Afatinib vs erlotinib for second-line treatment of Chinese patients with advanced squamous cell carcinoma of the lung

QALY-type preference and willingness-to-pay among end-of-life patients with cancer treatments: a pilot study using discrete choice experiment

PURPOSE

Quality-adjusted life-year (QALY) is a dominant measurement of health gain in economic evaluations for pricing drugs. However, end-of-life (EoL) patients' preference for QALY gains in life expectancy (LE) and quality of life (QoL) during different disease stages remains unknown and is seldom involved in decision-making. This study aims to measure preferences and willingness-to-pay (WTP) towards different types of QALY gain among EoL cancer patients.

METHODS

We attributed QALY gain to four types, gain in LE and QoL, respectively, and during both progression-free survival (PFS) and post-progression survival (PPS). A discrete choice experiment including five attributes (the four QALY attributes and one cost attribute) with three levels each was developed and conducted with 85 Chinese advanced non-small cell lung cancer patients in 2022. All levels were set with QALY gain/cost synthesised from research on anti-lung cancer drugs recently listed by Chinese National Healthcare Security Administration. Each respondent answered six choice tasks in a face-to-face interview. The data were analysed using mixed logit models.

RESULTS

Patients valued LE-related QALY gain in PFS most, with a relative importance of 81.8% and a WTP of $43,160 [95% CI 26,751 ~ 59,569] per QALY gain. Respondents consistently preferred LE-related to QoL-related QALY gain regardless of disease stage. Patients with higher income or lower education levels tended to pay more for QoL-related QALY gain.

CONCLUSION

Our findings suggest a prioritised resource allocation to EoL-prolonging health technologies. Given the small sample size and large individual heterogeneity, a full-scale study is needed to provide more robust results.

Association of Hypokalemia Incidence and Better Treatment Response in NSCLC Patients: A Meta-Analysis and Systematic Review on Anti-EGFR Targeted Therapy Clinical Trials

Background

This meta-analysis was designed to explore the relationship between the level of serum potassium and the treatment effect of epidermal growth factor receptor (EGFR) antagonist in advanced non-small cell lung cancer (aNSCLC).

Methods

We searched phase II/III prospective clinical trials on treatment with EGFR antagonists for aNSCLC patients. The objective response rate (ORR) and/or the disease control rate (DCR) and the incidence of hypokalemia of high grade (equal to or greater than grade 3) were summarized from all eligible trials. Heterogeneity, which was evaluated by Cochran’s Q-test and the I² statistics, was used to determine whether a random effects model or a fixed effects model will be used to calculate pooled proportions. Subgroup analysis was performed on different interventions, line types, phases, and drug numbers.

Results

From 666 potentially relevant articles, 36 clinical trials with a total of 9,761 participants were included in this meta-analysis. The pooled ORR was 16.25% (95%CI = 12.45–21.19) when the incidence of hypokalemia was 0%–5%, and it increased to 34.58% (95%CI = 24.09–45.07) when the incidence of hypokalemia was greater than 5%. The pooled DCR were 56.03% (95%CI = 45.03–67.03) and 64.38% (95%CI = 48.60–80.17) when the incidence rates of hypokalemia were 0%–5% and greater than 5%, respectively. The results of the subgroup analysis were consistent with the results of the whole population, except for not first-line treatment, which may have been confounded by malnutrition or poor quality of life in long-term survival.

Conclusion

The efficacy of anti-EGFR targeted therapy was positively associated with the hypokalemia incidence rate. Treatment effects on the different serum potassium strata need to be considered in future clinical trials with targeted therapy.

Case Report: Afatinib-Induced Interstitial Pneumonia: Experiences and Lessons From Two Patients

Background: Afatinib has shown good efficacy in patients harboring uncommon EGFR mutations, but the incidence of afatinib-induced interstitial pneumonia should be alert as its rapid progression. Here, we report two cases of interstitial pneumonia during afatinib treatment.

Case presentation: The first case was of a 58-year-old male with advanced lung adenocarcinoma (cT4bN3M1b) with exon 18 G719X and exon 20 S781I EGFR mutations and received afatinib therapy. After 68 days of therapy, he developed shortness of breath and fever. Drug-induced pneumonia was not diagnosed timely, the patient received empirical antibiotics and low-dose glucocorticoids. The pulmonary inflammation rapidly progressed and the patient died 15 days after symptom onset. The second case was of a 57-year-old man with stage IV (cT3N3M1b) lung adenocarcinoma with exon 21 L861Q EGFR mutation. He received afatinib as second-line therapy. Fever and shortness of breath occurred 22 days after afatinib therapy, he received empirical antibiotic therapy. Five days later, CT showed aggravated pulmonary inflammation, and afatinib-induced interstitial pneumonia was diagnosed. He received glucocorticoid therapy, and the pneumonia quickly improved.

Conclusion: Although the incidence of EGFR-TKI-associated pneumonia is uncommon, high vigilance for drug-induced interstitial pneumonia is necessary during treatment. Early diagnosis and early glucocorticoid therapy could reverse lung injury.

Reporting of harms in oncological clinical study reports submitted to the European Medicines Agency compared to trial registries and publications-a methodological review

BACKGROUND

An accurate and comprehensive assessment of harms is a fundamental part of an accurate weighing of benefits and harms of an intervention when making treatment decisions; however, harms are known to be underreported in journal publications. Therefore, we sought to compare the completeness of reporting of harm data, discrepancies in harm data reported, and the delay to access results of oncological clinical trials between three sources: clinical study reports (CSRs), clinical trial registries and journal publications.

METHODS

We used the EMA clinical data website to identify all trials submitted to the EMA between 2015 and 2018. We retrieved all CSRs and included all phase II, II/III or III randomised controlled trials (RCTs) assessing targeted therapy and immunotherapy for cancer. We then identified related records in clinical trial registries and journals. We extracted harms data for eight pre-specified variables and determined the completeness of reporting of harm data in each of the three sources.

RESULTS

We identified 42 RCTs evaluating 13 different drugs. Results were available on the EMA website in CSRs for 37 (88%) RCTs, ClinicalTrials.gov for 36 (86%), the European Clinical Trials Register (EUCTR) for 20 (48%) and in journal publications for 32 (76%). Harms reporting was more complete in CSRs than other sources. We identified marked discrepancies in harms data between sources, e.g. the number of patients discontinuing due to adverse events differed in CSRs and clinical trial registers for 88% of trials with data in both sources. For CSRs and publications, the corresponding number was 90%. The median (interquartile range) delay between the primary trial completion date and access to results was 4.34 (3.09-7.22) years for CSRs, 2.94 (1.16-4.52) years for ClinicalTrials.gov, 5.39 (4.18-7.33) years for EUCTR and 2.15 (0.64-5.04) years for publications.

CONCLUSIONS

Harms of recently approved oncological drugs were reported more frequently and in more detail in CSRs than in trial registries and journal publications. Systematic reviews seeking to address harms of oncological treatments should ideally use CSRs as the primary source of data; however, due to problems with access, this is currently not feasible.

Long-term response to second-line afatinib treatment for advanced squamous cell carcinoma non-small cell lung cancer: a rare case report

The ErbB family is composed of four cell membrane receptors: ErbB-1 (epidermal growth factor receptor or human epidermal growth factor receptor [HER]1), ErbB-2 (HER2), ErbB-3 (HER3), and ErbB-4 (HER4). All members of the ErbB family play a critical role in regulating cell growth, proliferation and migration of tumours. Afatinib is an irreversible ErbB family inhibitor that is approved for second-line treatment of advanced squamous cell carcinoma (SqCC) that has progressed following platinum-based chemotherapy. Here we describe the case of a 56-year-old male Chinese patient with SqCC who had previously failed chemotherapy and radiotherapy and was subsequently enrolled in the LUX-Lung 8 study. The patient responded well to treatment with afatinib (40 mg/day). His disease stabilised after 8 weeks and a complete response was achieved after 12 weeks of treatment. Follow-up of this patient is ongoing; he is still alive and has not experienced disease progression in the 7 years since initiation of afatinib. The long-term response and prolonged survival in this patient provide additional evidence for second-line treatment with afatinib in patients with SqCC.

Survival analysis of afatinib versus erlotinib for individuals with advanced del19 lung adenocarcinoma with asymptomatic brain metastasis after pemetrexed-cisplatin chemotherapy: a retrospective study

Objective

To evaluate survival following afatinib (AF) and erlotinib (ER) treatment in advanced del19 lung adenocarcinoma (AD19LA) with asymptomatic brain metastasis (ABM) after pemetrexed–cisplatin chemotherapy (PCC).

Methods

Data were retrospectively analysed from individuals with AD19LA and ABM after PCC who received AF or ER for 2 years or until intolerable adverse events (AEs), withdrawal, or death. The primary outcome was survival; secondary outcomes were AEs.

Results

The final analysis included 174 AD19LA individuals (AF: n = 86; ER: n = 88) with a median follow-up of 24.2 months (IQR 2.1–28.3). Significant differences in overall survival (16.2 months [95%CI 15.4–17.1] for AF vs 7.2 months [95%CI 6.3–8.1] for ER) (HR 0.50, 95%CI 0.36–0.71, p<0.0001) and median progression-free survival (9.4 months [95%CI 8.5–9.7] for AF vs 5.6 months [4.7–6.2] for ER) (HR 0.66, 95%CI 0.47–0.94, p=0.02) were observed between the groups. Rates of all-grade AEs were 82.5% for AF and 72.7% for ER, and rates of grade ≥3 AEs were 37.2% for AF and 34.0% for ER.

Conclusion

Compared with ER, AF treatment may be more beneficial in terms of survival in the management of AD19LA after PCC with a tolerable safety profile.

Clinical And Imageological Features Of Lung Squamous Cell Carcinoma With EGFR Mutations

Purpose

To analyze the distribution of epidermal growth factor receptor (EGFR) mutations; characterize the clinical and imageological features of lung squamous cell carcinoma (LSCC) in a large population of patients; and assess correlations between clinical and imageological characteristics and clinical outcomes of LSCC patients harboring EGFR mutations.

Patients and methods

Three pathologists retrospectively evaluated the morphological and immunohistochemical data of 2,322 patients with LSCC resected between February 2013 and December 2017. Data on the distribution of EGFR mutations and the clinical and imageological characteristics of the patients were retrospectively collected. Correlations between the EGFR mutation status and clinical outcomes were evaluated using univariate and multivariate analyses.

Results

EGFR mutations were found in 3.4% of patients with LSCC and predominantly in female and non-smoking patients. Tumor lesions in patients with EGFR-positive mutations were more irregularly shaped than those in patients with EGFR-negative mutations (P = 0.045). In non-smoking patients with LSCC, the proportion of marked spiculation was significantly higher in the EGFR-positive group than in the EGFR-negative group (P = 0.043). No significant difference in recurrence-free survival was noted between LSCC patients harboring EGFR-positive and those harboring EGFR-negative mutations. No difference in metastases was observed between the EGFR-positive and EGFR-negative cohorts.

Conclusion

Female gender, non-smoking habit, irregularly shaped tumor, and marked spiculation might predict the presence of EGFR mutations in LSCC. The administration of tyrosine kinase inhibitors to patients with LSCC after screening for EGFR mutations based on their clinical and imageological features would likely result in a population with a greater sensitivity to afatinib.

Development of treatment options for Chinese patients with advanced squamous cell lung cancer: focus on afatinib

Lung cancer is the leading cause of cancer death in China, and approximately one third of these cancers are squamous cell carcinoma (SqCC) of the lung. Ethnic diversity and country-specific environmental factors can account for interindividual variations in response to and tolerability of anticancer therapies. Although several targeted therapies have recently been approved for patients with relapsed/refractory SqCC of the lung, only afatinib, an irreversible ErbB family blocker, has data of Chinese patients. In the Phase III LUX-Lung 8 trial, afatinib demonstrated a significant clinical benefit vs the reversible first-generation EGFR tyrosine kinase inhibitor erlotinib in both the overall population and the Chinese subset, with a manageable safety profile. Emerging biomarker data from LUX-Lung 8 suggest that patients with ErbB mutations, especially ErbB2, and those classified as “good” in the VeriStrat^® proteomic test, may benefit from afatinib treatment in particular, regardless of ethnicity, and may get a long-term response. In conclusion, afatinib is a valid second-line option for Chinese patients with SqCC of the lung, and specific biomarkers may help guide in treatment decision-making. Ongoing studies will provide further guidance on afatinib’s place in the treatment algorithm, alongside the other novel targeted therapies.