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Chang AEB, Piper-Vallillo AJ, Mak RH, Lanuti M, Muzikansky A, Rotow J, Jänne PA, Mino-Kenudson M, Swanson S, Wright CD, Kozono D, Marcoux P, Piotrowska Z, Sequist LV, Willers H. The ASCENT Trial: a phase 2 study of induction and consolidation afatinib and chemoradiation with or without surgery in stage III EGFR-mutant NSCLC. Oncologist 2024:oyae107. [PMID: 38761385 DOI: 10.1093/oncolo/oyae107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Accepted: 05/04/2024] [Indexed: 05/20/2024] Open
Abstract
BACKGROUND The role of tyrosine kinase inhibitors (TKIs) in early-stage and metastatic oncogene-driven non-small cell lung cancer (NSCLC) is established, but it remains unknown how best to integrate TKIs with concurrent chemoradiotherapy (cCRT) in locally advanced disease. The phase 2 ASCENT trial assessed the efficacy and safety of afatinib and cCRT with or without surgery in locally advanced epidermal growth factor receptor (EGFR)-mutant NSCLC. PATIENTS AND METHODS Adults ≥18 years with histologically confirmed stage III (AJCC 7th edition) NSCLC with activating EGFR mutations were enrolled at Mass General and Dana-Farber/Brigham Cancer Centers, Boston, Massachusetts. Patients received induction afatinib 40 mg daily for 2 months, then cisplatin 75 mg/m2 and pemetrexed 500 mg/m2 IV every 3 weeks during RT (definitive or neoadjuvant dosing). Patients with resectable disease underwent surgery. All patients were offered consolidation afatinib for 2 years. The primary endpoint was the objective response rate (ORR) to induction TKI. Secondary endpoints were safety, conversion to operability, progression-free survival (PFS), and overall survival (OS). Analyses were performed on the intention-to-treat population. RESULTS Nineteen patients (median age 56 years; 74% female) were enrolled. ORR to induction afatinib was 63%. Seventeen patients received cCRT; 2/9 previously unresectable became resectable. Ten underwent surgery; 6 had a major or complete pathological response. Thirteen received consolidation afatinib. With a median follow-up of 5.0 years, median PFS and OS were 2.6 (95% CI, 1.4-3.1) and 5.8 years (2.9-NR), respectively. Sixteen recurred or died; 6 recurrences were isolated to CNS. The median time to progression after stopping consolidation TKI was 2.9 months (95% CI, 1.1-7.2). Four developed grade 2 pneumonitis. There were no treatment-related deaths. CONCLUSION We explored the efficacy of combining TKI with cCRT in oncogene-driven NSCLC. Induction TKI did not compromise subsequent receipt of multimodality therapy. PFS was promising, but the prevalence of CNS-only recurrences and rapid progression after TKI discontinuation speak to unmet needs in measuring and eradicating micrometastatic disease.
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Affiliation(s)
- Allison E B Chang
- Department of Medicine, Division of Hematology/Oncology, Massachusetts General Hospital, Boston, MA 02114, United States
| | - Andrew J Piper-Vallillo
- Department of Medicine, Division of Hematology/Oncology, Lahey Hospital and Medical Center, Burlington, MA 01805, United States
| | - Raymond H Mak
- Department of Radiation Oncology, Dana Farber Cancer Institute, Boston, MA 02215, United States
| | - Michael Lanuti
- Department of Surgery, Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA 02114, United States
| | - Alona Muzikansky
- Massachusetts General Hospital Biostatistics Center, Boston, MA 02114, United States
| | - Julia Rotow
- Lowe Center for Thoracic Medical Oncology, Dana Farber Cancer Institute, Boston, MA 02115, United States
| | - Pasi A Jänne
- Lowe Center for Thoracic Medical Oncology, Dana Farber Cancer Institute, Boston, MA 02115, United States
| | - Mari Mino-Kenudson
- Department of Pathology, Massachusetts General Hospital, Boston, MA 02114, United States
| | - Scott Swanson
- Department of Surgery, Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA 02115, United States
| | - Cameron D Wright
- Department of Surgery, Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA 02114, United States
| | - David Kozono
- Department of Radiation Oncology, Dana Farber Cancer Institute, Boston, MA 02215, United States
| | - Paul Marcoux
- Lowe Center for Thoracic Medical Oncology, Dana Farber Cancer Institute, Boston, MA 02115, United States
| | - Zofia Piotrowska
- Department of Medicine, Division of Hematology/Oncology, Massachusetts General Hospital, Boston, MA 02114, United States
| | - Lecia V Sequist
- Department of Medicine, Division of Hematology/Oncology, Massachusetts General Hospital, Boston, MA 02114, United States
| | - Henning Willers
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA 02114, United States
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Shin Y, Chang JS, Kim Y, Shin SJ, Kim J, Kim TH, Liu M, Olson R, Kim JS, Sung W. Mathematical prediction with pretreatment growth rate of metastatic cancer on outcomes: implications for the characterization of oligometastatic disease. Front Oncol 2023; 13:1061881. [PMID: 37313457 PMCID: PMC10258314 DOI: 10.3389/fonc.2023.1061881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 05/10/2023] [Indexed: 06/15/2023] Open
Abstract
Background Oligometastatic disease (OMD) represents an indolent cancer status characterized by slow tumor growth and limited metastatic potential. The use of local therapy in the management of the condition continues to rise. This study aimed to investigate the advantage of pretreatment tumor growth rate in addition to baseline disease burden in characterizing OMDs, generally defined by the presence of ≤ 5 metastatic lesions. Methods The study included patients with metastatic melanoma treated with pembrolizumab. Gross tumor volume of all metastases was contoured on imaging before (TP-1) and at the initiation of pembrolizumab (TP0). Pretreatment tumor growth rate was calculated by an exponential ordinary differential equation model using the sum of tumor volumes at TP-1 and TP0 and the time interval between TP-1. and TP0. Patients were divided into interquartile groups based on pretreatment growth rate. Overall survival, progression-free survival, and subsequent progression-free survival were the study outcomes. Results At baseline, median cumulative volume and number of metastases were 28.4 cc (range, 0.4-1194.8 cc) and 7 (range, 1-73), respectively. The median interval between TP-1 and TP0 was -90 days and pretreatment tumor growth rate (×10-2 days-1) was median 4.71 (range -0.62 to 44.1). The slow-paced group (pretreatment tumor growth rate ≤ 7.6 ×10-2 days-1, the upper quartile) had a significantly higher overall survival rate, progression-free survival, and subsequent progression-free survival compared to those of the fast-paced group (pretreatment tumor growth rate > 7.6 ×10-2 days-1). Notably, these differences were prominent in the subgroup with >5 metastases. Conclusion Pretreatment tumor growth rate is a novel prognostic metric associated with overall survival, progression-free survival, and subsequent progression-free survival among metastatic melanoma patients, especially patients with >5 metastases. Future prospective studies should validate the advantage of disease growth rate plus disease burden in better defining OMDs.
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Affiliation(s)
- Yerim Shin
- Department of Biomedical Engineering and of Biomedicine & Health Sciences, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jee Suk Chang
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Republic of Korea
- BC Cancer - Vancouver Centre, Vancouver, BC, Canada
| | - Yeseul Kim
- Department of Biomedical Engineering and of Biomedicine & Health Sciences, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sang Joon Shin
- Division of Medical Oncology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jina Kim
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Tae Hyung Kim
- Department of Radiation Oncology, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, Republic of Korea
| | - Mitchell Liu
- BC Cancer - Vancouver Centre, Vancouver, BC, Canada
| | - Robert Olson
- BC Cancer, Centre for the North, Prince George, BC, Canada
| | - Jin Sung Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Heavy Ion Therapy Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Wonmo Sung
- Department of Biomedical Engineering and of Biomedicine & Health Sciences, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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West J, Adler F, Gallaher J, Strobl M, Brady-Nicholls R, Brown J, Roberson-Tessi M, Kim E, Noble R, Viossat Y, Basanta D, Anderson ARA. A survey of open questions in adaptive therapy: Bridging mathematics and clinical translation. eLife 2023; 12:e84263. [PMID: 36952376 PMCID: PMC10036119 DOI: 10.7554/elife.84263] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 02/27/2023] [Indexed: 03/24/2023] Open
Abstract
Adaptive therapy is a dynamic cancer treatment protocol that updates (or 'adapts') treatment decisions in anticipation of evolving tumor dynamics. This broad term encompasses many possible dynamic treatment protocols of patient-specific dose modulation or dose timing. Adaptive therapy maintains high levels of tumor burden to benefit from the competitive suppression of treatment-sensitive subpopulations on treatment-resistant subpopulations. This evolution-based approach to cancer treatment has been integrated into several ongoing or planned clinical trials, including treatment of metastatic castrate resistant prostate cancer, ovarian cancer, and BRAF-mutant melanoma. In the previous few decades, experimental and clinical investigation of adaptive therapy has progressed synergistically with mathematical and computational modeling. In this work, we discuss 11 open questions in cancer adaptive therapy mathematical modeling. The questions are split into three sections: (1) integrating the appropriate components into mathematical models (2) design and validation of dosing protocols, and (3) challenges and opportunities in clinical translation.
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Affiliation(s)
- Jeffrey West
- Department of Integrated Mathematical Oncology, H. Lee Moffitt Cancer Center & Research InstituteTampaUnited States
| | - Fred Adler
- Department of Mathematics, University of UtahSalt Lake CityUnited States
- School of Biological Sciences, University of UtahSalt Lake CityUnited States
| | - Jill Gallaher
- Department of Integrated Mathematical Oncology, H. Lee Moffitt Cancer Center & Research InstituteTampaUnited States
| | - Maximilian Strobl
- Department of Integrated Mathematical Oncology, H. Lee Moffitt Cancer Center & Research InstituteTampaUnited States
| | - Renee Brady-Nicholls
- Department of Integrated Mathematical Oncology, H. Lee Moffitt Cancer Center & Research InstituteTampaUnited States
| | - Joel Brown
- Department of Integrated Mathematical Oncology, H. Lee Moffitt Cancer Center & Research InstituteTampaUnited States
| | - Mark Roberson-Tessi
- Department of Integrated Mathematical Oncology, H. Lee Moffitt Cancer Center & Research InstituteTampaUnited States
| | - Eunjung Kim
- Natural Product Informatics Research Center, Korea Institute of Science and TechnologyGangneungRepublic of Korea
| | - Robert Noble
- Department of Mathematics, University of LondonLondonUnited Kingdom
| | - Yannick Viossat
- Ceremade, Université Paris-Dauphine, Université Paris Sciences et LettresParisFrance
| | - David Basanta
- Department of Integrated Mathematical Oncology, H. Lee Moffitt Cancer Center & Research InstituteTampaUnited States
| | - Alexander RA Anderson
- Department of Integrated Mathematical Oncology, H. Lee Moffitt Cancer Center & Research InstituteTampaUnited States
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Remon J, Hendriks LEL. Targeted therapies for unresectable stage III non-small cell lung cancer. MEDIASTINUM (HONG KONG, CHINA) 2022; 5:22. [PMID: 35118328 PMCID: PMC8794453 DOI: 10.21037/med-21-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 05/01/2021] [Indexed: 12/15/2022]
Abstract
Until recently, the standard treatment in unresectable stage III non-small cell lung cancer was concurrent chemoradiotherapy, but often with dismal outcome. The introduction of consolidation treatment with immune checkpoint inhibitors has shifted the treatment landscape and prognosis of these patients. However, patients whose tumors harbors an epidermal growth factor receptor (EGFR) mutation derived less benefit, with an increased risk of immune-related adverse events. Moreover, current data suggested that patients with oncogenic addicted tumors, mainly EGFR-positive tumors, and also anaplastic lymphoma kinase (ALK)-positive have poorer progression free survival after chemoradiotherapy. Indeed, these tumors have also inferior distant control compared with those who have wild-type disease, especially in the central nervous system, highlighting the need for assessing the role of targeted therapies in this patient population. It is speculated that outcome could probably increase with a consolidation treatment strategy including an EGFR tyrosine kinase inhibitor. However, a personalized treatment approach is not considered standard of care in this setting due to lack of robust evidence, as the majority of trials were performed in unselected patients, number of patients is limited and the majority of these studies were underpowered. In this review we summarize the role of tyrosine kinase inhibitors in unresectable stage III NSCLC, specifically focusing on EGFR-mutant tumors.
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Affiliation(s)
- Jordi Remon
- Department of Medical Oncology, Centro Integral Oncológico Clara Campal (HM-CIOCC), Hospital HM Delfos, HM Hospitales, Barcelona, Spain
| | - Lizza E L Hendriks
- Department of Respiratory Medicine, Maastricht University Medical Centre, GROW School for Oncology and Developmental Biology, Maastricht, The Netherlands
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Scarborough JA, Tom MC, Kattan MW, Scott JG. Revisiting a Null Hypothesis: Exploring the Parameters of Oligometastasis Treatment. Int J Radiat Oncol Biol Phys 2021; 110:371-381. [PMID: 33484786 PMCID: PMC8122026 DOI: 10.1016/j.ijrobp.2020.12.044] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 12/23/2020] [Accepted: 12/28/2020] [Indexed: 12/25/2022]
Abstract
PURPOSE In the treatment of patients with metastatic cancer, the current paradigm states that metastasis-directed therapy does not prolong life. This paradigm forms the basis of clinical trial null hypotheses, where trials are built to test the null hypothesis that patients garner no overall survival benefit from targeting metastatic lesions. However, with advancing imaging technology and increasingly precise techniques for targeting lesions, a much larger proportion of metastatic disease can be treated. As a result, the life-extending benefit of targeting metastatic disease is becoming increasingly clear. METHODS AND MATERIALS In this work, we suggest shifting this qualitative null hypothesis and describe a mathematical model that can be used to frame a new, quantitative null. We begin with a very simple formulation of tumor growth, an exponential function, and illustrate how the same intervention (removing a given number of cells from the tumor) at different times affects survival. Additionally, we postulate where recent clinical trials fit into this parameter space and discuss the implications of clinical trial design in changing these quantitative parameters. RESULTS Our model shows that although any amount of cell kill will extend survival, in many cases the extent is so small as to be unnoticeable in a clinical context or is outweighed by factors related to toxicity and treatment time. CONCLUSIONS Recasting the null in these quantitative terms will allow trialists to design trials specifically to increase understanding of the circumstances (patient selection, disease burden, tumor growth kinetics) that can lead to improved overall survival when targeting metastatic lesions, rather than whether targeting metastases extends survival for patients with (oligo-) metastatic disease.
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Affiliation(s)
- Jessica A Scarborough
- Translational Hematology and Oncology Research, Cleveland Clinic, Cleveland, Ohio; Systems Biology and Bioinformatics Program, Department of Nutrition, Case Western Reserve School of Medicine, Cleveland, Ohio
| | - Martin C Tom
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
| | - Michael W Kattan
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Jacob G Scott
- Translational Hematology and Oncology Research, Cleveland Clinic, Cleveland, Ohio; Systems Biology and Bioinformatics Program, Department of Nutrition, Case Western Reserve School of Medicine, Cleveland, Ohio; Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio.
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A Quantitative Paradigm for Decision-Making in Precision Oncology. Trends Cancer 2021; 7:293-300. [PMID: 33637444 DOI: 10.1016/j.trecan.2021.01.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 01/16/2021] [Accepted: 01/20/2021] [Indexed: 11/24/2022]
Abstract
The complexity and variability of cancer progression necessitate a quantitative paradigm for therapeutic decision-making that is dynamic, personalized, and capable of identifying optimal treatment strategies for individual patients under substantial uncertainty. Here, we discuss the core components and challenges of such an approach and highlight the need for comprehensive longitudinal clinical and molecular data integration in its development. We describe the complementary and varied roles of mathematical modeling and machine learning in constructing dynamic optimal cancer treatment strategies and highlight the potential of reinforcement learning approaches in this endeavor.
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