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Lee JM, McNamee CJ, Toloza E, Negrao MV, Lin J, Shum E, Cummings AL, Kris MG, Sepesi B, Bara I, Kurtsikidze N, Schulze K, Ngiam C, Chaft JE. Neoadjuvant Targeted Therapy in Resectable NSCLC: Current and Future Perspectives. J Thorac Oncol 2023; 18:1458-1477. [PMID: 37451404 PMCID: PMC11040203 DOI: 10.1016/j.jtho.2023.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 06/20/2023] [Accepted: 07/06/2023] [Indexed: 07/18/2023]
Abstract
The standard of care (SoC) for medically operable patients with early-stage (stages I-IIIB) NSCLC is surgery combined with (neo)adjuvant systemic therapy for patients with stages II to IIIB disease and some stage IB or, rarely, chemoradiation (stage III disease with mediastinal lymph node metastases). Despite these treatments, metastatic recurrence is common and associated with poor survival, highlighting the need for systemic therapies that are more effective than the current SoC. After the success of targeted therapy (TT) in patients with advanced NSCLC harboring oncogenic drivers, these agents are being investigated for the perioperative (neoadjuvant and adjuvant) treatment of patients with early-stage NSCLC. Adjuvant osimertinib is the only TT approved for use in the early-stage setting, and there are no approved neoadjuvant TTs. We discuss the importance of comprehensive biomarker testing at diagnosis to identify individuals who may benefit from neoadjuvant targeted treatments and review emerging data from neoadjuvant TT trials. We also address the potential challenges for establishing neoadjuvant TTs as SoC in the early-stage setting, including the identification and validation of early response markers to guide care and accelerate drug development, and discuss safety considerations in the perioperative setting. Initial data indicate that neoadjuvant TTs are effective and well tolerated in patients with EGFR- or ALK-positive early-stage NSCLC. Data from ongoing trials will determine whether neoadjuvant targeted agents will become a new SoC for individuals with oncogene-addicted resectable NSCLC.
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Affiliation(s)
- Jay M Lee
- Division of Thoracic Surgery, Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California.
| | - Ciaran J McNamee
- Department of Surgery, Division of Thoracic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Eric Toloza
- Department of Thoracic Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida; Department of Surgery and Department of Oncologic Sciences, University of South Florida Health Morsani College of Medicine, Tampa, Florida
| | - Marcelo V Negrao
- Department of Thoracic/Head and Neck Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jules Lin
- Section of Thoracic Surgery, University of Michigan Rogel Cancer Center, Ann Arbor, Michigan
| | - Elaine Shum
- Division of Hematology and Medical Oncology, Department of Medicine, Perlmutter Cancer Center at NYU Langone Health, New York, New York
| | - Amy L Cummings
- Division of Hematology-Oncology, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - Mark G Kris
- Thoracic Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center and Weill Cornell Medical Center, New York, New York
| | - Boris Sepesi
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ilze Bara
- US Medical Affairs, Genentech, Inc., South San Francisco, California
| | - Nino Kurtsikidze
- Global Product Development and Medical Affairs Oncology, F. Hoffmann-La Roche Ltd., Basel, Switzerland
| | - Katja Schulze
- Translational Medicine, Oncology Biomarker Development, Genentech, Inc., South San Francisco, California
| | - Celina Ngiam
- US Medical Affairs, Genentech, Inc., South San Francisco, California
| | - Jamie E Chaft
- Thoracic Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center and Weill Cornell Medical Center, New York, New York
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Zhang Q, Lin JJ, Pal N, Polito L, Trinh H, Hilton M, Smoljanović V, Kurtsikidze N, Archer V, Krebs MG. Real-world Comparative Effectiveness of First-Line Alectinib Versus Crizotinib in Patients with Advanced ALK-Positive NSCLC with or without Baseline Central Nervous System Metastases. JTO Clin Res Rep 2023; 4:100483. [PMID: 37025119 PMCID: PMC10070922 DOI: 10.1016/j.jtocrr.2023.100483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 02/03/2023] [Accepted: 02/16/2023] [Indexed: 03/06/2023] Open
Abstract
Introduction Alectinib was found to have superior efficacy to crizotinib in the phase 3 ALEX study and is a preferred initial treatment for patients with advanced ALK-positive NSCLC. To understand the efficacy of alectinib in U.S. clinical practice, we conducted a retrospective real-world comparative effectiveness analysis of first-line alectinib versus crizotinib. Methods Adults with advanced ALK-positive NSCLC who received first-line alectinib (from December 11, 2015) or crizotinib (from January 1, 2014) were included from a real-world database. Propensity scores were applied to balance baseline characteristics. Real-world data (RWD), including real-world progression-free survival (rwPFS), real-world overall survival, real-world time to new central nervous system (CNS) metastases, and outcomes in patients with or without baseline CNS metastases were analyzed. The ALEX-like RWD cohort (filtered by ALEX laboratory eligibility criteria) was used to compare real-world comparative effectiveness with ALEX. Results The RWD cohort comprised 364 patients (141 alectinib; 223 crizotinib); rwPFS (weighted hazard ratio [wHR] = 0.46, 95% confidence interval [CI]: 0.33-0.65) and real-world overall survival (wHR = 0.46, 95% CI: 0.31-0.69) were significantly improved with alectinib versus crizotinib. In patients with baseline brain scans, a substantial rwPFS benefit was found regardless of baseline CNS metastases. Real-world time to new CNS metastases was delayed with alectinib versus crizotinib in patients with (wHR = 0.28, 95% CI: 0.16-0.52) and without (wHR = 0.42, 95% CI: 0.24-0.76) baseline CNS metastases. The ALEX-like RWD cohort comprised 325 patients (120 alectinib; 205 crizotinib); alectinib was found to have similar rwPFS benefits with ALEX. Conclusions Outcomes were significantly improved with first-line alectinib versus crizotinib in patients with advanced ALK-positive NSCLC in the U.S. real-world setting.
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Affiliation(s)
- Qing Zhang
- Genentech, Inc., South San Francisco, California
| | - Jessica J. Lin
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Navdeep Pal
- Genentech, Inc., South San Francisco, California
| | | | - Huong Trinh
- Genentech, Inc., South San Francisco, California
| | | | | | | | - Venice Archer
- Roche Products Ltd., Welwyn Garden City, United Kingdom
| | - Matthew G. Krebs
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester and The Christie NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
- Corresponding author. Address for correspondence: Matthew G. Krebs, MD, PhD, Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester and The Christie NHS Foundation Trust, Wilmslow Road, Manchester, M20 4BX, UK.
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Dziadziuszko R, Peters S, Ruf T, Cardona A, Guerini E, Kurtsikidze N, Smoljanovic V, Planchard D. Clinical experience and management of adverse events in patients with advanced ALK-positive non-small-cell lung cancer receiving alectinib. ESMO Open 2022; 7:100612. [PMID: 36375271 PMCID: PMC9663323 DOI: 10.1016/j.esmoop.2022.100612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 09/22/2022] [Accepted: 09/27/2022] [Indexed: 11/13/2022] Open
Abstract
Alectinib is a preferred first-line therapy for patients with advanced anaplastic lymphoma kinase (ALK)-positive non-small-cell lung cancer (NSCLC) in several national clinical practice guidelines. The randomized, global, phase III ALEX study has demonstrated significant improvement in progression-free survival for alectinib over crizotinib in treatment-naive ALK-positive NSCLC. It was also the first study to show clinically meaningful improvement in overall survival for a next-generation ALK tyrosine kinase inhibitor relative to crizotinib. The J-ALEX and ALESIA phase III studies confirmed the clinical benefit of alectinib relative to crizotinib in the first-line ALK-positive NSCLC treatment setting in Japanese and Asian patients, respectively. Across these pivotal phase III trials, alectinib had a manageable, well-characterized safety profile. Here, we review the safety and tolerability of long-term alectinib treatment in patients with advanced ALK-positive NSCLC and provide guidance for physicians, based on clinical experience, on the management of the most frequently reported adverse events (AEs). Most AEs associated with alectinib can be managed by dose reduction. Some alectinib-related AEs are not yet fully characterized, including myalgia and peripheral oedema and deciphering their underlying mechanism of action could enhance their management. With longer-term follow-up, the safety profile of alectinib continues to remain consistent in the ALEX study, with no new safety signals observed. Safety and tolerability data from the first-line phase III alectinib trials are also consistent with those observed in clinical trials of alectinib in later-line settings. These results add to the weight of evidence recommending alectinib as a preferred therapy for treatment-naive advanced ALK-positive NSCLC.
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Affiliation(s)
- R Dziadziuszko
- Department of Oncology and Radiotherapy, Medical University of Gdansk, Gdansk, Poland
| | - S Peters
- Lausanne University Hospital, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - T Ruf
- F. Hoffmann-La Roche Ltd., Basel, Switzerland
| | - A Cardona
- F. Hoffmann-La Roche Ltd., Basel, Switzerland
| | - E Guerini
- F. Hoffmann-La Roche Ltd., Basel, Switzerland
| | | | | | - D Planchard
- Department of Medical Oncology, Thoracic Oncology Unit, Gustave Roussy Cancer Campus, Villejuif, France.
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Dingemans AMC, Griesinger F, Paz-Ares L, Perol M, Ren S, Höglander E, Kurtsikidze N, Siena S. A randomized phase 3 study of entrectinib versus crizotinib in patients (pts) with locally advanced/metastatic ROS1 fusion-positive (fp) NSCLC with or without baseline CNS metastases (mets). J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.tps9141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
TPS9141 Background: ROS proto-oncogene 1 ( ROS1) fusions are found in 1–2% of NSCLC cases. As CNS mets are common in pts with ROS1-fp NSCLC and associated with poor prognosis, CNS-active treatments are needed for these pts. Entrectinib and crizotinib are tyrosine kinase inhibitors (TKIs) of ROS1, recommended as first-line treatments for ROS1-fp NSCLC. Both drugs have shown robust systemic efficacy and good tolerability in pts with ROS1-fp NSCLC. While crizotinib may have suboptimal CNS activity, entrectinib has shown intracranial efficacy in pts with baseline CNS mets by blinded independent central review (BICR, PMIDs 30215676; 33646820). We hypothesized that entrectinib may have greater CNS activity than crizotinib, potentially addressing the unmet need for pts with ROS1-fp NSCLC with CNS mets. Methods: This randomized, open-label, multicenter, phase 3 trial (NCT04603807) aims to compare the efficacy and safety of entrectinib vs crizotinib in adult pts with TKI-naïve advanced/metastatic ROS1-fp NSCLC, with or without CNS mets. Key eligibility criteria: advanced/recurrent/metastatic NSCLC with ROS1 fusion determined locally by certified clinical laboratory testing; measurable systemic disease (RECIST 1.1); age ≥18 years; ECOG PS ≤2; no prior ROS1 TKI or systemic treatment for advanced/metastatic disease; adequate hematologic, renal and hepatic functions; prior radiotherapy ≥14 days before randomization and neurologically stable CNS mets per RECIST 1.1 are permitted. Pts will be randomized 1:1 to receive 600 mg entrectinib once a day or 250 mg crizotinib twice a day. Stratification factors are baseline CNS mets (none/measurable/non-measurable) and prior brain radiotherapy ≤2 months (yes/no); to allow sufficient power, ≥30% of randomized pts will have baseline CNS mets. Study treatment will continue until progressive disease, unacceptable toxicity, death or withdrawal from the study. Pts with radiographic disease progression or isolated asymptomatic CNS progression may continue treatment at the investigator’s discretion. Tumor assessments (brain MRI and chest, abdomen and pelvis CT/MRI) will occur at screening, Wk 4, Wk 8 and every 8 wks thereafter. Blood samples will be collected at every visit. Primary endpoint: progression-free survival (PFS) by BICR in pts with baseline CNS mets (CNS population, target HR = 0.57). Secondary endpoints: CNS-PFS by BICR and ORR, duration of response (DoR) and PFS (by BICR and investigator) in the intent-to-treat (ITT) population; overall survival in the CNS and ITT populations; CNS-ORR and CNS-DoR by BICR in the CNS population. Impact on quality of life, functioning and lung cancer-specific symptoms will be evaluated via questionnaires in the ITT population. Safety endpoints and biomarkers will also be evaluated. As of 12 Jan 2022, 8 pts are enrolled (first pt enrolled in Oct 2021). Clinical trial information: NCT04603807.
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Affiliation(s)
| | - Frank Griesinger
- Department of Haematology and Oncology, Pius-Hospital Oldenburg Medical Campus, Oldenburg, Germany
| | - Luis Paz-Ares
- Hospital Universitario Doce de Octubre and CNIO, Madrid, Spain
| | - Maurice Perol
- Department of Medical Oncology, Centre Léon Bérard, Lyon, France
| | - Shengxiang Ren
- Department of Oncology, Shanghai Pulmonary Hospital & Thoracic Cancer Institute, Tongji University School of Medicine, Shanghai, China
| | - Elen Höglander
- Oncology Biomarker Development, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Nino Kurtsikidze
- Product Development and Medical Affairs, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Salvatore Siena
- Niguarda Cancer Center, Grande Ospedale Metropolitano Niguarda, and Dipartimento di Oncologia ed Emato-Oncologia, Università degli Studi di Milano, Milano, Italy
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Drilon A, Chiu CH, Fan Y, Cho BC, Lu S, Ahn MJ, Krebs MG, Liu SV, John T, Otterson GA, Tan DS, Patil T, Dziadziuszko R, Massarelli E, Seto T, Doebele RC, Pitcher B, Kurtsikidze N, Heinzmann S, Siena S. Long-Term Efficacy and Safety of Entrectinib in ROS1 Fusion-Positive Non-Small Cell Lung Cancer. JTO Clin Res Rep 2022; 3:100332. [PMID: 35663414 PMCID: PMC9160474 DOI: 10.1016/j.jtocrr.2022.100332] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 04/22/2022] [Indexed: 11/18/2022] Open
Affiliation(s)
- Alexander Drilon
- Department of Medicine, Memorial Sloan Kettering Cancer Center, and Weill Cornell Medical College, New York, New York
| | - Chao-Hua Chiu
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yun Fan
- Zhejiang Cancer Hospital, Hangzhou, People’s Republic of China
| | - Byoung Chul Cho
- Division of Medical Oncology, Yonsei Cancer Center, Seoul, Republic of Korea
| | - Shun Lu
- Department of Medical Oncology, Shanghai Lung Cancer Center, Shanghai Chest Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People’s Republic of China
| | - Myung-Ju Ahn
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Matthew G. Krebs
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester and The Christie National Health Service (NHS) Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | | | - Thomas John
- Department of Medical Oncology, Peter MacCallum Cancer Center, and Olivia Newton-John Cancer Centre, Austin Health, Melbourne, Australia
| | - Gregory A. Otterson
- Arthur G. James Cancer Hospital, and Richard J. Solove Research Institute, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio
| | - Daniel S.W. Tan
- Division of Medical Oncology, National Cancer Centre Singapore, Duke–National University of Singapore (NUS) Medical School, Singapore
| | - Tejas Patil
- Division of Medical Oncology, Department of Medicine, University of Colorado, Aurora, Colorado
| | - Rafal Dziadziuszko
- Department of Oncology and Radiotherapy and Early Clinical Trials Center, Medical University of Gdansk, Gdansk, Poland
| | - Erminia Massarelli
- Department of Medical Oncology & Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Takashi Seto
- Department of Thoracic Oncology, National Hospital Organization Kyushu Cancer Center, Fukuoka, Japan
| | - Robert C. Doebele
- Division of Medical Oncology, Department of Medicine, University of Colorado, Aurora, Colorado
| | | | | | - Sebastian Heinzmann
- Niguarda Cancer Center, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Salvatore Siena
- Niguarda Cancer Center, Grande Ospedale Metropolitano Niguarda, Milan, Italy
- Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milan, Italy
- Corresponding author. Address for correspondence: Salvatore Siena, MD, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano (La Statale), Ospedale Niguarda, Piazza Ospedale Maggiore 2, 20146 Milano, Italy.
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Krebs M, Lin J, Pal N, Polito L, Trinh H, Hilton M, Smoljanovic V, Kurtsikidze N, Archer V, Zhang Q. 1201P Real-world comparative effectiveness of 1L alectinib (ALC) vs crizotinib (CRZ) in patients (pts) with ALK+ advanced NSCLC with or without baseline CNS metastases (mets). Ann Oncol 2021. [DOI: 10.1016/j.annonc.2021.08.1806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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