551
|
Lewis JRR, Lipworth WL, Kerridge IH, Day RO. The economic evaluation of personalised oncology medicines: ethical challenges. Med J Aust 2013; 199:471-3. [DOI: 10.5694/mja13.10046] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Accepted: 08/13/2013] [Indexed: 01/31/2023]
Affiliation(s)
- Jan R R Lewis
- Centre for Values, Ethics and Law in Medicine, University of Sydney, Sydney, NSW
| | - Wendy L Lipworth
- Australian Institute of Health Innovation, University of New South Wales, Sydney, NSW
| | - Ian H Kerridge
- Centre for Values, Ethics and Law in Medicine, University of Sydney, Sydney, NSW
| | - Richard O Day
- Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, NSW
| |
Collapse
|
552
|
Abstract
Historically, all non-small cell lung cancers were essentially grouped together and considered to be a single disease. However, it is now recognized that non-small cell lung cancer actually comprises a genetically diverse group of tumours. This, in turn, affords a new opportunity for the development of effective treatments tailored to individual tumours and patients. Advances in molecular biology have made possible the development of drugs against specific molecular targets on cancer cells, most notably the tyrosine kinase inhibitors. The relevant literature and current practice guidelines are discussed. In addition, other related areas of active investigation, including tumour vaccines and pharmacogenetics, are briefly reviewed.
Collapse
|
553
|
Martin P, Owen SP, Leighl NB. Gefitinib: re-emerging from the shadows. Lung Cancer Manag 2013. [DOI: 10.2217/lmt.13.42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY In the past decade, the identification of mutations in the EGFR gene and the sensitivity of activating mutations to EGF receptor–tyrosine kinase inhibitors has improved survival in a subset of non-small-cell lung cancer patients. Over 70% of patients with EGFR mutations have a response to gefitinib therapy. Gefitinib, a first-generation EGF receptor–tyrosine kinase inhibitor, is well tolerated and continues to be widely used. However, eventually most patients develop resistance to gefitinib. This article reviews the pharmacology of gefitinib and summarizes the clinical trials that have resulted in its current day indications.
Collapse
Affiliation(s)
- Petra Martin
- Division of Medical Oncology, Princess Margaret Hospital/University Health Network, University of Toronto, Toronto, ON, Canada
| | - Scott P Owen
- Division of Medical Oncology, Princess Margaret Hospital/University Health Network, University of Toronto, Toronto, ON, Canada
| | - Natasha B Leighl
- Division of Medical Oncology, Princess Margaret Hospital/University Health Network, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
554
|
Ferreira CG, Montella TC, Baldotto CS, Domingues PM. Chemotherapy: still an essential player in non-small-cell lung cancer treatment? Lung Cancer Manag 2013. [DOI: 10.2217/lmt.13.43] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY Substantial advances have been made in understanding critical molecular and cellular mechanisms driving tumor initiation; these findings have led to the discovery of a variety of novel drug targets and the development of new treatment strategies. The treatment of non-small-cell lung cancer patients harboring gain-of-function hotspot mutations in EGFR gene or an ALK gene rearrangement, has provided an impressive clinical benefit and changed the management of this disease. The standard of care with cytotoxic chemotherapy empirically based on a patient’s clinicopathologic features is no longer acceptable. Nevertheless, chemotherapy still bears a crucial role in all subsets of patients diagnosed with non-small-cell lung cancer. This article aims to describe the emergence of these new treatment strategies and update the role of chemotherapy in the current setting.
Collapse
Affiliation(s)
- Carlos Gil Ferreira
- Clinical Research Department, Instituto Nacional de Câncer (INCA), Rio de Janeiro, Brazil
| | | | - Clarissa Seródio Baldotto
- Medical Oncology Department & Thoracic Oncology Tumor Group, Instituto Nacional de Câncer (INCA), Rio de Janeiro, Brazil
| | - Pedro Masson Domingues
- Clinical Research Department, Instituto Nacional de Câncer (INCA), Rio de Janeiro, Brazil
| |
Collapse
|
555
|
Abstract
Gefitinib and erlotinib are small-molecule reversible tyrosine kinase inhibitors (TKIs) of epidermal growth factor receptor (EGFR). Objective responses have been observed frequently in patients with non-small cell lung cancer (NSCLC) harbouring activating EGFR mutations, the most common being deletions in exon 19 and the exon 21 L858R mutation. EGFR mutations are prevalent in female patients, those who have never smoked, those of Asian ethnicity and those who have adenocarcinoma histology. Given the efficacy of EGFR TKIs in advanced NSCLC in the salvage setting, and their favourable toxicity profile compared with conventional chemotherapy, there is considerable interest in evaluating their efficacy in the first-line treatment of advanced NSCLC. To date, there have been several phase II and phase III studies that have examined the efficacy of first-line single-agent EGFR TKIs in unselected, clinically selected or molecularly selected populations. Here we review and compare the differences in these phase III trials. Most phase III trials chose progression-free survival (PFS) rather than overall survival (OS) as their primary endpoint. PFS was prolonged but OS was not. The recent development of novel irreversible EGFR TKIs, such as afatinib and dacomitinib, is also reviewed.
Collapse
|
556
|
Gelsomino F, Agustoni F, Niger M, Valota M, Haspinger ER. Epidermal Growth Factor Receptor Tyrosine Kinase Inhibitor Treatment in Patients With EGFR Wild-Type Non–Small-Cell Lung Cancer: The Never-Ending Story. J Clin Oncol 2013; 31:3291-3. [DOI: 10.1200/jco.2013.50.2617] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Francesco Gelsomino
- Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei Tumori, Milan, Italy
| | - Francesco Agustoni
- Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei Tumori, Milan, Italy
| | - Monica Niger
- Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei Tumori, Milan, Italy
| | - Marika Valota
- Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei Tumori, Milan, Italy
| | - Eva R. Haspinger
- Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei Tumori, Milan, Italy
| |
Collapse
|
557
|
Crizotinib in the Treatment of Non–Small-Cell Lung Cancer. Clin Lung Cancer 2013; 14:473-80. [DOI: 10.1016/j.cllc.2013.04.006] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Revised: 04/15/2013] [Accepted: 04/16/2013] [Indexed: 12/19/2022]
|
558
|
Practical tips and tricks with recently approved molecular targeted agents in non-small-cell lung cancer. EJC Suppl 2013. [PMID: 26217155 PMCID: PMC4041556 DOI: 10.1016/j.ejcsup.2013.07.058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
|
559
|
Passaro A, Gori B, de Marinis F. Afatinib as first-line treatment for patients with advanced non-small-cell lung cancer harboring EGFR mutations: focus on LUX-Lung 3 and LUX-Lung 6 phase III trials. J Thorac Dis 2013; 5:383-4. [PMID: 23991291 DOI: 10.3978/j.issn.2072-1439.2013.07.32] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2013] [Accepted: 07/24/2013] [Indexed: 11/14/2022]
Affiliation(s)
- Antonio Passaro
- 1 Oncological Pulmonary Unit, San Camillo, High Specialization Hospital, Rome, Italy
| | | | | |
Collapse
|
560
|
Are erlotinib and gefitinib interchangeable, opposite or complementary for non-small cell lung cancer treatment? Biological, pharmacological and clinical aspects. Crit Rev Oncol Hematol 2013; 89:300-13. [PMID: 24041630 DOI: 10.1016/j.critrevonc.2013.08.003] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2013] [Revised: 08/02/2013] [Accepted: 08/16/2013] [Indexed: 11/22/2022] Open
Abstract
Gefitinib and erlotinib are the two anti-epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) approved for treatment of advanced NSCLC patients. These drugs target one of the most important pathways in lung carcinogenesis and are able to exploit the phenomenon of 'oncogene addiction', with different efficacy according to EGFR gene mutational status in tumor samples. Gefitinib has been approved only for EGFR mutation bearing patients regardless the line of treatment, while erlotinib is also indicated in patients without EGFR mutation who undergo second- or third-line treatment. Some studies evaluated the main differences between these drugs both for direct comparison and to improve their sequential use. In particular, toxicity profile resulted partially different, and these observations may be explained by several molecular and pharmacokinetic features. Therefore, this review integrates preclinical data with clinical evidences of TKIs to guide the optimization of currently available treatments in advanced NSCLC patients.
Collapse
|
561
|
Langer CJ. Epidermal growth factor receptor inhibition in mutation-positive non-small-cell lung cancer: is afatinib better or simply newer? J Clin Oncol 2013; 31:3303-6. [PMID: 23980079 DOI: 10.1200/jco.2013.49.8782] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Corey J Langer
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
562
|
Suda K, Mitsudomi T. Development of personalized treatments in lung cancer: focusing on the EGFR mutations and beyond. LUNG CANCER (AUCKLAND, N.Z.) 2013; 4:43-53. [PMID: 28210134 PMCID: PMC5217442 DOI: 10.2147/lctt.s49603] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Lung cancers with epidermal growth factor receptor (EGFR) gene mutation account for ∼40% of adenocarcinoma in East Asians and ∼15% of that in Caucasians, which makes them one of the most common molecularly defined lung cancer subsets. The role of EGFR mutation as a strong predictive biomarker of response to EGFR-tyrosine kinase inhibitors (TKIs) was finally confirmed by the biomarker analysis of Iressa Pan-Asian Study (IPASS). Since the 2004 discovery of EGFR mutation in lung cancer, the EGFR mutation and EGFR-TKI treatment have been widely studied. These include characteristics of lung cancers with EGFR mutations; clinical efficacies and adverse effects of EGFR-TKIs in patients with EGFR-mutated lung cancers; development of novel EGFR-TKIs that may prolong progression-free survival of these patients or overcome resistance to first-generation EGFR-TKIs (gefitinib and erlotinib); optimal treatment schedules for EGFR-TKIs to delay emergence of resistance; molecular mechanisms of acquired resistance to EGFR-TKIs; treatment strategies after patients acquire resistance to EGFR-TKIs; and predictive biomarkers for EGFR-TKIs among patients with EGFR-mutated lung cancers. Some of these results are widely accepted, while others are apparent only in cell line models, preclinical animal models, or retrospective analyses (and sometimes conflict with each other). In this review, we summarize accumulated reports from the past decade, especially focusing on unanswered but important clinical questions in treating patients with EGFR-mutated lung cancers.
Collapse
Affiliation(s)
- Kenichi Suda
- Division of Thoracic Surgery, Department of Surgery, Kinki University Faculty of Medicine, Osaka-Sayama, Japan
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tetsuya Mitsudomi
- Division of Thoracic Surgery, Department of Surgery, Kinki University Faculty of Medicine, Osaka-Sayama, Japan
| |
Collapse
|
563
|
A phase II study of erlotinib in combination with bevacizumab versus chemotherapy plus bevacizumab in the first-line treatment of advanced non-squamous non-small cell lung cancer. Lung Cancer 2013; 82:276-81. [PMID: 23992877 DOI: 10.1016/j.lungcan.2013.08.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Revised: 07/29/2013] [Accepted: 08/01/2013] [Indexed: 12/30/2022]
Abstract
BACKGROUND Molecularly targeted agents for non-small cell lung cancer (NSCLC) can provide similar efficacy to chemotherapy without chemotherapy-associated toxicities. Combining two agents with different modes of action could further increase the efficacy of these therapies. The TASK study evaluated the efficacy and safety of the epidermal growth factor receptor tyrosine kinase inhibitor erlotinib in combination with the anti-angiogenic agent bevacizumab as first-line therapy in unselected, advanced non-squamous NSCLC patients. METHODS Patients were recruited from December 2007 to September 2008. Planned sample size was 200 patients, a total of 124 patients were randomized. Patients were randomized using a minimization algorithm 1:1 to receive bevacizumab (iv 15 mg/kg day 1 of each 21-day cycle) plus chemotherapy (gemcitabine/cisplatin or carboplatin/paclitaxel standard doses, 4-6 cycles) (BC arm) or bevacizumab plus erlotinib (p.o. 150 mg/day; BE arm) until disease progression or unacceptable toxicity. The primary endpoint was progression-free survival (PFS). If the hazard ratio (HR) of PFS for BE relative to BC was above 1.25 at the pre-planned interim analysis in favor of BC, the study would be re-evaluated. Secondary endpoints included overall survival, response rate and safety. RESULTS All randomized patients (n = 63 BE; n = 61 BC) were evaluated for the efficacy analyses. At the updated interim analysis, median PFS was 18.4 weeks (95% confidence interval [CI] 17.0-25.1) versus 25.0 weeks (95% CI 20.6-[not reached]) for BE versus BC, respectively (HR for death or disease progression, BE relative to BC, 2.05, p = 0.0183). The incidence of death was 19% for BE treatment compared with 11.5% for BC treatment. The HR for PFS at the updated interim analysis was above 1.25, therefore patients on the BE arm were permitted to change arms or switch to another drug and the study was terminated. Adverse events reported were as expected. CONCLUSIONS The TASK study did not show a benefit in terms of PFS for the combination of erlotinib with bevacizumab in unselected first-line advanced non-squamous NSCLC compared with chemotherapy plus bevacizumab.
Collapse
|
564
|
SEOM clinical guidelines for the treatment of non-small cell lung cancer (NSCLC) 2013. Clin Transl Oncol 2013; 15:977-84. [DOI: 10.1007/s12094-013-1085-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2013] [Accepted: 07/16/2013] [Indexed: 10/26/2022]
|
565
|
Lee Y, Han JY, Kim HT, Yun T, Lee GK, Kim HY, Lee JS. Impact of EGFR tyrosine kinase inhibitors versus chemotherapy on the development of leptomeningeal metastasis in never smokers with advanced adenocarcinoma of the lung. J Neurooncol 2013; 115:95-101. [DOI: 10.1007/s11060-013-1199-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Accepted: 06/26/2013] [Indexed: 12/31/2022]
|
566
|
Zhang JW, Zhao YY, Guo Y, Xue C, Hu ZH, Huang Y, Zhao HY, Zhang J, Wu X, Fang WF, Ma YX, Zhang L. The impact of both platinum-based chemotherapy and EGFR-TKIs on overall survival of patients with advanced non-small cell lung cancer. CHINESE JOURNAL OF CANCER 2013; 33:105-14. [PMID: 23816558 PMCID: PMC3935012 DOI: 10.5732/cjc.012.10274] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Both platinum-based doublet chemotherapy (PBC) and epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) prolong the survival of patients with advanced non-small cell lung cancer (NSCLC). In early studies, most patients underwent PBC as first-line treatment, but not all patients could afford EGFR-TKIs as second-line treatment. To understand the impact of PBC and EGFR-TKIs on NSCLC prognosis, we evaluated the association between the receipt of both regimens and overall survival (OS). Using MEDLINE and EMBASE, we identified prospective, randomized, controlled phase III clinical trials in advanced NSCLC that met the inclusion criteria: in general population with advanced NSCLC, the percentage of patients treated with both PBC and EGFR-TKIs was available in the trial and OS was reported. After collecting data from the selected trials, we correlated the percentage of patients treated with both PBC and EGFR-TKIs with the reported OS, using a weighted analysis. Fifteen phase III clinical trials—involving 11,456 adult patients in 32 arms—were included in the analysis, including 6 trials in Asian populations and 9 in non-Asian (predominantly Caucasian) populations. The OS was positively correlated with the percentage of patients treated with both PBC and EGFR-TKIs (r = 0.797, P < 0.001). The correlation was obvious in the trials in Asian populations (r = 0.936, P < 0.001) but was not statistically significant in the trials in predominantly Caucasian populations (r = 0.116, P = 0.588). These results suggest that treatment with PBC and EGFR-TKIs may provide a survival benefit to patients with advanced NSCLC, highlighting the importance of having both modalities available for therapy.
Collapse
Affiliation(s)
- Jian-Wei Zhang
- State Key Laboratory of Oncology in South China; Department of Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong 510060, P. R. China.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
567
|
Lindeman NI, Cagle PT, Beasley MB, Chitale DA, Dacic S, Giaccone G, Jenkins RB, Kwiatkowski DJ, Saldivar JS, Squire J, Thunnissen E, Ladanyi M, College of American Pathologists International Association for the Study of Lung Cancer and Association for Molecular Pathology. Molecular testing guideline for selection of lung cancer patients for EGFR and ALK tyrosine kinase inhibitors: guideline from the College of American Pathologists, International Association for the Study of Lung Cancer, and Association for Molecular Pathology. J Mol Diagn 2013; 15:415-53. [PMID: 23562183 DOI: 10.1016/j.jmoldx.2013.03.001] [Citation(s) in RCA: 343] [Impact Index Per Article: 31.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Accepted: 02/12/2013] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE To establish evidence-based recommendations for the molecular analysis of lung cancers that are required to guide EGFR- and ALK-directed therapies, addressing which patients and samples should be tested, and when and how testing should be performed. PARTICIPANTS Three cochairs without conflicts of interest were selected, one from each of the 3 sponsoring professional societies: College of American Pathologists, International Association for the Study of Lung Cancer, and Association for Molecular Pathology. Writing and advisory panels were constituted from additional experts from these societies. EVIDENCE Three unbiased literature searches of electronic databases were performed to capture published articles from January 2004 through February 2012, yielding 1533 articles whose abstracts were screened to identify 521 pertinent articles that were then reviewed in detail for their relevance to the recommendations. EVIDENCE was formally graded for each recommendation. CONSENSUS PROCESS Initial recommendations were formulated by the cochairs and panel members at a public meeting. Each guideline section was assigned to at least 2 panelists. Drafts were circulated to the writing panel (version 1), advisory panel (version 2), and the public (version 3) before submission (version 4). CONCLUSIONS The 37 guideline items address 14 subjects, including 15 recommendations (evidence grade A/B). The major recommendations are to use testing for EGFR mutations and ALK fusions to guide patient selection for therapy with an epidermal growth factor receptor (EGFR) or anaplastic lymphoma kinase (ALK) inhibitor, respectively, in all patients with advanced-stage adenocarcinoma, regardless of sex, race, smoking history, or other clinical risk factors, and to prioritize EGFR and ALK testing over other molecular predictive tests. As scientific discoveries and clinical practice outpace the completion of randomized clinical trials, evidence-based guidelines developed by expert practitioners are vital for communicating emerging clinical standards. Already, new treatments targeting genetic alterations in other, less common driver oncogenes are being evaluated in lung cancer, and testing for these may be addressed in future versions of these guidelines.
Collapse
Affiliation(s)
- Neal I Lindeman
- Department of Pathology, Brigham & Women's Hospital, Boston, MA 02115-6110, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
568
|
Lindeman NI, Cagle PT, Beasley MB, Chitale DA, Dacic S, Giaccone G, Jenkins RB, Kwiatkowski DJ, Saldivar JS, Squire J, Thunnissen E, Ladanyi M. Molecular testing guideline for selection of lung cancer patients for EGFR and ALK tyrosine kinase inhibitors: guideline from the College of American Pathologists, International Association for the Study of Lung Cancer, and Association for Molecular Pathology. J Thorac Oncol 2013; 8:823-59. [PMID: 23552377 PMCID: PMC4159960 DOI: 10.1097/jto.0b013e318290868f] [Citation(s) in RCA: 606] [Impact Index Per Article: 55.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To establish evidence-based recommendations for the molecular analysis of lung cancers that are that are required to guide EGFR- and ALK-directed therapies, addressing which patients and samples should be tested, and when and how testing should be performed. PARTICIPANTS Three cochairs without conflicts of interest were selected, one from each of the 3 sponsoring professional societies: College of American Pathologists, International Association for the Study of Lung Cancer, and Association for Molecular Pathology. Writing and advisory panels were constituted from additional experts from these societies. EVIDENCE Three unbiased literature searches of electronic databases were performed to capture articles published published from January 2004 through February 2012, yielding 1533 articles whose abstracts were screened to identify 521 pertinent articles that were then reviewed in detail for their relevance to the recommendations. Evidence was formally graded for each recommendation. CONSENSUS PROCESS Initial recommendations were formulated by the cochairs and panel members at a public meeting. Each guideline section was assigned to at least 2 panelists. Drafts were circulated to the writing panel (version 1), advisory panel (version 2), and the public (version 3) before submission (version 4). CONCLUSIONS The 37 guideline items address 14 subjects, including 15 recommendations (evidence grade A/B). The major recommendations are to use testing for EGFR mutations and ALK fusions to guide patient selection for therapy with an epidermal growth factor receptor (EGFR) or anaplastic lymphoma kinase (ALK) inhibitor, respectively, in all patients with advanced-stage adenocarcinoma, regardless of sex, race, smoking history, or other clinical risk factors, and to prioritize EGFR and ALK testing over other molecular predictive tests. As scientific discoveries and clinical practice outpace the completion of randomized clinical trials, evidence-based guidelines developed by expert practitioners are vital for communicating emerging clinical standards. Already, new treatments targeting genetic alterations in other, less common driver oncogenes are being evaluated in lung cancer, and testing for these may be addressed in future versions of these guidelines.
Collapse
Affiliation(s)
- Neal I Lindeman
- Department of Pathology, Brigham & Women's Hospital, Boston, Massachusetts 02115-6110, USA.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
569
|
Mechanisms of resistance to EGFR tyrosine kinase inhibitors gefitinib/erlotinib and to ALK inhibitor crizotinib. Lung Cancer 2013; 81:328-336. [PMID: 23809060 DOI: 10.1016/j.lungcan.2013.05.020] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Revised: 04/24/2013] [Accepted: 05/29/2013] [Indexed: 01/15/2023]
Abstract
The discovery of several molecular alterations that underlie non-small cell lung cancer (NSCLC) pathogenesis has led to the development of targeted therapies. In particular, gefitinib and erlotinib have become the standard of care in patients harboring epidermal growth factor receptor mutations, while crizotinib showed an impressive efficacy in patients with ALK-positive NSCLC. Nevertheless, the occurrence of clinical resistance limits the long term results of these novel agents. The identification of the molecular mechanisms responsible for acquired resistance to targeted therapy is crucial in order to pursue the creation of rational strategies to overcome resistance. In the current review, we will focus on the acquired resistance mechanisms to EGFR-TKIs and crizotinib and the therapeutic strategies currently under study to overcome resistance.
Collapse
|
570
|
Krawczyk P, Kowalski DM, Krawczyk KW, Szczyrek M, Mlak R, Rolski A, Szudy A, Kieszko R, Winiarczyk K, Milanowski J, Krzakowski M. Predictive and prognostic factors in second- and third-line erlotinib treatment in NSCLC patients with known status of the EGFR gene. Oncol Rep 2013; 30:1463-72. [PMID: 23783797 DOI: 10.3892/or.2013.2553] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Accepted: 05/14/2013] [Indexed: 11/05/2022] Open
Abstract
Erlotinib is a reversible tyrosine kinase inhibitor of epidermal growth factor receptor (TKI EGFR). In Poland, as of July 2012, it is used in the treatment only of patients with non-small cell lung cancer (NSCLC) and with EGFR mutation gene after standard chemotherapy failure. The effectiveness of erlotinib in second- or third-line treatment of NSCLC patients without EGFR activating mutation gene remains debatable. Clinical trial results indicated that TKI EGFR showed an efficacy of 70‑80% in patients with EGFR mutations, while the clinical response to treatment among unselected Caucasian patients is only 10%. The present study was conducted in a group of 71 patients with inoperable, locally advanced or metastatic NSCLC treated with erlotinib as the second- or third-line therapy. Molecular tests (examination of EGFR mutation and gene amplification) were carried out retrospectively. Objective response rate, overall survival (OS) and progression-free survival (PFS) were calculated. Effects of clinical and molecular factors including the presence of EGFR mutations, EGFR gene amplification, patient performance status, rash, smoking status, time from diagnosis to start of therapy, weight loss and the serum LDH levels were analyzed. An objective response in the form of partial response occurred in only 5 patients (7%), who carried EGFR gene mutation. Median time to PFS for the entire group of patients was 1.5 months and median OS was 10 months. The strongest factors increasing the risk of progression in patients treated with erlotinib were the absence of activating mutations in the EGFR gene (6‑fold increased risk) and no treatment‑related rash (4.5‑fold increased risk). The most important factors affecting the risk of early mortality were poor performance status (HR 37.344; P>0.0001), no treatment-related rash (HR 14.9348; P=0.0002) and a short response time on the first-line chemotherapy (HR 9.519; P=0.0445).
Collapse
Affiliation(s)
- Paweł Krawczyk
- Department of Pneumonology, Oncology and Allergology, Medical University of Lublin, Lublin, Poland
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
571
|
Landi L, Minuti G, D’Incecco A, Salvini J, Cappuzzo F. MET overexpression and gene amplification in NSCLC: a clinical perspective. LUNG CANCER (AUCKLAND, N.Z.) 2013; 4:15-25. [PMID: 28210131 PMCID: PMC5217438 DOI: 10.2147/lctt.s35168] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The transmembrane tyrosine kinase mesenchymal-epidermal transition (MET) receptor and its ligand, hepatocyte growth factor, also known as scatter factor, have recently been identified as novel promising targets in several human malignancies, including non-small cell lung cancer (NSCLC). Amplification, mutation, or overexpression of the MET gene can result in aberrant activation of the MET axis, leading to migration, invasion, proliferation, metastasis, and neoangiogenesis of cancer cells, suggesting that interfering with the MET/hepatocyte growth factor pathway could represent a potential antitumor strategy. While the role of MET mutations in NSCLC is not as yet fully understood, retrospective studies have shown that an increased MET gene copy number is a negative prognostic factor. In NSCLC, amplification of the MET gene is a relatively rare event, occurring in approximately 4% of patients not previously exposed to systemic therapies and in up to 20% of patients with acquired resistance to epidermal growth factor receptor tyrosine kinase inhibitors. In preclinical models, the presence of MET amplification is a predictor of high sensitivity to anti-MET compounds, and several agents have entered in clinical trials for patients having advanced disease, with promising results. The aim of the present review is to summarize available data on the role of MET in NSCLC and to describe therapeutic strategies under investigation.
Collapse
Affiliation(s)
- Lorenza Landi
- Medical Oncology Department, Istituto Toscano Tumori, Ospedale Civile, Livorno, Italy
| | - Gabriele Minuti
- Medical Oncology Department, Istituto Toscano Tumori, Ospedale Civile, Livorno, Italy
| | - Armida D’Incecco
- Medical Oncology Department, Istituto Toscano Tumori, Ospedale Civile, Livorno, Italy
| | - Jessica Salvini
- Medical Oncology Department, Istituto Toscano Tumori, Ospedale Civile, Livorno, Italy
| | - Federico Cappuzzo
- Medical Oncology Department, Istituto Toscano Tumori, Ospedale Civile, Livorno, Italy
| |
Collapse
|
572
|
Intercalated combination of chemotherapy and erlotinib for patients with advanced stage non-small-cell lung cancer (FASTACT-2): a randomised, double-blind trial. Lancet Oncol 2013; 14:777-86. [PMID: 23782814 DOI: 10.1016/s1470-2045(13)70254-7] [Citation(s) in RCA: 241] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The results of FASTACT, a randomised, placebo-controlled, phase 2 study, showed that intercalated chemotherapy and erlotinib significantly prolonged progression-free survival (PFS) in patients with advanced non-small-cell lung cancer. We undertook FASTACT-2, a phase 3 study in a similar patient population. METHODS In this phase 3 trial, patients with untreated stage IIIB/IV non-small-cell lung cancer were randomly assigned in a 1:1 ratio by use of an interactive internet response system with minimisation algorithm (stratified by disease stage, tumour histology, smoking status, and chemotherapy regimen) to receive six cycles of gemcitabine (1250 mg/m(2) on days 1 and 8, intravenously) plus platinum (carboplatin 5 × area under the curve or cisplatin 75 mg/m(2) on day 1, intravenously) with intercalated erlotinib (150 mg/day on days 15-28, orally; chemotherapy plus erlotinib) or placebo orally (chemotherapy plus placebo) every 4 weeks. With the exception of an independent group responsible for monitoring data and safety monitoring board, everyone outside the interactive internet response system company was masked to treatment allocation. Patients continued to receive erlotinib or placebo until progression or unacceptable toxicity or death, and all patients in the placebo group were offered second-line erlotinib at the time of progression. The primary endpoint was PFS in the intention-to-treat population. This trial is registered with ClinicalTrials.gov, number NCT00883779. FINDINGS From April 29, 2009, to Sept 9, 2010, 451 patients were randomly assigned to chemotherapy plus erlotinib (n=226) or chemotherapy plus placebo (n=225). PFS was significantly prolonged with chemotherapy plus erlotinib versus chemotherapy plus placebo (median PFS 7·6 months [95% CI 7·2-8·3], vs 6·0 months [5·6-7·1], hazard ratio [HR] 0·57 [0·47-0·69]; p<0·0001). Median overall survival for patients in the chemotherapy plus erlotinib and chemotherapy plus placebo groups was 18·3 months (16·3-20·8) and 15·2 months (12·7-17·5), respectively (HR 0·79 [0·64-0·99]; p=0·0420). Treatment benefit was noted only in patients with an activating EGFR gene mutation (median PFS 16·8 months [12·9-20·4] vs 6·9 months [5·3-7·6], HR 0·25 [0·16-0·39]; p<0·0001; median overall survival 31·4 months [22·2-undefined], vs 20·6 months [14·2-26·9], HR 0·48 [0·27-0·84]; p=0·0092). Serious adverse events were reported by 76 (34%) of 222 patients in the chemotherapy plus placebo group and 69 (31%) of 226 in the chemotherapy plus erlotinib group. The most common grade 3 or greater adverse events were neutropenia (65 [29%] patients and 55 [25%], respectively), thrombocytopenia (32 [14%] and 31 [14%], respectively), and anaemia (26 [12%] and 21 [9%], respectively). INTERPRETATION Intercalated chemotherapy and erlotinib is a viable first-line option for patients with non-small-cell lung cancer with EGFR mutation-positive disease or selected patients with unknown EGFR mutation status. FUNDING F Hoffmann-La Roche.
Collapse
|
573
|
Routine EGFR molecular analysis in non-small-cell lung cancer patients is feasible: exons 18-21 sequencing results of 753 patients and subsequent clinical outcomes. Lung 2013; 191:491-9. [PMID: 23749122 DOI: 10.1007/s00408-013-9482-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Accepted: 05/15/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Epidermal growth factor receptor (EGFR)-targeting therapies dramatically modified the prognosis of stage 4 non-small-cell lung cancer. Sensitizing EGFR mutations are the best efficacy factor of these treatments. In 2006, the French National Cancer Institute launched a network of 28 centers for EGFR molecular analysis in routine practice. The aim of this retrospective study was to describe the results of routine EGFR analysis in one of these centers (Lyon University Hospital) and to assess outcomes in patients with the mutation. METHODS EGFR mutations were analyzed for exons 18-21 by direct sequencing. The characteristics of each sample were retrospectively collected from the lab archives. Subsequent outcomes for patients harboring at least one mutation were retrospectively collected from each referring physician. RESULTS During 1 year, 792 samples were analyzed, corresponding to 753 patients. A total of 133 mutations were diagnosed in 124 samples (15.7 %), corresponding to 121 patients. Most of them (77.4 %) were sensitizing mutations and were located in exons 19 and 21. Others were resistance mutations (8.3 %) or rare mutations (14.3 %) for which effects on tyrosine kinase inhibitor (TKI) sensitivity are unknown. The rate of indeterminate results (i.e., no sequencing of the entire exon 19 or 21) was 6.3 % (n = 50 samples). The only factor statistically associated with a risk of failure was sample from bone tissue: 13.7 % gave incomplete results (i.e., no whole sequencing of exons 18-21). CONCLUSIONS Eighty-five of the 121 patients with EGFR mutations were treated with TKI. There were no differences in progression free survival (PFS) according to the type of molecule (erlotinib or gefitinib) or to the line of prescription of TKI. By contrast, exon 18 sensitizing mutations showed a worse PFS than exon 19 or 21 mutations. Finally, dose reduction was significantly more frequent in the erlotinib group than in the gefitinib group.
Collapse
|
574
|
Kaneda H, Yoshida T, Okamoto I. Molecularly targeted approaches herald a new era of non-small-cell lung cancer treatment. Cancer Manag Res 2013; 5:91-101. [PMID: 23785245 PMCID: PMC3682814 DOI: 10.2147/cmar.s32973] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
The discovery of activating mutations in the epidermal growth-factor receptor (EGFR) gene in 2004 opened a new era of personalized treatment for non-small-cell lung cancer (NSCLC). EGFR mutations are associated with a high sensitivity to EGFR tyrosine kinase inhibitors, such as gefitinib and erlotinib. Treatment with these agents in EGFR-mutant NSCLC patients results in dramatically high response rates and prolonged progression-free survival compared with conventional standard chemotherapy. Subsequently, echinoderm microtubule-associated protein-like 4 (EML4)–anaplastic lymphoma kinase (ALK), a novel driver oncogene, has been found in 2007. Crizotinib, the first clinically available ALK tyrosine kinase inhibitor, appeared more effective compared with standard chemotherapy in NSCLC patients harboring EML4-ALK. The identification of EGFR mutations and ALK rearrangement in NSCLC has further accelerated the shift to personalized treatment based on the appropriate patient selection according to detailed molecular genetic characterization. This review summarizes these genetic biomarker-based approaches to NSCLC, which allow the instigation of individualized therapy to provide the desired clinical outcome.
Collapse
Affiliation(s)
- Hiroyasu Kaneda
- Department of Medical Oncology, Kinki University, Osakasayama, Japan
| | | | | |
Collapse
|
575
|
Lindeman NI, Cagle PT, Beasley MB, Chitale DA, Dacic S, Giaccone G, Jenkins RB, Kwiatkowski DJ, Saldivar JS, Squire J, Thunnissen E, Ladanyi M. Molecular testing guideline for selection of lung cancer patients for EGFR and ALK tyrosine kinase inhibitors: guideline from the College of American Pathologists, International Association for the Study of Lung Cancer, and Association for Molecular Pathology. Arch Pathol Lab Med 2013; 137:828-60. [PMID: 23551194 PMCID: PMC4162344 DOI: 10.5858/arpa.2012-0720-oa] [Citation(s) in RCA: 331] [Impact Index Per Article: 30.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To establish evidence-based recommendations for the molecular analysis of lung cancers that are required to guide EGFR- and ALK-directed therapies, addressing which patients and samples should be tested, and when and how testing should be performed. PARTICIPANTS Three cochairs without conflicts of interest were selected, one from each of the 3 sponsoring professional societies: College of American Pathologists, International Association for the Study of Lung Cancer, and Association for Molecular Pathology. Writing and advisory panels were constituted from additional experts from these societies. EVIDENCE Three unbiased literature searches of electronic databases were performed to capture articles published from January 2004 through February 2012, yielding 1533 articles whose abstracts were screened to identify 521 pertinent articles that were then reviewed in detail for their relevance to the recommendations. Evidence was formally graded for each recommendation. CONSENSUS PROCESS Initial recommendations were formulated by the cochairs and panel members at a public meeting. Each guideline section was assigned to at least 2 panelists. Drafts were circulated to the writing panel (version 1), advisory panel (version 2), and the public (version 3) before submission (version 4). CONCLUSIONS The 37 guideline items address 14 subjects, including 15 recommendations (evidence grade A/B). The major recommendations are to use testing for EGFR mutations and ALK fusions to guide patient selection for therapy with an epidermal growth factor receptor (EGFR) or anaplastic lymphoma kinase (ALK) inhibitor, respectively, in all patients with advanced-stage adenocarcinoma, regardless of sex, race, smoking history, or other clinical risk factors, and to prioritize EGFR and ALK testing over other molecular predictive tests. As scientific discoveries and clinical practice outpace the completion of randomized clinical trials, evidence-based guidelines developed by expert practitioners are vital for communicating emerging clinical standards. Already, new treatments targeting genetic alterations in other, less common driver oncogenes are being evaluated in lung cancer, and testing for these may be addressed in future versions of these guidelines.
Collapse
Affiliation(s)
- Neal I Lindeman
- Department of Pathology, Brigham & Women's Hospital, Boston, MA 02115-6110, USA.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
576
|
Berardi R, Santoni M, Morgese F, Ballatore Z, Savini A, Onofri A, Mazzanti P, Pistelli M, Pierantoni C, De Lisa M, Caramanti M, Pagliaretta S, Pellei C, Cascinu S. Novel small molecule EGFR inhibitors as candidate drugs in non-small cell lung cancer. Onco Targets Ther 2013; 6:563-76. [PMID: 23723712 PMCID: PMC3665567 DOI: 10.2147/ott.s28155] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
In the last decade, better understanding of the role of epidermal growth factor receptor in the pathogenesis and progression of non-small cell lung cancer has led to a revolution in the work-up of these neoplasms. Tyrosine kinase inhibitors, such as erlotinib and gefitinib, have been approved for the treatment of non-small cell lung cancer, demonstrating an improvement in progression-free and overall survival, particularly in patients harboring activating EGFR mutations. Nevertheless, despite initial responses and long-lasting remissions, resistance to tyrosine kinase inhibitors invariably develops, most commonly due to the emergence of secondary T790M mutations or to the amplification of mesenchymal-epithelial transition factor (c-Met), which inevitably leads to treatment failure. Several clinical studies are ongoing (http://www.clinicaltrials.gov), aimed to evaluate the efficacy and toxicity of combined approaches and to develop novel irreversible or multitargeted tyrosine kinase inhibitors and mutant-selective inhibitors to overcome such resistance. This review is an overview of ongoing Phase I, II, and III trials of novel small molecule epidermal growth factor receptor inhibitors and combinations in non-small cell lung cancer patients.
Collapse
Affiliation(s)
- Rossana Berardi
- Medical Oncology Unit, Universita Politecnica delle Marche, Azienda Ospedaliero-Universitaria Ospedali Riuniti Umberto I - GM Lancisi - G Salesi, Ancona, Italy
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
577
|
Chen X, Zhu Q, Zhu L, Pei D, Liu Y, Yin Y, Schuler M, Shu Y. Clinical perspective of afatinib in non-small cell lung cancer. Lung Cancer 2013; 81:155-61. [PMID: 23664448 DOI: 10.1016/j.lungcan.2013.02.021] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Accepted: 02/27/2013] [Indexed: 01/09/2023]
Abstract
Reversible ATP-competitive inhibitors targeting the epidermal growth factor receptor (EGFR) have been established as the most effective treatment of patients with advanced non-small cell lung cancer (NSCLC) harboring "activating" mutations in exons 19 and 21 of the EGFR gene. However, clinical activity is limited by acquired resistance which on average develops within 10 months of continued treatment. The mechanisms for acquired resistance include selection of the EGFR T790M mutation in approximately 50% of cases, and MET gene amplification, PIK3CA gene mutation, transdifferentiation into small-cell lung cancer and additional rare or unkown mechanisms. Afatinib is a small molecule covalently binding and inhibiting the EGFR, HER2 and HER4 receptor tyrosine kinases. In preclinical studies, afatinib not only inhibited the growth of models with common activating EGFR mutations, but was also active in lung cancer models harboring wild-type EGFR or the EGFR L858R/T790M double mutant. Clinical efficacy of afatinib has been extensively studied in the LUX-Lung study program. These trials showed promising efficacy in patients with EGFR-mutant NSCLC or enriched for clinical benefit from EGFR tyrosine kinase inhibitors gefitinib or erlotinib. Here we review the current status of clinical application of afatinib in NSCLC. We also discuss clinical aspects of resistance to afatinib and strategies for its circumvention.
Collapse
Affiliation(s)
- Xiaofeng Chen
- Department of Oncology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | | | | | | | | | | | | | | |
Collapse
|
578
|
Bayraktar S, Rocha-Lima CM. Molecularly targeted therapies for advanced or metastatic non-small-cell lung carcinoma. World J Clin Oncol 2013; 4:29-42. [PMID: 23696960 PMCID: PMC3659261 DOI: 10.5306/wjco.v4.i2.29] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Revised: 04/09/2013] [Accepted: 04/17/2013] [Indexed: 02/06/2023] Open
Abstract
Non-small-cell lung cancer (NSCLC) remains the leading cause of cancer-related death in both men and women in the United States. Platinum-based doublet chemotherapy has been a standard for patients with advanced stage disease. Improvements in overall survival and quality of life have been modest. Improved knowledge of the aberrant molecular signaling pathways found in NSCLC has led to the development of biomarkers with associated targeted therapeutics, thus changing the treatment paradigm for many NSCLC patients. In this review, we present a summary of many of the currently investigated biologic targets in NSCLC, discuss their current clinical trial status, and also discuss the potential for development of other targeted agents.
Collapse
|
579
|
Ou SHI. Lung cancer in never-smokers. Does smoking history matter in the era of molecular diagnostics and targeted therapy? J Clin Pathol 2013; 66:839-46. [PMID: 23661716 DOI: 10.1136/jclinpath-2012-201296] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Lung cancer in never-smokers was recognised as a distinct clinical entity around the mid-2000s because these patients tended to be Asian women and diagnosed at a younger age with a preponderance of adenocarcinoma and better survival outcome despite a more advanced stage of presentation. It was soon discovered that lung cancer in never-smokers had a higher prevalence of activating EGFR mutations and we tend to classify lung cancer by smoking status for screening purpose. With the discoveries of many actionable driver mutations such as activating EGFR mutations and ALK rearrangement in adenocarcinoma of the lung we have switched to classifying non-small cell lung cancer into different individual molecular subgroups based on the presence of a dominant driver mutation. Although many actionable driver mutations are found in never-smokers with adenocarcinoma, this review will summarise that a substantial proportion of patients with these actionable driver mutations had a previous smoking history. Alternatively among the driver mutations that are associated with smoking history, a fair amount of these patients were never-smokers. Thus smoking status should not be used as a screen strategy for identifying driver mutations in clinical practice. Finally smoking history may have predictive and/or prognostic significance within individual molecular subgroups and identifying the difference according to smoking history may help optimise future targeted therapy.
Collapse
|
580
|
Pallis A, Syrigos K. Epidermal growth factor receptor tyrosine kinase inhibitors in the treatment of NSCLC. Lung Cancer 2013; 80:120-30. [DOI: 10.1016/j.lungcan.2012.12.025] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Revised: 12/08/2012] [Accepted: 12/16/2012] [Indexed: 01/16/2023]
|
581
|
Cardarella S, Johnson BE. Meta-Analysis of EGFR Kinase Inhibitors: Not Always Greater Than the Sum of Its Parts. J Natl Cancer Inst 2013; 105:589-90. [DOI: 10.1093/jnci/djt085] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
582
|
Lee CK, Brown C, Gralla RJ, Hirsh V, Thongprasert S, Tsai CM, Tan EH, Ho JCM, Chu DT, Zaatar A, Osorio Sanchez JA, Vu VV, Au JSK, Inoue A, Lee SM, Gebski V, Yang JCH. Impact of EGFR inhibitor in non-small cell lung cancer on progression-free and overall survival: a meta-analysis. J Natl Cancer Inst 2013; 105:595-605. [PMID: 23594426 DOI: 10.1093/jnci/djt072] [Citation(s) in RCA: 382] [Impact Index Per Article: 34.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Chee Khoon Lee
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, Australia.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
583
|
Tsao AS, Papadimitrakopoulou V. The importance of molecular profiling in predicting response to epidermal growth factor receptor family inhibitors in non-small-cell lung cancer: focus on clinical trial results. Clin Lung Cancer 2013; 14:311-21. [PMID: 23582282 DOI: 10.1016/j.cllc.2013.01.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Revised: 01/16/2013] [Accepted: 01/29/2013] [Indexed: 01/28/2023]
Abstract
In recent years, the epidermal growth factor receptor (EGFR) family has become a key focus of non-small-cell lung cancer biology and targeted therapies, such as the reversible EGFR tyrosine kinase inhibitors erlotinib and gefitinib. Initially, response to these agents was associated with certain demographic and clinical characteristics; subsequently, it was discovered that these subgroups were more likely to harbor specific mutations in the EGFR gene that enhanced tumor response. However, the presence of these mutations does not equate to therapeutic success. Other aspects of EGFR family signaling, including other types of EGFR mutations, EGFR protein expression, EGFR gene amplification, mediators of downstream signaling, and other receptors with similar downstream pathways may all play a role in response or resistance to treatment. The identification of these and other molecular determinants is driving the development of novel therapies designed to achieve improved clinical outcomes in patients.
Collapse
Affiliation(s)
- Anne S Tsao
- Department of Thoracic/Head and Neck Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
| | | |
Collapse
|
584
|
Cheema P, Burkes R. Overall survival should be the primary endpoint in clinical trials for advanced non-small-cell lung cancer. Curr Oncol 2013; 20:e150-60. [PMID: 23559882 PMCID: PMC3615866 DOI: 10.3747/co.20.1226] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
An article in a recent edition of Current Oncology explored the validation of progression-free survival (pfs) as an endpoint in clinical trials of antineoplastic agents for metastatic colorectal cancer, metastatic renal cell carcinoma, and ovarian cancer. The support for pfs as a surrogate endpoint for overall survival (os) was elucidated. As with the aforementioned tumour types, advanced non-small-cell lung cancer (nsclc) has seen a rise in active agents since the year 2000. Those agents range from improved cytotoxics such as pemetrexed, to targeted therapies such as tyrosine kinase inhibitors of the epidermal growth factor receptor and agents that target the EML4-ALK gene mutation. More recently, it has also become apparent that histology plays an important role in the response to and outcomes of treatment. With the therapeutic options for patients with advanced nsclc increasing, concerns are being raised that the efficacy of drugs measured by os may be diluted in clinical trials, thereby underestimating their true clinical benefit. That possibility, together with the need to have efficacious drugs available to patients earlier, has resulted in the search for a surrogate to the os endpoint in advanced nsclc. The present article follows up the recent article on pfs as a surrogate. Although advances in identifying pfs as a valid surrogate endpoint for os have been made in other tumour types, in advanced nsclc, such surrogacy has not been formally validated. Until it has, os should remain the primary endpoint of clinical trials in advanced nsclc.
Collapse
Affiliation(s)
- P.K. Cheema
- Sunnybrook Health Sciences Centre/Odette Cancer Centre, Toronto, ON
| | - R.L. Burkes
- Mount Sinai Hospital, Toronto, ON
- University of Toronto, Department of Medicine, Toronto, ON
| |
Collapse
|
585
|
Pilotto S, Bria E. Predictors of outcome for EGFR-mutant non-small-cell lung cancer treated with first-line tyrosine kinase inhibitors. Lung Cancer Manag 2013. [DOI: 10.2217/lmt.12.57] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Sara Pilotto
- Medical Oncology, ‘GB Rossi’ Academic Hospital, Azienda Ospedaliera Universitaria Integrata, University of Verona, Verona, Italy
| | - Emilio Bria
- Medical Oncology, ‘GB Rossi’ Academic Hospital, Azienda Ospedaliera Universitaria Integrata, University of Verona, Verona, Italy.
| |
Collapse
|
586
|
马 宇, 黄 岩, 赵 洪, 刘 俊, 陈 丽, 吴 海, 周 宁. [The cost-effectiveness analysis of gefitinib or erlotinib in the treatment of advanced EGFR mutant non-small cell lung cancer patients]. ZHONGGUO FEI AI ZA ZHI = CHINESE JOURNAL OF LUNG CANCER 2013; 16:203-10. [PMID: 23601301 PMCID: PMC6000588 DOI: 10.3779/j.issn.1009-3419.2013.04.06] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Revised: 03/20/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND Targeted therapy in non-small cell lung cancer (NSCLC) had become a research hotspot. Both of gefitinib and erlotinib had already been recommended as first line treatment in epidermal growth factor receptor (EGFR) mutant advanced NSCLC patients. The study aimed to compare the effectiveness and prognosis of advanced NSCLC with gefitinib or erlotinib, as well as the cost-effectiveness ratio of the two drugs. METHODS Data of 66 EGFR mutant NSCLC patients who were included in Guangzhou medical insurance were analyzed. The efficacy and adverse reactions were evaluated. All the patients were followed-up regularly and the cost of the treatment was recorded. RESULTS The median progression free survival (PFS) of all patients was 15.0 months. 49 patients received gefintib and 17 patients had erlotinib. The PFS for the two groups of patients was 17.5 month and 13 months, respectively (P=0.459). 31 (62.3%) patients had rash in gefitinib group, 16 (94.1%) in erlotinib group. Cost-effectiveness ratio (CER) in gefitinib group was 3,027 RMB per month, while 6,800 RMB in erlotinib group. The incremental cost-effectiveness ratio (ICEA) of erlotinib was 2.25 times of gefitinib. CONCLUSIONS For EGFR mutant advanced NSCLC patients, equal efficacy and survival benefit were observed in patients with gefitinib and erlotinib. The adverse reaction was milder in gefitinib group than that of erlotinib group. And with Guangzhou medical insurance, gefitinib had a superior cost-effectiveness ratio.
Collapse
Affiliation(s)
- 宇翔 马
- />510060 广州,中山大学附属肿瘤医院内科Department of Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou 510060, China
| | - 岩 黄
- />510060 广州,中山大学附属肿瘤医院内科Department of Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou 510060, China
| | - 洪云 赵
- />510060 广州,中山大学附属肿瘤医院内科Department of Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou 510060, China
| | - 俊玲 刘
- />510060 广州,中山大学附属肿瘤医院内科Department of Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou 510060, China
| | - 丽昆 陈
- />510060 广州,中山大学附属肿瘤医院内科Department of Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou 510060, China
| | - 海鹰 吴
- />510060 广州,中山大学附属肿瘤医院内科Department of Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou 510060, China
| | - 宁宁 周
- />510060 广州,中山大学附属肿瘤医院内科Department of Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou 510060, China
| |
Collapse
|
587
|
Wu YL, Fukuoka M, Mok TSK, Saijo N, Thongprasert S, Yang JCH, Chu DT, Yang JJ, Rukazenkov Y. Tumor response and health-related quality of life in clinically selected patients from Asia with advanced non-small-cell lung cancer treated with first-line gefitinib: post hoc analyses from the IPASS study. Lung Cancer 2013; 81:280-7. [PMID: 23540718 DOI: 10.1016/j.lungcan.2013.03.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Revised: 02/21/2013] [Accepted: 03/05/2013] [Indexed: 10/27/2022]
Abstract
BACKGROUND In IPASS (NCT00322452), progression-free survival (PFS, primary endpoint) was significantly longer with first-line gefitinib versus carboplatin/paclitaxel in never/light ex-smokers with advanced pulmonary adenocarcinoma in Asia, both in the overall intent-to-treat (ITT) population and in the EGFR mutation-positive subgroup. To further characterize the clinical relevance of these data, we investigated objective response rate (ORR) and health-related quality of life (HRQoL) in patients treated with gefitinib. METHODS Objective response was assessed (RECIST) 6-weekly (previously reported). Post hoc assessments included median time to response, median duration of response and change in tumor size. The analysis of response population included those patients treated with gefitinib who responded (n = 262 from ITT; n = 94 from EGFR mutation-positive subgroup). The percentage of patients with deterioration in HRQoL (Functional Assessment of Cancer Therapy-Lung [FACT-L], Trial Outcome Index [TOI]) and symptoms (Lung Cancer Subscale [LCS]) at 4 months post-randomization was analyzed according to progression status (EFQ population grouped by progressors/non-progressors in both treatment arms). The ORR (ITT) and incidence of skin rash/acne (evaluable-for-safety) were summarized. RESULTS In patients whose tumors responded to gefitinib, median time to response was 6.1 weeks in the ITT population (n = 262) and 6.0 weeks in the EGFR mutation-positive subgroup (n = 94); median duration of response was 9.7 and 8.7 months in these groups, respectively. There was significant tumor shrinkage with gefitinib. A greater percentage of patients in the EFQ population whose tumors progressed experienced deterioration in HRQoL and symptoms at 4 months versus patients whose tumors did not progress (FACT-L 33.7% vs 16.3%; TOI 33.7% vs 13.2%; LCS 31.7% vs 15.5%). In the gefitinib arm of the EFS population, incidence of rash was 75.8% and 68.1% in EGFR mutation-positive and -negative subgroups, respectively (with ORR for the gefitinib arm of the ITT 71.2% vs 1.1%, respectively). CONCLUSIONS Patients whose tumors responded to first-line gefitinib experienced significant tumor shrinkage and a rapid, durable response. Deterioration in HRQoL and lung cancer symptoms at 4 months post-randomization was found to be associated with tumor progression, highlighting the role of patient-reported outcomes in the evaluation of advanced NSCLC disease. Rash was not supported as a predictive marker of response to gefitinib.
Collapse
Affiliation(s)
- Yi-Long Wu
- Guangdong Lung Cancer Institute, Guangdong General Hospital & Guangdong Academy of Medical Sciences, Guangzhou, China.
| | | | | | | | | | | | | | | | | |
Collapse
|
588
|
Laurie SA, Goss GD. Role of Epidermal Growth Factor Receptor Inhibitors in Epidermal Growth Factor Receptor Wild-Type Non–Small-Cell Lung Cancer. J Clin Oncol 2013; 31:1061-9. [DOI: 10.1200/jco.2012.43.4522] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Worldwide, the majority of patients with advanced non–small-cell lung cancer (NSCLC) do not have activating mutations in the tyrosine kinase domain of the epidermal growth factor receptor (EGFR). These wild-type patients comprise a significant proportion of those treated with inhibitors of this pathway, and data from randomized trials suggest that some of these wild-type patients will derive a modest benefit from these agents. Although the detection of an activating mutation predicts for a greater likelihood of response and longer progression-free survival from an EGFR tyrosine kinase inhibitor, currently there are no biomarkers that consistently and reproducibly predict for lack of benefit in wild-type patients. Several strategies to increase the efficacy of these inhibitors in wild-type NSCLC are the subject of ongoing investigations.
Collapse
Affiliation(s)
- Scott A. Laurie
- All authors: Ottawa Hospital Cancer Centre, University of Ottawa, Ottawa, Ontario, Canada
| | - Glenwood D. Goss
- All authors: Ottawa Hospital Cancer Centre, University of Ottawa, Ottawa, Ontario, Canada
| |
Collapse
|
589
|
Mok T, Yang JJ, Lam KC. Treating Patients With EGFR-Sensitizing Mutations: First Line or Second Line—Is There a Difference? J Clin Oncol 2013; 31:1081-8. [PMID: 23401448 DOI: 10.1200/jco.2012.43.0652] [Citation(s) in RCA: 90] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
First-line epidermal growth factor receptor tyrosine kinase inhibitor (EGFR TKI) is a standard treatment for patients with activating EGFR mutations. Six randomized studies have demonstrated consistent improvement in tumor response rate and progression-free survival over platinum-based combination chemotherapy. The only reason to consider EGFR TKI as second-line therapy is that none of the six comparative studies has shown improvement in overall survival, which can be explained by the high proportion of patients from the chemotherapy arm crossing over to the EGFR TKI arm on progression. It is true that patients with EGFR mutations may benefit from second-line EGFR TKI therapy, but we cannot conclude that the benefit is either equal to or inferior to first-line EGFR TKI therapy. To date, there are no direct comparative data between first- and second-line EGFR TKI in patients with activating EGFR mutations. Tumor response rates to second-line EGFR TKI have been inconsistent, which could potentially be explained by the impact of first-line chemotherapy on the abundance of tumor cells with activating EGFR mutations. However, numerous arguments, including assurance on drug exposure, improvement in quality of life, better tolerance by patients with poor performance status, and deferral of whole-brain radiation therapy for patients with brain metastasis, support the general application of first-line EGFR TKI.
Collapse
Affiliation(s)
- Tony Mok
- Tony Mok and Kwok-Chi Lam, The Chinese University of Hong Kong, Sir Y.K. Pau Cancer Center, State Key Laboratory of Southern China, Prince of Wales Hospital, Hong Kong; and Jin-Ji Yang, Guangdong General Hospital, Guangdong, China
| | - Jin-Ji Yang
- Tony Mok and Kwok-Chi Lam, The Chinese University of Hong Kong, Sir Y.K. Pau Cancer Center, State Key Laboratory of Southern China, Prince of Wales Hospital, Hong Kong; and Jin-Ji Yang, Guangdong General Hospital, Guangdong, China
| | - Kwok-Chi Lam
- Tony Mok and Kwok-Chi Lam, The Chinese University of Hong Kong, Sir Y.K. Pau Cancer Center, State Key Laboratory of Southern China, Prince of Wales Hospital, Hong Kong; and Jin-Ji Yang, Guangdong General Hospital, Guangdong, China
| |
Collapse
|
590
|
|
591
|
Real world impact of epidermal growth factor receptor mutation status on treatment patterns in patients with non-small cell lung cancer. Lung Cancer 2013; 80:191-6. [PMID: 23384673 DOI: 10.1016/j.lungcan.2013.01.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2012] [Revised: 12/17/2012] [Accepted: 01/14/2013] [Indexed: 11/20/2022]
Abstract
BACKGROUND Epidermal growth factor receptor (EGFR) mutation status is an important predictor of the efficacy of EGFR tyrosine kinase inhibitor (TKI) therapy in patients with non-small cell lung cancer (NSCLC). We evaluated the real impact of EGFR mutation status on chemotherapy patterns of NSCLC patients. PATIENTS AND METHODS This is a retrospective cohort study of consecutive advanced NSCLC patients attended at the Samsung Medical Centre in Seoul, Korea, from January 2007 through July 2010. EGFR mutation was analyzed by direct sequencing testing. RESULTS Among 1164 patients treated during the study period, 166 (14.3%) were EGFR mutation positive, 275 (23.6%) were mutation negative, and 723 (62.1%) had mutation status unknown. Overall, 605 (52%) received TKI therapy as a first-, second-, or third-line therapy. The proportions of patients receiving TKI therapy among those with positive, negative and unknown EGFR mutation status were 88.0, 46.5, and 45.8%, respectively. After adjustment for other factors, patients with a positive EGFR mutation status (odds ratio [OR] 7.88, 95% CI 4.58, 13.57), and those who were female (OR 2.83, 95% CI 2.04, 3.92) or had poor performance status (OR 1.58, 95% CI 1.13, 2.22) were significantly more likely to receive TKI treatment. Furthermore, the temporal relationship between EGFR mutation reporting and initiation of TKI therapy significantly differed by EGFR mutation status. CONCLUSION EGFR mutation status significantly affected the chemotherapy patterns in advanced NSCLC. More widespread EGFR testing and the use of faster and more sensitive mutation tests will result in more timely and appropriate use of TKI therapy in advanced NSCLC.
Collapse
|
592
|
Abstract
Lung cancer is the leading worldwide cause of cancer deaths. Smoking is the dominant cause of lung cancer and smoking cessation is the established method to reduce lung cancer mortality. While lung cancer risk is reduced in former smokers, they have a lifelong increase in risk, compared to never-smokers. Novel chemoprevention strategies, such as oral or inhaled prostacyclin analogs, hold promise for these subjects. Low-dose spiral computed tomography screening reduced lung cancer mortality by 20% in high-risk heavy smokers older than 50 years. However, the high false-positive rate (96%) means that screened patients required controlled follow-up in experienced centers. An increasing percentage of patients with advanced lung cancer have molecular drivers in genes for which oral tyrosine kinase inhibitors have been developed.
Collapse
Affiliation(s)
- Paul A Bunn
- Division of Medical Oncology, University of Colorado, Aurora, CO 80045, USA.
| |
Collapse
|
593
|
Clinical meta-analyses of targeted therapies in adenocarcinoma. Target Oncol 2013; 8:35-45. [PMID: 23354875 DOI: 10.1007/s11523-013-0262-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2012] [Accepted: 01/15/2013] [Indexed: 01/01/2023]
Abstract
Although the interpretation of the data reported in meta-analyses may hide several issues, it is undoubtable that this methodological approach may significantly contribute to implement the results of clinical trials, and represent a useful and practical tool for the evidence-based medicine process. Indeed, level-one recommendations should consider well-conducted meta-analyses as well as large and adequately powered randomized trials as the main contributors for the definition of guidelines for clinical practice. In addition, the role of meta-analyses for issues whereas conflicting data (and/or unpowered results) are provided, is well established. In the field of lung cancer, meta-analyses already participated to change the current standard, and are now facing the challenging issues of predictive biomarkers of prognosis and/or efficacy of targeted agents. With this aim, the meta-analytic approach helped in the recent years to implement the quantification of the magnitude of the benefit of targeted agents, and added new insights by interpreting the data coming from clinical trials by integrating them with biomarkers. The treatment-interaction analyses according to putative predictive factors of efficacy may clarify unknown issues and generate new hypotheses for future perspectives. The current review attempts to put in the context of the clinical data of targeted agents for lung cancer all the pros and cons of the meta-analytic process published to date, and critically analyze all the potential perspectives which this methodology may add for both current practice and forthcoming research.
Collapse
|
594
|
Clinical outcomes in elderly patients administered gefitinib as first-line treatment in epidermal growth factor receptor-mutated non-small-cell lung cancer: retrospective analysis in a Nagano Lung Cancer Research Group study. Med Oncol 2013; 30:450. [PMID: 23315220 DOI: 10.1007/s12032-012-0450-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Accepted: 12/15/2012] [Indexed: 10/27/2022]
Abstract
The clinical efficacy and outcomes of gefitinib therapy as a first-line treatment for elderly patients with non-small-cell lung cancer (NSCLC) with epidermal growth factor receptor (EGFR) mutations were analyzed retrospectively. We analyzed chemotherapy-naïve NSCLC patients aged 75 years or older who had EGFR mutations (exon 19 deletion mutation or L858R), who were initially treated with gefitinib (250 mg) once daily in Nagano Prefecture. A total of 55 patients (16 men, 39 women) with a median age of 81.1 years (range; 75-94 years) treated between April 2007 and July 2012 were analyzed. The overall response rate and disease control rate were 72.7 % (95 % confidence interval (CI); 59.5-82.9 %) and 92.7 % (95 % CI; 82.0-97.6 %), respectively. Median progression-free survival and overall survival from the start of gefitinib treatment were 13.8 months (95 % CI; 9.9-18.8 months) and 29.1 months (95 % CI; 22.4 months-not reached), respectively. Two-year survival rate was 59.5 % (95 % CI; 41.0-78.0 %). Major grade 3 toxicities were skin rash (1.8 %) and increased levels of aspartate aminotransferase or alanine aminotransferase (7.3 %). First-line treatment with gefitinib for elderly EGFR-mutated NSCLC patients was effective and well tolerated. The results suggest that first-line gefitinib should be considered as a preferable standard treatment in elderly patients with advanced NSCLC harboring EGFR mutations.
Collapse
|
595
|
Noronha V, Prabhash K, Thavamani A, Chougule A, Purandare N, Joshi A, Sharma R, Desai S, Jambekar N, Dutt A, Mulherkar R. EGFR mutations in Indian lung cancer patients: clinical correlation and outcome to EGFR targeted therapy. PLoS One 2013; 8:e61561. [PMID: 23620765 PMCID: PMC3631198 DOI: 10.1371/journal.pone.0061561] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Accepted: 03/11/2013] [Indexed: 02/05/2023] Open
Abstract
Screening for EGFR mutation is a key molecular test for management of lung cancer patients. Outcome of patients with mutation receiving EGFR tyrosine kinase inhibitor is known to be better across different ethnic populations. However, frequency of EGFR mutations and the clinical response in most other ethnic populations, including India, remains to be explored. We conducted a retrospective analysis of Indian lung cancer patients who were managed with oral tyrosine kinase inhibitors. Majority of the patients in the study had adenocarcinoma and were non-smokers. 39/111 patients tested positive for EGFR kinase domain mutations determined by Taqman based real time PCR. The overall response to oral TKI therapy was 30%. Patients with an activating mutation of EGFR had a response rate of 74%, while the response rate in patients with wild type EGFR was 5%, which was a statistically significant difference. Progression free survival of patients with EGFR mutations was 10 months compared to 2 months for EGFR mutation negative patients. Overall survival was 19 months for EGFR mutation patients and 13 months for mutation negative patients. This study emphasizes EGFR mutation as an important predictive marker for response to oral tyrosine kinase inhibitors in the Indian population.
Collapse
Affiliation(s)
- Vanita Noronha
- Department of Medical Oncology, Tata Memorial Hospital, Tata Memorial Center, Mumbai, India
| | - Kumar Prabhash
- Department of Medical Oncology, Tata Memorial Hospital, Tata Memorial Center, Mumbai, India
- * E-mail: (KP); (AD)
| | - Abhishek Thavamani
- Department of Medical Oncology, Tata Memorial Hospital, Tata Memorial Center, Mumbai, India
| | - Anuradha Chougule
- Department of Medical Oncology, Tata Memorial Hospital, Tata Memorial Center, Mumbai, India
| | - Nilendu Purandare
- Department of Radiology, Tata Memorial Hospital, Tata Memorial Center, Mumbai, India
| | - Amit Joshi
- Department of Medical Oncology, Tata Memorial Hospital, Tata Memorial Center, Mumbai, India
| | - Rashmi Sharma
- Department of Medical Oncology, Tata Memorial Hospital, Tata Memorial Center, Mumbai, India
| | - Saral Desai
- Department of Pathology, Tata Memorial Hospital, Tata Memorial Center, Mumbai, India
| | - Nirmala Jambekar
- Department of Pathology, Tata Memorial Hospital, Tata Memorial Center, Mumbai, India
| | - Amit Dutt
- Advanced Centre for Treatment, Research and Education in Cancer, Tata Memorial Center, Navi Mumbai, India
- * E-mail: (KP); (AD)
| | - Rita Mulherkar
- Advanced Centre for Treatment, Research and Education in Cancer, Tata Memorial Center, Navi Mumbai, India
| |
Collapse
|
596
|
Di Maio M, Leighl NB, Gallo C, Feld R, Ciardiello F, Butts C, Maione P, Gebbia V, Morgillo F, Wierzbicki R, Favaretto A, Alam Y, Cinieri S, Siena S, Bianco R, Riccardi F, Spatafora M, Ravaioli A, Felletti R, Fregoni V, Genestreti G, Rossi A, Mancuso G, Fasano M, Morabito A, Tsao MS, Signoriello S, Perrone F, Gridelli C. Quality of life analysis of TORCH, a randomized trial testing first-line erlotinib followed by second-line cisplatin/gemcitabine chemotherapy in advanced non-small-cell lung cancer. J Thorac Oncol 2012; 7:1830-1844. [PMID: 23154555 DOI: 10.1097/jto.0b013e318275b327] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION The TORCH (Tarceva or Chemotherapy) trial randomized patients with advanced non-small-cell lung cancer to first-line erlotinib followed by second-line cisplatin/gemcitabine versus. standard inverse sequence. The trial, designed to test noninferiority in overall survival, was stopped at interim analysis because of inferior survival in the experimental arm. Quality of life (QoL), a secondary outcome, is reported here. METHODS QoL was assessed at baseline and every 3 weeks during first-line, using European Organization for Research and Treatment of Cancer Quality of Life Questionnaire - Core 30 and QLQ-lung cancer specific module (LC13). Mean changes from baseline within arms were reported. QoL response and time-to-deterioration of QoL using a competing-risk approach were compared between treatment arms. RESULTS Six hundred and thirty patients (83%) completed baseline questionnaires. Compliance was affected by differential treatment efficacy, but was similar between arms for patients without progression or death. Significant differences in QoL responses were observed favoring chemotherapy for pain, sleeping, dyspnea, diarrhea, and favoring erlotinib for vomiting, constipation, sore mouth, and alopecia. In the small subset of patients with EGFR-mutated tumors, all selected items (global QoL, physical functioning, cough, dyspnea and pain) improved, whereas worsening or no change was observed in wild-type patients. Improvement was particularly evident in the first-line erlotinib arm as for global QoL and physical functioning. CONCLUSIONS QoL was impacted by differential toxicity and efficacy between arms. Functional domains and global QoL did not differ, although some symptoms were better controlled with chemotherapy in unselected non-small-cell lung cancer patients.
Collapse
Affiliation(s)
- Massimo Di Maio
- Clinical Trials Unit, National Cancer Institute, Naples, Italy
| | - Natasha B Leighl
- Thoraco-Pulmonary Medical Oncology, National Cancer Institute, Naples, Italy
| | - Ciro Gallo
- Medical Statistics, Second University, Naples, Italy
| | - Ronald Feld
- Medical Oncology, Princess Margaret Hospital/University Health Network, Toronto, Canada
| | | | - Charles Butts
- Medical Oncology, Cross Cancer Institute, Edmonton, Canada
| | - Paolo Maione
- Medical Oncology, S.G.Moscati Hospital, Avellino, Italy
| | | | | | - Rafal Wierzbicki
- Medical Oncology, Casa di Cura La Maddalena, Palermo, Italy; Oncology Clinical Trials, Durham Regional Cancer Centre, Oshawa, Canada
| | | | - Yasmin Alam
- Windsor Regional Cancer, Centre, Windsor, Canada; Medical Oncology, A.Perrino Hospital, Brindisi and European Institute of Oncology, Milan, Italy
| | | | | | | | | | | | | | | | | | - Giovenzio Genestreti
- medical Oncology, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori, Meldola (FO), Italy
| | - Antonio Rossi
- Medical Oncology, S.G.Moscati Hospital, Avellino, Italy
| | | | | | - Alessandro Morabito
- Thoraco-Pulmonary Medical Oncology, National Cancer Institute, Naples, Italy
| | - Ming Sound Tsao
- Pathology, Princess Margaret Hospital/University Health Network, Toronto, Canada
| | | | | | | |
Collapse
|
597
|
Ellison G, Zhu G, Moulis A, Dearden S, Speake G, McCormack R. EGFR mutation testing in lung cancer: a review of available methods and their use for analysis of tumour tissue and cytology samples. J Clin Pathol 2012; 66:79-89. [PMID: 23172555 PMCID: PMC3582044 DOI: 10.1136/jclinpath-2012-201194] [Citation(s) in RCA: 231] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Aims Activating mutations in the gene encoding epidermal growth factor receptor (EGFR) can confer sensitivity to EGFR tyrosine kinase inhibitors such as gefitinib in patients with advanced non-small-cell lung cancer. Testing for mutations in EGFR is therefore an important step in the treatment-decision pathway. We reviewed reported methods for EGFR mutation testing in patients with lung cancer, initially focusing on studies involving standard tumour tissue samples. We also evaluated data on the use of cytology samples in order to determine their suitability for EGFR mutation analysis. Methods We searched the MEDLINE database for studies reporting on EGFR mutation testing methods in patients with lung cancer. Results Various methods have been investigated as potential alternatives to the historical standard for EGFR mutation testing, direct DNA sequencing. Many of these are targeted methods that specifically detect the most common EGFR mutations. The development of targeted mutation testing methods and commercially available test kits has enabled sensitive, rapid and robust analysis of clinical samples. The use of screening methods, subsequent to sample micro dissection, has also ensured that identification of more rare, uncommon mutations is now feasible. Cytology samples including fine needle aspirate and pleural effusion can be used successfully to determine EGFR mutation status provided that sensitive testing methods are employed. Conclusions Several different testing methods offer a more sensitive alternative to direct sequencing for the detection of common EGFR mutations. Evidence published to date suggests cytology samples are viable alternatives for mutation testing when tumour tissue samples are not available.
Collapse
|
598
|
Lee Y, Yoon KA, Joo J, Lee D, Bae K, Han JY, Lee JS. Prognostic implications of genetic variants in advanced non-small cell lung cancer: a genome-wide association study. Carcinogenesis 2012; 34:307-13. [PMID: 23144319 DOI: 10.1093/carcin/bgs356] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
The prognostic significance of inherited genetic variants in advanced-stage non-small cell lung cancer (NSCLC) patients remains unknown. In this study, we genotyped 271 817 single-nucleotide polymorphisms in 348 advanced NSCLC patients who received chemotherapy and analyzed their association with prognosis by using Cox proportional hazard regression model adjusted for known prognostic factors. Top candidate single-nucleotide polymorphisms (SNPs) were selected using the bootstrap re-sampling procedure. Median age of patient population was 56 years. Proportions of female, never smokers and adenocarcinoma were 64.9, 67.5 and 80.4%, respectively. We identified 17 top candidate SNPs related to prognosis using cut-off minimum P value of <5.0 × 10(-5) in at least 70% of 1000 bootstrap samples. These SNPs were located in the genomic regions of the FAM154A, ANKS1A, DLST, THSD7B, NCOA2, CDH8, SLC35D2, NALCN and EGF genes. The most significant SNP, rs1571228 (9p22.1:FAM154A), was significantly associated with overall survival in dominant model [AG+GG to AA, hazard ratio (HR) of death (95% CI) = 0.53 (0.42-0.67); P = 2.025 × 10(-7)]. The SNP at 4q25:EGF, rs11098063, for which some genetic variations was previously reported to be associated with prognosis, also showed significant association with overall survival in additive model [CC versus CT versus TT, HR (95% CI) = 1.00 versus 0.61 (0.47-0.78) versus 0.39 (0.19-0.79); P = 9.582 × 10(-6)]. Survival differences according to the genotype of these SNPs were independent of sex, smoking, histology and chemotherapy regimens. These results suggested the variants at multiple genetic loci might contribute to the risk of death in advanced NSCLC patients receiving chemotherapy.
Collapse
Affiliation(s)
- Youngjoo Lee
- Center for Lung Cancer, National Cancer Center, Goyang, Gyeonggi, Republic of Korea
| | | | | | | | | | | | | |
Collapse
|
599
|
Han JY, Nam BH, Kim HY, Yoon SJ, Kim HT, Lee JS. A randomized phase II study of irinotecan plus cisplatin versus irinotecan plus capecitabine with or without isosorbide-5-mononitrate in advanced non-small-cell lung cancer. Ann Oncol 2012; 23:2925-2930. [PMID: 22782331 DOI: 10.1093/annonc/mds122] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND We investigated the efficacy of irinotecan/cisplatin (IP) versus irinotecan/capecitabine (IX) with or without isosorbide-5-mononitrate (ISMN) in chemo-naïve advanced non-small-cell lung cancer. PATIENTS AND METHODS Initially, 74 patients were randomly assigned to either IP or IX. Given the potential benefits of ISMN on chemotherapy, the protocol was amended during the study. Subsequently, 72 patients were randomly assigned to either IP + ISMN or IX + ISMN. Patients were treated with predefined second-line therapies (docetaxel/capecitabine for IP or IP + ISMN, docetaxel/cisplatin for IX or IX + ISMN) when disease progressed. RESULTS A total of 146 received treatment. Response rate (RR), median progression-free survival (PFS) and overall survival (OS) were 49%, 5.5 months, 14.5 months in IP; 33%, 3.3 months, 13.0 months in IP + ISMN; 30%, 4.3 months, 16.1 months in IX; and 25%, 3.4 months, 13.6 months in IX + ISMN, respectively. While IP arm showed a trend toward higher RR and longer PFS than IX arm, IX arm showed a trend toward longer OS than IP arm. No significant differences were observed between IP + ISMN and IX + ISMN. CONCLUSION IP showed better RR and PFS but no OS benefit when compared with IX. The addition of ISMN to IP or IX chemotherapy did not seem to improve the treatment outcome.
Collapse
Affiliation(s)
- J Y Han
- Center for Lung Cancer; Center for Clinical Trial, Research Institute and Hospital, National Cancer Center, Goyang-si, Gyeonggi-do, Republic of Korea
| | - B H Nam
- Center for Clinical Trial, Research Institute and Hospital, National Cancer Center, Goyang-si, Gyeonggi-do, Republic of Korea
| | | | | | - H T Kim
- Center for Lung Cancer; Center for Clinical Trial, Research Institute and Hospital, National Cancer Center, Goyang-si, Gyeonggi-do, Republic of Korea
| | | |
Collapse
|
600
|
Yang JJ, Chen HJ, Yan HH, Zhang XC, Zhou Q, Su J, Wang Z, Xu CR, Huang YS, Wang BC, Yang XN, Zhong WZ, Nie Q, Liao RQ, Jiang BY, Dong S, Wu YL. Clinical modes of EGFR tyrosine kinase inhibitor failure and subsequent management in advanced non-small cell lung cancer. Lung Cancer 2012; 79:33-9. [PMID: 23079155 DOI: 10.1016/j.lungcan.2012.09.016] [Citation(s) in RCA: 132] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Revised: 08/30/2012] [Accepted: 09/24/2012] [Indexed: 11/30/2022]
Abstract
BACKGROUND There is no published overview of epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (TKI) failure modes in advanced non-small-cell lung cancer (NSCLC). This study aimed to classify the diversity of EGFR-TKI failure, and to investigate the usefulness of clinical modes in subsequent management and prognosis. METHODS One-hundred and twenty consecutive clinical trial patients with EGFR-TKI failure were enrolled as the training set to establish a clinical model based on clinical factors. Another 107 routine patients were enrolled as the validating set according to a Bayes discriminant analysis. EGFR mutations and c-MET amplification were analyzed. Kaplan-Meier survival analysis was used to test the differences among three clinical modes and subsequent management. RESULTS The duration of disease control, evolution of tumor burden, and clinical symptom were verified as feasible grouping variables. A correct grouping rate achieved 87.9%. The cohort was classified into three groups, as follows: 130 patients with dramatic progression, 42 with gradual progression, and 55 with local progression. Progression-free survivals (PFSs) for the dramatic progression, gradual progression, and local progression groups were 9.3, 12.9, and 9.2 months, respectively (P = 0.007). Overall survivals for the groups (OSs) were 17.1, 39.4, and 23.1 months, respectively (P < 0.001). TKI continuation was superior to switching chemotherapy in a subsequent setting for gradual progression (39.4 months vs. 17.8 months; P = 0.02). The difference of EGFR or c-MET among the three groups was not significant. CONCLUSIONS Clinical modes of EGFR-TKI failure could favor strategies for subsequent treatment and predicting a survival benefit in advanced NSCLC.
Collapse
Affiliation(s)
- Jin-Ji Yang
- Division of Pulmonary Oncology, Guangdong Lung Cancer Institute, Guangdong General Hospital & Guangdong Academy of Medical Sciences, Guangzhou, PR China
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|