Alectinib for treating patients with metastatic ALK-positive NSCLC: systematic review and network metanalysis

First-Line Alectinib, Brigatinib, and Lorlatinib for Advanced Anaplastic Lymphoma Kinase-Positive Non-Small Cell Lung Cancer: A Cost-Effectiveness Analysis

OBJECTIVES

To evaluate the cost-effectiveness of alectinib, brigatinib, and lorlatinib as first-line therapies for anaplastic lymphoma kinase-positive advanced non-small cell lung cancer from a US healthcare sector perspective.

METHODS

We developed a 4-state partitioned survival model using progression-free survival, intracranial progression-free survival, and overall survival data from the ALEX, ALTA-1L, and CROWN clinical trials and published network meta-analyses. This model simulated patient transitions through progression-free, central-nervous-system-related progressed disease, non- central nervous system progressed disease, and death states over a 5-year horizon. Costs (2024 USD) included drug acquisition based on median of Department of Veteran Affairs and wholesale acquisition cost prices, healthcare utilization, and adverse events, all sourced from published literature. Quality-adjusted life years (QALYs) were derived using health utilities bootstrapped from these trials and adjusted for adverse events. We performed sensitivity and scenario analyses to evaluate uncertainty and explore various pricing and efficacy specifications.

RESULTS

Over a 5-year horizon, alectinib cost $1 105 814 for 2.85 QALYs gained, brigatinib cost $1 059 283 for 2.66 QALYs gained, and lorlatinib cost $1 163 519 for 2.88 QALYs gained. Incremental cost-effectiveness ratios for alectinib and lorlatinib versus brigatinib were $245 536/QALY and $481 386/QALY, respectively. Probabilistic sensitivity analysis indicated that at a willingness-to-pay threshold of $150 000 per QALY, brigatinib had a 54% chance of being the cost-effective option, with alectinib at 36% and lorlatinib at 10%.

CONCLUSIONS

Although our model slightly favors brigatinib at a $150 000/QALY willingness-to-pay threshold, substantial uncertainty precludes definitive cost-effectiveness conclusions among the 3 first-line therapies.

Unraveling the unforeseen: anuric acute kidney injury induced by alectinib

INTRODUCTION

Alectinib, a second-generation anaplastic lymphoma kinase (ALK) inhibitor, is pivotal in managing ALK-positive non-small cell lung cancer (NSCLC) due to its efficacy and favorable safety profile. However, severe renal toxicity, including acute kidney injury (AKI), remains a rare but significant adverse effect.

CASE REPORT

We present the case of a 71-year-old female with a history of diabetes and recently diagnosed ALK-positive NSCLC. She had been on alectinib therapy (600 mg twice daily) for two months. The patient was admitted with symptoms of shortness of breath and anuria. Initial laboratory results revealed a significant rise in serum creatinine from a baseline of 1.0 mg/dL to 3.64 mg/dL, indicating AKI. Alectinib was discontinued, and the patient underwent a single session of hemodialysis. The patient exhibited rapid clinical improvement with significant recovery of renal function, and she was discharged without the need for further dialysis. A subsequent switch to brigatinib was well-tolerated, with stable renal function observed at the 4-month follow-up.

CONCLUSION

This case underscores the potential for severe AKI associated with alectinib therapy, highlighting the importance of vigilant renal function monitoring in patients undergoing treatment, especially those with predisposing conditions. Early recognition and prompt intervention are crucial to mitigate renal complications and optimize patient outcomes. Brigatinib may serve as a suitable alternative for patients intolerant to alectinib.

First case report of a novel KIF13A-ALK fusion in a lung adenocarcinoma patient and response to alectinib with a 4-year follow-up

The prevalence of Anaplastic Lymphoma Kinase gene (ALK) fusion is about 5% among patients with lung adenocarcinoma, underscoring the importance of pinpointing distinct fusion variants for optimizing treatment approaches. This is the first reported case of a 74-year-old female with stage IV lung adenocarcinoma, featuring a novel Kinesin Family Member 13A (KIF13A)-ALK fusion, identified via next-generation sequencing (NGS) and confirmed with fluorescence in situ hybridization (FISH). Initially undergoing chemotherapy and then crizotinib, she achieved a partial response (PR) before progressing with multiple bone metastases. However, subsequent treatment with alectinib as a third-line option yielded positive results. A stable disease state persisted for an impressive 31 months of progression-free survival (PFS), accompanied by minimal toxicity symptoms. Up until now, a remarkable near 4-year span of overall survival (OS) has been consistently observed and monitored. This report of a KIF13A-ALK fusion case benefit significantly from alectinib with extensive follow-up. The case diversifies the array of ALK fusion partners and holds clinical relevance in refining therapeutic choices for KIF13A-ALK fusion-associated lung cancer.