Analysis of Serious Weight Gain in Patients Using Alectinib for ALK-Positive Lung Cancer

Sex and Common Germline Variants Affect the Toxicity Profile and Pharmacokinetics of Alectinib: A Nationwide Cohort Study in Patients With ALK-Positive NSCLC

INTRODUCTION

Alectinib, a small-molecule kinase inhibitor, is used as first-line treatment for ALK-positive (ALK+) NSCLC. Albeit generally well-tolerated, a considerable subset of patients requires dose adjustments due to drug-related toxicity. Single-nucleotide polymorphisms in genes related to the metabolism of alectinib may upfront identify patients at risk for toxicity.

METHODS

In this multicenter observational cohort study in patients with advanced ALK+ NSCLC receiving alectinib treatment, we investigated the association between toxicity, pharmacokinetics, and key genetic variants in ABCB1, CYP3A4, PPAR-α, POR, and CYP3A5. Data on demographics, adverse events, and alectinib trough levels were collected from five hospitals.

RESULTS

Among 215 patients, 47% experienced severe toxicity. Women experienced more severe toxicity (female versus male: 56% versus 34%; p = 0.001) and had +35% higher alectinib trough levels (p < 0.001). Homozygous carriers of the PPAR-α 209G>A variant exhibited a higher incidence of grade greater than or equal to 3 toxicity (38%) compared with patients who carried at least one wild-type allele (11%) (p = 0.004). This remained significant after Bonferroni correction. Patients who experienced severe toxicity had +18.5% (95% confidence interval: 2.9%-36.6%; p = 0.019) higher trough levels.

CONCLUSIONS

Female patients encounter more severe toxicity due to higher alectinib exposure, which warrants further exploration. PPAR-α 209G>A significantly increased relevant alectinib-induced toxicity, most likely due to an increase in alectinib exposure. Pretreatment testing for genetic variants with a subsequent dose reduction could provide a viable approach to reduce alectinib-related toxicity.

Body Weight Gain Associated With Alectinib in Patients With ALK+ Non-Small Cell Lung Cancer: Pooled Analysis of Individual Patient Data From Four Prospective Clinical Trials

PURPOSE

Weight gain is a known adverse event (AE) of alectinib. This study evaluates the progression of actual weight gain over time and explores its association with baseline characteristics.

METHODS

A pooled analysis of individual patient data from four clinical trials (ALEX, J-ALEX, ALUR, and ML29453) was conducted. Actual weight gain was calculated as the percent change from baseline. A linear mixed model estimated weight change over time and associations between clinical characteristics and weight change.

RESULTS

Follow-up weights were available for three trials (J-ALEX, ALUR, and ML29453) and missing for ALEX. In total, 2,622 weights were recorded in the first year (N = 302). At baseline, 13.6% of the Japanese population were underweight and 5.0% in the Western population. Actual weight gain of any grade was substantially higher than reported AE rates (49% v 5%), with 18% experiencing ≥10% weight gain (from median 55.6 kg to 64.1 kg). Time on alectinib was positively associated with weight change (β = .37; 95% CI, 0.24 to 0.51; P < .001), corresponding to an average increase of 4.4% over 1 year. Baseline BMI was not associated with weight change in J-ALEX (β = -.090 [95% CI, -0.19 to 0.012]; P = .092) and ALUR/ML29453 (β = -.016 [95% CI, -0.077 to 0.044]; P = .59). Baseline albumin was positively associated with weight change in ALUR/ML29453 (β = .084 [95% CI, 0.027 to 0.14]; P = .0045), although not considered a clinically meaningful predictor.

CONCLUSION

Weight gain is under-reported as AE in trials. Actual weights showed ≥10% weight gain in 18% of patients. Clinicians should be aware of this AE, emphasizing the importance of timely identification and monitoring weight. Identifying predictors for weight gain remains challenging.

Multiparameter body composition analysis on chest CT predicts clinical outcomes in resectable non-small cell lung cancer

OBJECTIVES

This study investigates the association between baseline CT body composition parameters and clinical outcomes in patients with resectable non-small cell lung cancer (NSCLC).

METHODS

Patients who underwent surgical resection for NSCLC between January 2006 and December 2017 were retrospectively enrolled in this multicenter study. Body composition metrics, including the area of skeletal muscle, intermuscular adipose tissue, subcutaneous adipose tissue, visceral adipose tissue, muscle radiodensity, and derivative parameters from five basic metrics mentioned before, were calculated based on preoperative non-contrast-enhanced chest CT images at L1 level. The Cox proportional hazards regression analysis was used to evaluate the association between body composition metrics and survival outcomes including overall survival (OS) and disease-free survival (DFS).

RESULTS

A total of 2712 patients (mean age, 61.53 years; 1146 females) were evaluated. A total of 635 patients (23.41%) died. 465 patients (19.51%) experienced recurrence and/or distant metastasis. After multivariable adjustment, skeletal muscle index (SMI, HR = 0.86), intermuscular adipose index (IMAI, HR = 1.49), and subcutaneous adipose index (SAI, HR = 0.96) were associated with OS. Similar results were found after stratification by gender, TNM stage, and center. There was no significant association between all body composition metrics and DFS (all p > 0.05). The body composition metrics significantly enhance the model including clinicopathological factors, resulting in an improved AUC for predicting 1-year and 3-year OS, with AUC values of 0.707 and 0.733, respectively.

CONCLUSIONS

SMI, IMAI, and SAI body composition metrics have been identified as independent prognostic factors and may indicate mortality risk for resectable NSCLC patients.

CRITICAL RELEVANCE STATEMENT

Our findings emphasize the significance of muscle mass, quality, and fat energy storage in clinical decision-making for patients with non-small cell lung cancer (NSCLC). Nutritional and exercise interventions targeting muscle quality and energy storage could be considered for patients with NSCLC.

KEY POINTS

Multiparameter body composition analysis is associated with the clinical outcome in NSCLC patients. Assessing muscle mass, quality, and adipose tissue helps predict overall survival in NSCLC. The quantity and distribution of body composition can contribute to unraveling the adiposity paradox.

Selpercatinib mitigates cancer cachexia independent of anti-tumor activity in the HT1080 tumor model

Anorexia is a major cause of cancer cachexia and is induced by growth differentiation factor-15 (GDF15), which activates the rearranged during transfection (RET) protein tyrosine kinase in the hindbrain through GDF family receptor α-like (GFRAL), raising the possibility of targeting RET for cancer cachexia treatment. RET-altered cancer patients treated with RET-selective kinase inhibitors gain weight, however, it is unclear whether this results from tumor regression that improves the overall health of patients. Thus, the potential of using a RET inhibitor to address cancer cachexia remains unknown. Using a RET-negative tumor model, we evaluated the activity of the RET-selective inhibitor selpercatinib (LOXO-292) against cancer cachexia. In tumor-bearing animals, selpercatinib significantly increased food consumption, skeletal muscle mass and strength, adipose tissues, and body temperature, as well as reducing body weight loss, without significantly affecting tumor growth. Transcriptomes of skeletal muscle from mock-treated tumor-bearing mice were enriched in starvation and muscle atrophy genes, whereas those from selpercatinib-treated mice were enriched in myoblast proliferation, gluconeogenesis, and insulin receptor signaling genes. In parallel, retrospective analysis of weight gain in selpercatinib-treated patients showed that weight gain was not correlated with tumor response to selpercatinib. Our data demonstrate that selpercatinib could alleviate anorexia and cancer cachexia in an animal model and that weight gain in selpercatinib-treated patients is not dependent on tumor regression. These results identify a RET inhibitor as the first protein tyrosine kinase inhibitor for mitigating cancer cachexia.

Lorlatinib-associated weight gain and dyslipidaemia: A retrospective analysis and implications for future care

OBJECTIVES

The objective of our study was to benchmark the incidence and severity of lorlatinib-related weight gain and dyslipidaemia in a real-world context, to guide future therapeutic strategies to mitigate these toxicities.

METHODS

We conducted a retrospective, observational analysis of patients with ALK and ROS1-positive NSCLC at a single institution in the UK who were commenced on lorlatinib from 11/2016 to 11/2022. Non-small cell lung cancer (NSCLC) patients prescribed lorlatinib were identified through institutional electronic pharmacy records. Descriptive analyses were conducted. Patients without recorded baseline weight were excluded from the analysis. Changes in weight, body mass index (BMI), triglycerides, and total/low-density lipoprotein (LDL)/high-density lipoprotein (HDL) cholesterol were calculated from serial measurements and graded in accordance with CTCAE v5.0.

RESULTS

43 patients were evaluated. 81 % of patients developed weight gain on lorlatinib (median: 4.5 kg, 6.5 % increase from baseline); Grade < 1 in 37 % (n = 16/43), Grade 1 in 23 % (n = 10/43), Grade 2 in 12 % (n = 5/43), and Grade ≥ 3 in 9 % (n = 4/43). BMI increase was observed in 79 % of patients. 35 % of patients with healthy baseline BMI moved into overweight/obese categories. Of patients with recorded baseline lipid levels, 91 % developed increase in total cholesterol, and 68 % an increase in triglycerides, respectively. 7 % (n = 1/15) patients with normal baseline total cholesterol developed Grade ≥ 3 elevated cholesterol; no patients with normal baseline triglycerides developed Grade ≥ 3 elevated hypertriglyceridaemia (n = 12). Median time to onset of total cholesterol elevation was 21 days. Lipid-lowering therapy was required in most patients (86 %). One patient developed a non-ST elevation myocardial infarction (NSTEMI) which may have been attributable to lorlatinib.

CONCLUSION

Weight gain and dyslipidaemia are commonly observed with lorlatinib, highlighting the need for effective pharmacologic and non-pharmacologic strategies to manage these toxicities. Rates were similar to those reported in the CROWN trial. Given the 60 % 5-year progression-free survival (PFS) demonstrated in CROWN, mitigation of treatment-related toxicities is paramount to minimise impact on patient quality of life (QOL) and cancer-independent morbidity in this subgroup of NSCLC patients with favourable outcomes.

A pragmatic guide for management of adverse events associated with lorlatinib

Lorlatinib is a brain-penetrant, third-generation tyrosine kinase inhibitor (TKI) indicated for the treatment of anaplastic lymphoma kinase (ALK)-positive metastatic non-small cell lung cancer (NSCLC). In clinical trials, lorlatinib has shown durable efficacy and a manageable safety profile in treatment-naive patients and in those who have experienced progression while receiving first- and/or second-generation ALK TKIs. Lorlatinib has a distinct safety profile from other ALK TKIs, including hyperlipidemia and central nervous system effects. Clinical trial data showed that most adverse events (AEs) can be managed effectively or reversed with dose modifications (such as dose interruptions or reductions) or with concomitant medications without compromising clinical efficacy or quality of life for patients. A pragmatic approach to managing AEs related to lorlatinib is required. We present patient-focused recommendations for the evaluation and management of select AEs associated with lorlatinib developed by clinicians and nurses with extensive lorlatinib expertise in routine clinical practice. The recommendations follow the general framework of "prepare, monitor, manage, reassess" to streamline AE management and assist in practical, actionable, and personalized patient care.

Evaluation of Efficacy of ALK Inhibitors According to Body Mass Index in ALK Rearranged NSCLC Patients-A Retrospective Observational Study

No evidence exists as to whether body mass index (BMI) impairs clinical outcomes from ALK inhibitors (ALKi) in patients with ALK-rearranged non-small cell lung cancer (NSCLC). Retrospective data of patients affected by metastatic ALK-rearranged NSCLC treated with ALKi were collected. We divided patients into "low- BMI" (≤25 kg/m²) and "high- BMI" (>25 kg/m²) categories and correlated them with overall survival (OS) and progression-free survival (PFS). We included 40 patients treated with ALKi. We observed a 3-year OS of 81.5% in high-BMI vs. 49.6% in low-BMI categories (p = 0.049); the 3-year first-line PFS was superior in high-BMI vs. low-BMI patients (47% vs. 19%, p = 0.019). As expected, patients treated with Alectinib had a 55.6% 3-year PFS vs. 7.1% for others treated with ALKi (p = 0.025). High-BMI was associated with a 100% 3-year PFS rate vs. 25.4% in low-BMI Alectinib patients (p = 0.03). BMI was independently correlated with first-line PFS and OS at multivariate analysis with PS (HR 0.39, CI 95% 0.16-0.96, p = 0.042; HR 0.18, CI 95% 0.05-0.61, p = 0.006). High-BMI was associated with higher efficacy in ALK-rearranged patients. These results are particularly exciting for Alectinib and could be correlated to mechanisms that should be investigated in subsequent prospective studies.