Indian consensus statement for treatment of advanced non small cell lung cancer: First line, maintenance, and second line

The management of advanced nonsmall cell lung cancer (NSCLC) patients is becoming complex with the identification of driver mutations and targeted therapies. The expert group of academic medical oncologists used data from published literature, practical experience to arrive at practical consensus recommendations to treat advanced NSCLC for use by the community oncologists.

Osimertinib: A third-generation tyrosine kinase inhibitor for treatment of epidermal growth factor receptor-mutated non-small cell lung cancer with the acquired Thr790Met mutation

Osimertinib is a third-generation epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (TKI) approved for the treatment of metastatic EGFR T790M mutation-positive non-small cell lung cancer (NSCLC) in patients failing previous TKI therapy. The T790M mutation is an acquired resistance mechanism found in over half of patients with NSCLC progressing on first-generation TKIs. First- and second-generation TKIs do not inhibit the T790M mutation at clinically relevant concentrations. Osimertinib is selective for mutated forms of EGFR, including the TKI-sensitizing mutations L858R and exon 19 deletions, as well as the acquired T790M resistance mutation. In a trial comparing osimertinib to platinum doublet therapy among patients with the T790M mutation progressing on first-line TKI therapy, median progression-free survival was significantly longer in patients receiving osimertinib. Osimertinib has a favorable safety profile compared to platinum-doublet chemotherapy. Common adverse events include diarrhea, skin rash, dry skin, and paronychia; however, because it spares wild-type EGFR, these toxicities appear to occur with less frequency and severity compared to other TKIs. Serious, but rare, adverse events include pneumonitis, interstitial lung disease-like events, QT interval prolongation, and reduced ejection fraction. Osimertinib has the unique ability to distribute readily into brain tissue compared with other TKIs, giving it a potential role in the treatment and/or prevention of CNS metastases; future studies are warranted in this area. An ongoing study evaluating osimertinib versus first-generation TKIs as first-line treatment for patients with EGFR mutation-positive NSCLC may help to define the role of osimertinib as front-line therapy.

Feasibility of Rebiopsy in Non-Small Cell Lung Cancer Treated with Epidermal Growth Factor Receptor-Tyrosine Kinase Inhibitors

OBJECTIVE

Analyses of tumor biopsy samples from non-small cell lung cancer patients with acquired epidermal growth factor receptor (EGFR)-tyrosine kinase inhibitor (TKI) resistance are expected to reveal the molecular mechanisms of resistance. However, due to limited tissue availability, performing such analyses can be challenging. We herein investigated the feasibility of tumor rebiopsy in this patient population.

METHODS

From April 2004 to March 2013, 53 consecutive patients were treated with EGFR-TKIs at our department. A retrospective medical chart review was conducted among patients with progressive disease (PD) according to the Response Evaluation Criteria in Solid Tumors criteria, as assessed radiographically. Sites of progression were evaluated at the time of PD.

RESULTS

Forty patients experienced PD at the following sites: isolated central nervous system (CNS) in 10 patients; isolated bone in five patients; isolated lymph nodes in two patients; the primary lesion in 10 patients; and systemic disease in 11 patients. Concerning the site of progression, 20 of the 40 patients had a lesion that could be accessed using endobronchial, transbronchial or percutaneous biopsy procedures. Among the 19 patients with oligoprogressive disease or CNS failure, the median overall survival was 24.1 months in eight patients who had received continuing treatment with EGFR-TKIs following radiotherapy and 16.8 months in 11 patients who received other therapies after PD.

CONCLUSION

In this study, few patients had a site of progression capable of being accessed using relatively noninvasive biopsy procedures. Further investigations are warranted to develop more optimal treatment strategies after PD in patients with oligoprogressive disease or CNS failure.

EGFR-TKIs combined with chemotherapy versus EGFR-TKIs single agent as first-line treatment for molecularly selected patients with non-small cell lung cancer

EGFR-TKIs added to chemotherapy and EGFR-TKIs single agent have been used as first-line treatment for advanced non-small cell lung cancer patients with and without EGFR mutations. However, direct head-to-head comparison between them is still lacking. We performed indirect comparisons to assess the treatment effects of EGFR-TKIs added to chemotherapy versus EGFR-TKIs alone via common comparator of standard chemotherapy in both subgroups. A comprehensive literature search was undertaken. Finally, 12 randomized controlled trials enrolling more than 2,160 patients with EGFR mutation analysis met the inclusion criteria. We found that EGFR-TKIs combined with chemotherapy did confer an additive PFS advantage over standard chemotherapy both for patients with mutant EGFR tumors (HR 0.54, 95 % CI [0.30, 0.95], P = 0.03) and for patients with wild-type EGFR tumors (HR 0.82, [0.68, 0.98], P = 0.03), but no survival difference between the treatments in both subgroups. When using standard chemotherapy as common comparator, indirect comparison indicated that addition of chemotherapy to EGFR-TKIs did confer an additive PFS benefit (HR 0.38, [0.32, 0.46], P < 0.001) and survival benefit (HR 0.75, [0.66, 0.85], P < 0.001) over EGFR-TKIs alone in patients with wild-type EGFR, but showed a PFS disadvantage (HR 1.35, [1.03, 1.77], P = 0.03) and a marginal trend toward survival disadvantage (HR 1.16, [0.99, 1.35], P = 0.06) compared with EGFR-TKIs alone in patients with mutant EGFR tumors. In summary, addition of chemotherapy to EGFR-TKIs as first-line treatment did confer an additive benefit over EGFR-TKIs alone in patients with wild-type EGFR tumors, but was inferior to EGFR-TKIs alone in patients with mutant EGFR tumors.

[Personalized targeted therapy for lung cancer]

由于每一肺癌患者在临床特征、预后、治疗反应和耐受性方面的进展都是独特的，所以肺癌被认为是异质性疾病。个体化用药是指运用标志物来预测哪些患者更易获益于某种治疗。对于肺癌而言，日趋完善的表皮生长因子受体(epidermal growth factor receptor, EGFR)和新发现的棘皮动物微管相关蛋白样4-间变淋巴瘤激酶(echinoderm microtubule associated protein like 4-anaplastic lymphoma kinase, EML4-ALK)是重要的治疗靶标。本综述包括EGFR和EML4-ALK活化的机制、预测性生物标记物、耐药的机理和已有的靶向性酪氨酸激酶抑制剂。本文将通过总结基于生物标记物筛选患者而进行的前瞻性临床试验来探讨EGFR和ALK靶向治疗的疗效。此外，由于革命性的测序和系统生物学技术会为癌症的分子特征提供一个全面的理解，有助于为更适宜靶向治疗的患者提供更精确的区分从而提供更有前景的个体化治疗，本综述也将包括这些技术。同时，非亚裔人群中EGFR和ALK相对较低的突变发生率和突变患者反应的缺乏限制了靶向于EGFR或ALK的治疗的应用。测序和系统生物学策略则可能为这些患者提供新的解决方案。

Impact of EGFR inhibitor in non-small cell lung cancer on progression-free and overall survival: a meta-analysis

BACKGROUND

The epidermal growth factor receptor (EGFR) signaling pathway is crucial for regulating tumorigenesis and cell survival and may be important in the development and progression of non-small cell lung cancer (NSCLC). We examined the impact of EGFR-tyrosine kinase inhibitors (TKIs) on progression-free survival (PFS) and overall survival (OS) in advanced NSCLC patients with and without EGFR mutations.

METHODS

Randomized trials that compared EGFR-TKIs monotherapy or combination EGFR-TKIs-chemotherapy with chemotherapy or placebo were included. We used published hazard ratios (HRs), if available, or derived treatment estimates from other survival data. Pooled estimates of treatment efficacy of EGFR-TKIs for the EGFR mutation-positive (EGFRmut(+)) and EGFR mutation-negative (EGFRmut(-)) subgroups were calculated with the fixed-effects inverse variance weighted method. All statistical tests were two-sided.

RESULTS

We included 23 eligible trials (13 front-line, 7 second-line, 3 maintenance; n = 14570). EGFR mutation status was known in 31% of patients. EGFR-TKIs treatment prolonged PFS in EGFRmut(+) patients, and EGFR mutation was predictive of PFS in all settings: The front-line hazard ratio for EGFRmut(+) was 0.43 (95% confidence interval [CI] = 0.38 to 0.49; P < .001), and the front-line hazard ratio for EGFRmut(-) was 1.06 (95% CI = 0.94 to 1.19; P = .35; P interaction < .001). The second-line hazard ratio for EGFRmut(+) was 0.34 (95% CI = 0.20 to 0.60; P < .001), and the second-line hazard ratio for EGFRmut(-) was 1.23 (95% CI = 1.05 to 1.46; P = .01; P interaction < .001). The maintenance hazard ratio for EGFRmut(+) was 0.15 (95% CI = 0.08 to 0.27; P < .001), and the maintenance hazard ratio for EGFRmut(-) was 0.81 (95% CI = 0.68 to 0.97; P = .02; P interaction < .001). EGFR-TKIs treatment had no impact on OS for EGFRmut(+) and EGFRmut(-) patients.

CONCLUSIONS

EGFR-TKIs therapy statistically significantly delays disease progression in EGFRmut(+) patients but has no demonstrable impact on OS. EGFR mutation is a predictive biomarker of PFS benefit with EGFR-TKIs treatment in all settings. These findings support EGFR mutation assessment before initiation of treatment. EGFR-TKIs should be considered as front-line therapy in EGFRmut(+) advanced NSCLC patients.

Personalized targeted therapy for lung cancer

Lung cancer has long been recognized as an extremely heterogeneous disease, since its development is unique in every patient in terms of clinical characterizations, prognosis, response and tolerance to treatment. Personalized medicine refers to the use of markers to predict which patient will most likely benefit from a treatment. In lung cancer, the well-developed epidermal growth factor receptor (EGFR) and the newly emerging EML4-anaplastic lymphoma kinase (ALK) are important therapeutic targets. This review covers the basic mechanism of EGFR and EML4-ALK activation, the predictive biomarkers, the mechanism of resistance, and the current targeted tyrosine kinase inhibitors. The efficacy of EGFR and ALK targeted therapies will be discussed in this review by summarizing the prospective clinical trials, which were performed in biomarker-based selected patients. In addition, the revolutionary sequencing and systems strategies will also be included in this review since these technologies will provide a comprehensive understanding in the molecular characterization of cancer, allow better stratification of patients for the most appropriate targeted therapies, eventually resulting in a more promising personalized treatment. The relatively low incidence of EGFR and ALK in non-Asian patients and the lack of response in mutant patients limit the application of the therapies targeting EGFR or ALK. Nevertheless, it is foreseeable that the sequencing and systems strategies may offer a solution for those patients.

Surrogate end points for survival in the target treatment of advanced non-small-cell lung cancer with gefitinib or erlotinib

BACKGROUND

It is controversial for the use of survival surrogate end points including response rate (RR), disease control rate (DCR), time to progression, and progression-free survival (PFS) in trials of molecular targeted agents. Our aim was to determine the correlations of these surrogates with survival in the treatment of advanced non-small-cell lung cancer (ANSCLC) with epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs), gefitinib and erlotinib.

METHODS

Summary data of median survival time (MST) and surrogates from prospective trials of EGFR-TKIs in ANSCLC were identified. Patient- or trial-related characteristics were introduced as covariates. Simple and multivariate linear regression models were fitted for MST and each surrogate, respectively. And the significance of each surrogate as a survival marker was compared by calculating the area under their receiver operating characteristic (ROC) curves.

RESULTS

Sixty eligible trials (9,903 patients) were enrolled. RR, DCR, and PFS were all strongly associated with MST. In their simple linear regression models, the coefficient of determination (R(2)) was 0.83 (p < 0.000001), 0.58 (p < 0.0001), and 0.70 (p < 0.0001), respectively. And in their multivariate linear regression models, the standard coefficient was 0.71 (p < 0.001), 0.40 (p < 0.001), and 0.74 (p < 0.001), respectively, while RR and PFS were the preferred survival predictors in the ROC analysis.

CONCLUSION

RR or PFS may serve as an appropriate survival surrogate in the clinical trials of EGFR-TKIs for ANSCLC.

Individualized therapy for patients with non-small cell lung cancer: emerging trends and challenges

Non-small cell lung cancer is the leading cause of cancer death in the United States. Efforts to improve outcomes have led to a greater understanding of the predictive and prognostic value of histologic and molecular characteristics of individual tumors. In standard practice, biopsy specimens are examined first on a histologic level, then on a molecular level with the recognition that both histologic subtype and gene expression profile can guide treatment decisions and have a profound effect on clinical outcomes. Epidermal growth factor activation mutations were among the first biomarkers shown to have therapeutic implications, and levels of gene expression for an array of other biomarkers are being evaluated in clinical trials. Ongoing studies underscore the need to implement molecular and histologic screening as part of routine clinical practice. To achieve an integration of clinical, histologic, and molecular parameters when making treatment decisions, collaboration between oncologists and pathologists is essential.