67.6%) never smoked, and 534 (91.0%) with stage IV disease. Patients who received next-generation ALK-TKIs during the treatment course had longer median time to ALK-TKI TTD and OS. The TTD of the G1, G1+2, G1+2+3, G2, and G2+3 groups was 7.5 (5.4-11.1), 40.6 (29.4-not calculated (NC)), 50.3 (41.3-NC), 34.3 (29.2-43.0), and 36.3 (22.4-NC) months, respectively (p < 0.001). The median OS of the patients in the G1, G1+2, G1+2+3, G2, and G2+3 groups was 10.6 (7.5-14.6), not reached (NR) (NC-NC), NR (NC-NC), 43.0 (36.3-NC), and NR (30.3-NC) months, respectively (p < 0.001). Compared with treatment with crizotinib alone, the multivariate analysis revealed that treatment with next-generation TKIs was independently associated with longer TTD (G1+2 (hazard ratio (HR), 0.24; 95% CI 0.17-0.33; p < 0.001), G1+2+3 or G1+3 (HR, 0.17; 95% confidence interval (CI), 0.10-0.28; p < 0.001), G2 (HR, 0.26; 95% CI 0.19-0.36; p < 0.001), and G2+3 (HR, 0.25; 95% CI 0.14-0.44; p < 0.001)) and median OS (G12 (HR, 0.24; 95% CI 0.17-0.35; p < 0.001), G1+2+3 or G1+3 (HR, 0.09; 95% CI 0.04-0.21; p < 0.001), G2 (HR, 0.22; 95% CI 0.15-0.31; p < 0.001), and G2+3 (HR, 0.20; 95% CI 0.10-0.42; p < 0.001)).

CONCLUSIONS

For patients with ALK+ NSCLC, treatments including next-generation ALK-TKIs were independently associated with longer survival outcomes.

Real-world treatment sequencing and effectiveness of second- and third-generation ALK tyrosine kinase inhibitors for ALK-positive advanced non-small cell lung cancer

INTRODUCTION

With multiple targeted therapies approved for anaplastic lymphoma kinase (ALK)-positive metastatic non-small cell lung cancer (NSCLC), it is increasingly important to understand outcomes with various sequences of next-generation ALK tyrosine kinase inhibitors (TKIs). We describe contemporary sequencing patterns and treatment effectiveness of first-line (1L) and second-line (2L) treatments in patients who received second-generation ALK TKIs in the 1L treatment of ALK-positive NSCLC in the United States.

METHODS

A cohort of adults with ALK-positive advanced NSCLC who initiated treatment with 1L alectinib or brigatinib between June 2017 and April 2021 in the Flatiron Health electronic health record-derived de-identified database were followed through April 2023. Time to treatment discontinuation (TTD) in 1L and 2L, TTD on 1L plus 2L sequential therapy (TTD2), and total time on sequential ALK TKI therapy (including beyond 2L) were evaluated.

RESULTS

Patients (N=273) were followed up for a median duration of 28.9 months. Among patients who discontinued 1L therapy, 22% died after 1L discontinuation (median time from discontinuation to death, 4.0 months) without receiving 2L therapy. Median (95% confidence interval [CI]) TTD was 21.9 (15.2-25.8) and 7.3 (5.3-10.2) months in 1L and 2L, respectively. Median (95% CI) TTD2 was 29.4 (25.1-36.1) months and total time on sequential ALK TKI treatment was 28.0 (23.6-32.9) months.

CONCLUSIONS

In this large real-world study, TTD2 and the total time on sequential ALK TKIs was approximately 2.5 years. The high attrition rate from 1L to 2L and the longest clinical benefit observed with 1L therapy support using the drug with the longest 1L effectiveness up front in patients with ALK-positive advanced NSCLC.

Lung cancer patients with anaplastic lymphoma kinase rearrangement lose affiliation with labor market at diagnosis

Aim: The main purpose of the present study was to investigate the labor market affiliation of ALK+ NSCLC patients in long-term treatment as well as overall survival and incidence/prevalence. Materials & methods: Nationwide retrospective study of all patients with ALK+ NSCLC in Denmark diagnosed between 2012 and 2018. Results: During the study period ALK+ NSCLC patients had a median overall survival of 44.0 months and a 7.8-fold increase in disease prevalence. Six months prior to diagnosis, 81% of ALK+ NSCLC patients ≤60 years of age were employed. At the end of the 18-month follow-up period, 36% were employed. Conclusion: ALK+ NSCLC patients have prolonged survival following diagnosis, but a large fraction of patients lose affiliation with the labor market.

Prospective observational study to explore genes and proteins predicting efficacy and safety of brigatinib for ALK-gene rearranged non-small-cell lung cancer: study protocol for ABRAID study (WJOG11919L)

Background

ALK-tyrosine kinase inhibitors (ALK-TKIs) are effective for treating non-small-cell lung cancer with ALK gene rearrangement; however, resistance is inevitable. Brigatinib is a unique ALK-TKI that is effective against many resistance mutations. However, data on factors associated with its efficacy and resistance mechanisms are limited.

Objectives

This study will evaluate the efficacy and safety of brigatinib in the real world and explore factors related to its efficacy, safety, and resistance mechanisms.

Design

Prospective observational study.

Ethics

This study is approved by the Ethics Committee of Wakayama Medical University. Written informed consent will be obtained from all patients before study-related procedures.

Methods and analysis

This study comprises three cohorts. Cohorts A, B, and 0 will enroll patients receiving alectinib as the first ALK-TKI, receiving alectinib as the first ALK-TKI and subsequently cytotoxic agents and/or lorlatinib after alectinib, and without a history of ALK-TKI, respectively. Overall, 100, 30, and 50 patients will be enrolled in Cohorts A, B, and 0, respectively. Circulating tumor DNA before starting brigatinib and at disease progression will be analyzed in all cohorts using a hypersensitive next-generation sequencing (NGS) PGDx Elio plasma resolve panel. Serum protein levels will be analyzed using the Milliplex xMAP assay system with a Luminex 200 (Luminex, Austin, USA). The enrollment period is 31 months and the patients will be observed for 2 years after enrollment. Archived tissues will be collected for NGS analysis, gene expression analysis, and immunohistochemistry staining 1 year after completion of registration. Quality of life and safety evaluation using electronic patient-reported outcomes will be investigated.

Discussion

This study will elucidate predictors of ALK-TKI efficacy and resistance mechanisms and evaluate the efficacy and safety of brigatinib in a real-world setting. The results will provide crucial information for establishing treatment strategies, discovering novel biomarkers, and developing new therapeutic agents.

Trial registration

UMIN000042439.

Cost in the United States of FDA-approved small molecule protein kinase inhibitors used in the treatment of neoplastic and non-neoplastic diseases

Because genetic alterations including mutations, overexpression, translocations, and dysregulation of protein kinases are involved in the pathogenesis of many illnesses, this enzyme family is the target of many drug discovery programs worldwide. The FDA has approved 80 small molecule protein kinase inhibitors with 77 drugs orally bioavailable. The data indicate that 69 of these medicinals are approved for the management of neoplasms including solid tumors such as breast and lung cancer as well as non-solid tumors such as leukemia. Moreover, the remaining 11 drugs target non-neoplastic diseases including psoriasis, rheumatoid arthritis, and ulcerative colitis. The cost of drugs was obtained from www.pharmacychecker.com using the FDA label to determine the dosage and number of tablets required per day. This methodology excludes any private or governmental insurance coverage, which would cover the entire cost or more likely a fraction of the stated price. The average monthly cost for the treatment of neoplastic diseases was $17,900 with a price of $44,000 for futibatinib (used to treat cholangiocarcinomas with FGFR2 fusions) and minimum of $5100 for binimetinib (melanoma). The average monthly cost for the treatment of non-neoplastic diseases was $6800 with a maximum of $17,000 for belumosudil (graft vs. host disease) and a minimum of $200 for netarsudil eye drops (glaucoma). There is a negative correlation of the cost of the drugs and the incidence of the targeted disease. Many of these agents are or were designated as orphan drugs meaning that there are fewer than 200,000 potential patients in the United States.

Comparing efficacy and safety of upfront treatment strategies for anaplastic lymphoma kinase-positive non-small cell lung cancer: a network meta-analysis

Aim

This article is based on our previous research, which was presented as a post at the Congress Aiom 2022 Congress and published in Tumori Journal as Conference Abstract (Tumori J. 2022;108:1-194. doi: 10.1177/03008916221114500). In this paper, a comprehensive presentation of all the achieved results is provided. Several tyrosine kinase inhibitors (TKIs) have been investigated to treat patients with anaplastic lymphoma kinase (ALK)-positive non-small cell lung cancer (NSCLC). However, direct comparisons between these TKIs are lacking, with many only being compared to crizotinib. To address this gap, a network meta-analysis was conducted to compare the efficacy and safety of various first-line systemic therapies for ALK-positive NSCLC.

Methods

A thorough search of PubMed, Embase, and Cochrane Library was performed to identify randomized controlled trials (RCTs) published between January 01, 2000 and April 01, 2022, and included trials that investigated upfront treatments for this molecular subgroup and reported overall survival (OS), progression-free survival (PFS), objective response rate (ORR), and adverse events (AEs) of grade 3 or higher (grade ≥ 3 AEs).

Results

The analysis included 9 RCTs with 2,443 patients receiving eight different treatments: alectinib (at two different dosages), brigatinib, ceritinib, crizotinib, ensartinib, lorlatinib, and chemotherapy. Second and third-generation TKIs significantly prolonged PFS compared to crizotinib, with lorlatinib having the highest probability of yielding the most favorable PFS, followed by alectinib (300 mg or 600 mg). However, only alectinib has been shown to significantly prolong OS compared to crizotinib to date. Lorlatinib appears superior in reducing the risk of central nervous system (CNS) progression, followed by alectinib 600 mg. Ceritinib had the highest rate of AEs, followed by lorlatinib and brigatinib.

Conclusions

Based on the network meta-analysis, alectinib and lorlatinib emerged as the most promising upfront treatment options. These treatments provide prolonged disease control while maintaining an acceptable safety profile.

Clinical outcomes of ALK+ non-small cell lung cancer in Denmark

BACKGROUND

Real-world clinical outcomes of anaplastic lymphoma kinase positive (ALK+) non-small cell lung cancer (NSCLC) patients vary. This study aimed to investigate the treatment and clinical outcomes of all ALK+ NSCLC patients in Denmark in the period 2011-2018, regardless of disease stage.

MATERIALS AND METHODS

A national pathology database with complete coverage was used to identify ALK+ NSCLC patients diagnosed between 2011 and 2018. Clinical data were obtained through retrospective chart reviews. Overall survival (OS) and duration of treatment (DOT) were analyzed using Kaplan-Meier methodologies.

RESULTS

A total of 209 ALK+ NSCLC patients were included. The cohort had a slight overrepresentation of female patients (56.5%) with a mean age of 61.6 years. Most patients were adenocarcinoma cases (97%) and presented with an ECOG performance status of 0-1 (79%). Stage IIIb-IVb patients comprised 70% of the cohort. The use of ALK-tyrosine kinase inhibitors (TKIs) as first-line treatment increased over time, with the 1st generation ALK-TKI crizotinib being the predominant treatment in the 1st line. In 1st line treatment, 2nd generation ALK-TKIs had a median DOT more than twice the median DOT of crizotinib (25.1 and 9.1 months, respectively). The median OS for the entire cohort was 44.0 months. Patients with stage I-IIIA disease had a median OS that had not been reached, while those with stage IIIb-IVb disease had a median OS of 31.8 months. Patients with stage IIIb-IVb disease receiving an ALK-TKI as 1st line treatment had a median OS of 42.5 months with immature follow-up. Brain metastases at diagnosis or choice of 1st line treatment did not statistically significantly impact OS.

CONCLUSION

This study gives insights into the treatment and outcome of ALK+ NSCLC patients in Denmark and provides a real-world confirmation of the superior disease control provided by 2nd generation ALK-TKIs as compared to the 1st generation ALK-TKI crizotinib.

Tailoring Therapeutic Strategies in Non-Small-Cell Lung Cancer: The Role of Genetic Mutations and Programmed Death Ligand-1 Expression in Survival Outcomes

BACKGROUND

This study aims to assess the real-world impact of advancements in first-line systemic therapies for non-small-cell lung cancer (NSCLC), focusing on the role of driver gene mutations and programmed death-ligand 1 (PD-L1) expression levels.

METHODS

Conducted across eight medical facilities in Japan, this multicenter, retrospective observational research included 863 patients diagnosed with NSCLC and treated between January 2015 and December 2022. The patients were categorized based on the type of systemic therapy received: cytotoxic agents, molecular targeting agents, immune checkpoint inhibitors, and combination therapies. Comprehensive molecular and immunohistochemical analyses were conducted, and statistical evaluations were performed.

RESULTS

The median overall survival (OS) shows significant variations among treatment groups, with targeted therapies demonstrating the longest OS. This study also revealed that high PD-L1 expression was common in the group treated with immune checkpoint inhibitors. Multivariate analysis was used to identify the type of anticancer drug and the expression of PD-L1 at diagnosis as the impactful variables affecting 5-year OS.

CONCLUSIONS

This study underscores the efficacy of targeted therapies and the critical role of comprehensive molecular diagnostics and PD-L1 expression in affecting OS in NSCLC patients, advocating for their integration into routine clinical practice.

Personalized medicine: paradigm shift in ALK positive non-small cell lung cancer: a case report

BACKGROUND

Since the identification of multiple therapeutic targets, as is the case of anaplastic lymphoma kinase (ALK) translocation, the paradigm of treating patients with non-small cell lung cancer (NSCLC) has improved. In order to guarantee the possibility of longer survival outcomes with a better quality of life we must invest in the determination, in suitable time, of the consensual biomarkers and in the availability of the best treatments to our patients.

CASE PRESENTATION

We present a case of a caucasian male in his fifth decade of life, non-smoker, who highlights the complex journey of ALK-positive patients. This particular case, demonstrates the efficacy and tolerability of the new ALK target therapies, allowing our patients to maintain their routines without compromising the effectiveness of the therapy.

CONCLUSION

Focusing on the reality of ALK positive patients and the impact that this therapy has on the daily lives of our patients, we can contribute to the awareness of this specific pathology.

Real-World Data on EGFR and ALK Testing and TKI Usage in Norway-A Nation-Wide Population Study

Clinical studies have shown the efficacy of EGFR- and ALK-directed therapies in non-small cell lung cancer (NSCLC). Real-world data on, e.g., testing patterns, uptake, and duration of treatment are scarce. Reflex EGFR and ALK testing of non-squamous NSCLCs were implemented in Norwegian guidelines in 2010 and 2013, respectively. We present a complete national registry data on incidence, pathology procedures, and drug prescription in the period of 2013 to 2020. Test rates for both EGFR and ALK increased over time and were 85% and 89%, respectively, at the end of the study period, independent of age up to 85 years. The positivity rate for EGFR was higher among females and young patients, whereas no sex difference was observed for ALK. EGFR-treated patients were older than ALK-treated patients (71 vs. 63 years at start, p < 0.001). Male ALK-treated patients were significantly younger than females at the start of treatment (58 vs. 65 years, p = 0.019). The time from the first dispensation to the last dispensation of TKI (as a surrogate for progression-free survival) was shorter for EGFR- than for ALK-TKI, and survival for both EGFR- and ALK-positive patients was substantially longer than for non-mutated patients. We found a high adherence to molecular testing guidelines, good concordance of mutation positivity and treatment, and the real-world replication of findings in clinical trials, indicating that the relevant patients are provided substantially life-prolonging therapy.