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Géraud A, Combarel D, Funck-Brentano C, Beaulieu Q, Zahr N, Broutin S, Spano JP, Massard C, Besse B, Gougis P. A Score to Predict the Clinical Usefulness of Therapeutic Drug Monitoring: Application to Oral Molecular Targeted Therapies in Cancer. Clin Pharmacol Ther 2024; 116:678-689. [PMID: 38389482 DOI: 10.1002/cpt.3193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 01/22/2024] [Indexed: 02/24/2024]
Abstract
Therapeutic drug monitoring (TDM) involves measuring and interpreting drug concentrations in biological fluids to adjust drug dosages. In onco-hematology, TDM guidelines for oral molecular targeted therapies (oMTTs) are varied. This study evaluates a quantitative approach with a score to predict the clinical usefulness of TDM for oMTTs. We identified key parameters for an oMTT's suitability for TDM from standard TDM recommendations. We gathered oMTT pharmacological data, which covered exposure variability (considering pharmacokinetic (PK) impact of food and proton pump inhibitors), technical intricacy (PK linearity and active metabolites), efficacy (exposure-response relationship), and safety (maximum tolerated dose, and exposure-safety relationship). To assess the validity and the relevance of the score and define relevant thresholds, we evaluated molecules with prospective validation or strong recommendations for TDM, both in oncology and in other fields. By September 1, 2021, the US Food and Drug Administration (FDA) approved 67 oMTTs for onco-hematological indications. Scores ranged from 15 (acalabrutinib) to 80 (sunitinib) with an average of 48.3 and a standard deviation of 15.6. Top scorers included sunitinib, sorafenib, cabozantinib, nilotinib, and abemaciclib. Based on scores, drugs were categorized into low (< 40), intermediate (≥ 40 and < 60), and high (≥ 60) relevance for TDM. Notably, negative controls generally scored around or under 40, whereas positive controls had a high score across different indications. In this work, we propose a quantitative and reproducible score to compare the potential usefulness of TDM for oMTTs. Future guidelines should prioritize the TDM for molecules with the highest score.
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Affiliation(s)
- Arthur Géraud
- Department of Cancer Medicine, Gustave Roussy, Villejuif, France
- Early Drug Development Department (DITEP), Gustave Roussy, Villejuif, France
- Paris-Saclay University, Orsay, France
| | - David Combarel
- Pharmacology Department, Gustave Roussy, Villejuif, France
- Faculty of Pharmacy, Paris-Saclay University, Chatenay-Malabry, France
| | - Christian Funck-Brentano
- Department of Pharmacology and Clinical Investigation Center (CIC-1901), AP-HP.Sorbonne Université, Pitié-Salpêtrière Hospital, INSERM, CIC-1901 and UMR-S 1166, Sorbonne Université Médecine, Paris, France
| | - Quentin Beaulieu
- Department of Pharmacology and Clinical Investigation Center (CIC-1901), AP-HP.Sorbonne Université, Pitié-Salpêtrière Hospital, INSERM, CIC-1901 and UMR-S 1166, Sorbonne Université Médecine, Paris, France
| | - Noël Zahr
- Department of Pharmacology and Clinical Investigation Center (CIC-1901), AP-HP.Sorbonne Université, Pitié-Salpêtrière Hospital, INSERM, CIC-1901 and UMR-S 1166, Sorbonne Université Médecine, Paris, France
| | - Sophie Broutin
- Pharmacology Department, Gustave Roussy, Villejuif, France
| | - Jean-Philippe Spano
- Oncology Department, APHP-Sorbonne Université, Cancer Institute (IUC), Paris, France
- INSERM, UMRS 1136, Paris, France
| | - Christophe Massard
- Early Drug Development Department (DITEP), Gustave Roussy, Villejuif, France
- Centre Eugène Marquis, Rennes, France
| | - Benjamin Besse
- Department of Cancer Medicine, Gustave Roussy, Villejuif, France
- Paris-Saclay University, Orsay, France
| | - Paul Gougis
- Department of Pharmacology and Clinical Investigation Center (CIC-1901), AP-HP.Sorbonne Université, Pitié-Salpêtrière Hospital, INSERM, CIC-1901 and UMR-S 1166, Sorbonne Université Médecine, Paris, France
- Oncology Department, APHP-Sorbonne Université, Cancer Institute (IUC), Paris, France
- Residual Tumor & Response to Treatment Laboratory, RT2Lab, INSERM, U932 Immunity and Cancer, Curie Institute, Université Paris, Paris, France
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2
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Lin L, van der Noort V, Steeghs N, Ruiter G, Beijnen JH, Huitema ADR. A joint model of longitudinal pharmacokinetic and time-to-event data to study exposure-response relationships: a proof-of-concept study with alectinib. Cancer Chemother Pharmacol 2024:10.1007/s00280-024-04698-w. [PMID: 38992166 DOI: 10.1007/s00280-024-04698-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 07/05/2024] [Indexed: 07/13/2024]
Abstract
PURPOSE In exposure-response analyses of oral targeted anticancer agents, longitudinal plasma trough concentrations are often aggregated into a single value even though plasma trough concentrations can vary over time due to dose adaptations, for example. The aim of this study was to compare joint models to conventional exposure-response analyses methods with the application of alectinib as proof-of-concept. METHODS Joint models combine longitudinal pharmacokinetic data and progression-free survival data to infer the dependency and association between the two datatypes. The results from the best joint model and the standard and time-dependent cox proportional hazards models were compared. To normalize the data, alectinib trough concentrations were normalized using a sigmoidal transformation to transformed trough concentrations (TTC) before entering the models. RESULTS No statistically significant exposure-response relationship was observed in the different Cox models. In contrast, the joint model with the current value of TTC in combination with the average TTC over time did show an exposure-response relationship for alectinib. A one unit increase in the average TTC corresponded to an 11% reduction in progression (HR, 0.891; 95% confidence interval, 0.805-0.988). CONCLUSION Joint models are able to give insights in the association structure between plasma trough concentrations and survival outcomes that would otherwise not be possible using Cox models. Therefore, joint models should be used more often in exposure-response analyses of oral targeted anticancer agents.
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Affiliation(s)
- Lishi Lin
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Vincent van der Noort
- Department of Biometrics, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Neeltje Steeghs
- Department of Medical Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Gerrina Ruiter
- Department of Thoracic Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Jos H Beijnen
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
- Department of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Alwin D R Huitema
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.
- Department of Pharmacology, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
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3
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Lin L, Barkman HJ, Smit EF, de Langen AJ, Steeghs N, Beijnen JH, Huitema ADR. Clinical Relevance of High Plasma Trough Levels of the Kinase Inhibitors Crizotinib, Alectinib, Osimertinib, Dabrafenib, and Trametinib in NSCLC Patients. Ther Drug Monit 2024; 46:73-79. [PMID: 37348074 PMCID: PMC10769168 DOI: 10.1097/ftd.0000000000001120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 12/13/2022] [Indexed: 06/24/2023]
Abstract
BACKGROUND the study aims to evaluate whether high plasma trough levels of the kinase inhibitors (K.I.s) crizotinib, alectinib, osimertinib, dabrafenib, and trametinib were associated with a higher risk of toxicity in non-small-cell lung cancer patients. METHODS In this retrospective cohort study, patients with non-small-cell lung cancer treated with the selected K.I.s were included if at least one plasma trough level at steady state (C min,ss ) was available. Data were extracted from electronic medical records and laboratory databases. The high group for each K.I. was defined as 10% of patients with the highest first C min,ss . The remaining patients were placed in the non-high group. The frequency of dose-limiting toxicities (DLTs), defined as adverse events leading to dose reduction, dose interruption, or permanent discontinuation, was compared between the 2 groups. RESULTS A total of 542 patients were included in the different K.I. groups. A high C min,ss of crizotinib (n = 96), alectinib (n = 105), osimertinib (n = 227), dabrafenib (n = 52), and trametinib (n = 62) correlated with a C min,ss ≥490, ≥870, ≥405, ≥150, and ≥25 ng/mL, respectively. DLTs were more common in the alectinib high group than in the alectinib non-high group (64% vs. 29%, P = 0.036). Liver toxicity was observed in 4 (36%) patients in the high group and 5 (5%) patients in the non-high group ( P = 0.007). For other K.I.s, no significant differences were observed in the frequency of DLTs between the high and non-high groups. CONCLUSIONS For alectinib, high C min,ss was correlated with a higher risk of DLT. No differences in the frequency of DLTs were observed between the high and non-high groups for crizotinib, osimertinib, dabrafenib, and trametinib.
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Affiliation(s)
- Lishi Lin
- Department of Pharmacy and Pharmacology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Hannerieke J. Barkman
- Department of Pharmacy and Pharmacology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Egbert F. Smit
- Department of Thoracic Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
- Department of Pulmonology, Leiden University Medical Center, Leiden, The Netherlands
| | - Adrianus J. de Langen
- Department of Thoracic Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Neeltje Steeghs
- Department of Medical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Jos H. Beijnen
- Department of Pharmacy and Pharmacology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
- Department of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Alwin D. R. Huitema
- Department of Pharmacy and Pharmacology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
- Department of Pharmacology, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands; and
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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van der Kleij MBA, Guchelaar NAD, Mathijssen RHJ, Versluis J, Huitema ADR, Koolen SLW, Steeghs N. Therapeutic Drug Monitoring of Kinase Inhibitors in Oncology. Clin Pharmacokinet 2023; 62:1333-1364. [PMID: 37584840 PMCID: PMC10519871 DOI: 10.1007/s40262-023-01293-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2023] [Indexed: 08/17/2023]
Abstract
Although kinase inhibitors (KI) frequently portray large interpatient variability, a 'one size fits all' regimen is still often used. In the meantime, relationships between exposure-response and exposure-toxicity have been established for several KIs, so this regimen could lead to unnecessary toxicity and suboptimal efficacy. Dose adjustments based on measured systemic pharmacokinetic levels-i.e., therapeutic drug monitoring (TDM)-could therefore improve treatment efficacy and reduce the incidence of toxicities. Therefore, the aim of this comprehensive review is to give an overview of the available evidence for TDM for the 77 FDA/EMA kinase inhibitors currently approved (as of July 1st, 2023) used in hematology and oncology. We elaborate on exposure-response and exposure-toxicity relationships for these kinase inhibitors and provide practical recommendations for TDM and discuss corresponding pharmacokinetic targets when possible.
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Affiliation(s)
- Maud B A van der Kleij
- Division of Medical Oncology, Department of Clinical Pharmacology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, The Netherlands.
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands.
| | - Niels A D Guchelaar
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Ron H J Mathijssen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Jurjen Versluis
- Department of Hematology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Alwin D R Huitema
- Department of Pharmacy and Pharmacology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, The Netherlands
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Pharmacology, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Stijn L W Koolen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
- Department of Pharmacy, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Neeltje Steeghs
- Division of Medical Oncology, Department of Clinical Pharmacology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, The Netherlands
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Meertens M, Muntinghe-Wagenaar MB, Sikkema BJ, Lopez-Yurda M, Retèl VP, Paats MS, Ter Heine R, Schuuring E, Timens W, Touw DJ, van Boven JFM, de Langen AJ, Hashemi SMS, Hendriks LEL, Croes S, van den Heuvel MM, Dingemans AMC, Mathijssen RHJ, Smit EF, Huitema ADR, Steeghs N, van der Wekken AJ. Therapeutic drug monitoring guided dosing versus standard dosing of alectinib in advanced ALK positive non-small cell lung cancer patients: Study protocol for an international, multicenter phase IV randomized controlled trial (ADAPT ALEC). Front Oncol 2023; 13:1136221. [PMID: 36969063 PMCID: PMC10035072 DOI: 10.3389/fonc.2023.1136221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 02/22/2023] [Indexed: 03/11/2023] Open
Abstract
BackgroundAlectinib is first-line therapy in patients with stage IV non-small cell lung carcinoma (NSCLC) and an anaplastic lymphoma kinase (ALK) fusion. A shorter median progression-free survival (mPFS) was observed when alectinib minimum plasma concentrations during steady state (Cmin,SS) were below 435 ng/mL. This may suggest that patients should have an alectinib Cmin,SS ≥ 435 ng/mL for a more favorable outcome. This potential target could be attained by using therapeutic drug monitoring (TDM), i.e. adjusting the dose based on measured plasma trough concentrations. Hypothetically, this will increase mPFS, but this has not yet been evaluated in a randomized controlled trial (RCT). Therefore, the ADAPT ALEC trial is designed, with the primary objective to prolong mPFS in NSCLC patients treated with alectinib by using TDM.MethodsADAPT ALEC is a multicenter, phase IV RCT, in which patients aged ≥ 18 years with advanced ALK positive (+) NSCLC eligible for alectinib in daily care are enrolled. Participants will be randomized (1:1 ratio) into intervention arm A (TDM) or B (control), stratified by brain metastases and prior ALK treatments. Starting dose in both arms is the approved flat fixed dose of alectinib 600 mg taken twice daily with food. In case of alectinib Cmin,SS < 435 ng/mL, arm A will receive increased doses of alectinib till Cmin,SS ≥ 435 ng/mL when considered tolerable. The primary outcome is mPFS, where progressive disease is defined according to RECIST v1.1 or all-cause death and assessed by CT-scans and MRI brain. Secondary endpoints are feasibility and tolerability of TDM, patient and physician adherence, overall response rate, median overall survival, intracranial PFS, quality of life, toxicity, alectinib-M4 concentrations and cost-effectiveness of TDM. Exploratory endpoints are circulating tumor DNA and body composition.DiscussionThe ADAPT ALEC will show whether treatment outcomes of patients with advanced ALK+ NSCLC improve when using TDM-guided dosing of alectinib instead of fixed dosing. The results will provide high quality evidence for deciding whether TDM should be implemented as standard of care and this will have important consequences for the prescribing of alectinib.Clinical trial registrationClinicalTrials.gov, identifier NCT05525338.
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Affiliation(s)
- Marinda Meertens
- Department of Pharmacy and Pharmacology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - M. Benthe Muntinghe-Wagenaar
- Department of Pulmonology and Tuberculosis, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Barend J. Sikkema
- Department of Medical Oncology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Marta Lopez-Yurda
- Department of Biometrics, The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Valesca P. Retèl
- Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Marthe S. Paats
- Department of Pulmonary Medicine, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Rob Ter Heine
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center Nijmegen, Nijmegen, Netherlands
| | - Ed Schuuring
- Department of Pathology and Medical Biology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Wim Timens
- Department of Pathology and Medical Biology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Daan J. Touw
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Job F. M. van Boven
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Adrianus. J. de Langen
- Department of Thoracic Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - Sayed M. S. Hashemi
- Department of Pulmonary Medicine, Amsterdam University Medical Center, VU University Medical Center, Amsterdam, Netherlands
| | - Lizza E. L. Hendriks
- Department of Respiratory Medicine, Maastricht University Medical Center, GROW School for Oncology and Reproduction, Maastricht, Netherlands
| | - Sander Croes
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Center, CARIM School for Cardiovascular disease, Maastricht, Netherlands
| | | | - Anne-Marie C. Dingemans
- Department of Pulmonary Medicine, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Ron H. J. Mathijssen
- Department of Medical Oncology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Egbert F. Smit
- Department of Pulmonology, Leiden University Medical Center, Leiden, Netherlands
| | - Alwin D. R. Huitema
- Department of Pharmacy and Pharmacology, Netherlands Cancer Institute, Amsterdam, Netherlands
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, Netherlands
- Department of Pharmacology, Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
| | - Neeltje Steeghs
- Department of Clinical Pharmacology, Division of Medical Oncology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - Anthonie J. van der Wekken
- Department of Pulmonology and Tuberculosis, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
- *Correspondence: Anthonie J. van der Wekken,
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Honeycomb resin-based spin-column solid-phase extraction for efficient determination of alectinib and its metabolite in human urine. J Chromatogr A 2023; 1690:463787. [PMID: 36652815 DOI: 10.1016/j.chroma.2023.463787] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 12/17/2022] [Accepted: 01/08/2023] [Indexed: 01/11/2023]
Abstract
Alectinib and its metabolite, M4, have demonstrated a satisfactory clinical therapeutic effect in the treatment of anaplastic lymphoma kinase-positive advanced non-small-cell lung cancer. Due to individual differences among patients, therapeutic drug monitoring (TDM) is critical for guaranteeing appropriate clinical drug use. To realize TDM for alectinib and its metabolite, M4, a honeycomb phenol-formaldehyde resin (PFR) with excellent hydrophilic properties, abundant adsorption force, and a stable porous structure was synthesized by modifying the porogens F127 and P123. The prepared PFR was employed as an adsorbent in a simple and efficient spin-column solid-phase extraction (SPE) process. A rapid method for detecting alectinib and its metabolite M4 in urine was thereby established. The established method showed a linear range of 0.0200 μg mL-1-5.00 μg mL-1 and the recovery range of 98.8-103% for spiked urine samples, with relative standard deviations of ≤ 4.87% (n = 3). Our results proved the practicability of the proposed honeycomb-PFR spin-column SPE method in TDM for alectinib and its metabolite, M4.
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7
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Chen P, Liu Y, Wen Y, Zhou C. Non-small cell lung cancer in China. Cancer Commun (Lond) 2022; 42:937-970. [PMID: 36075878 PMCID: PMC9558689 DOI: 10.1002/cac2.12359] [Citation(s) in RCA: 165] [Impact Index Per Article: 82.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 07/21/2022] [Accepted: 08/24/2022] [Indexed: 04/08/2023] Open
Abstract
In China, lung cancer is a primary cancer type with high incidence and mortality. Risk factors for lung cancer include tobacco use, family history, radiation exposure, and the presence of chronic lung diseases. Most early-stage non-small cell lung cancer (NSCLC) patients miss the optimal timing for treatment due to the lack of clinical presentations. Population-based nationwide screening programs are of significant help in increasing the early detection and survival rates of NSCLC in China. The understanding of molecular carcinogenesis and the identification of oncogenic drivers dramatically facilitate the development of targeted therapy for NSCLC, thus prolonging survival in patients with positive drivers. In the exploration of immune escape mechanisms, programmed cell death protein 1 (PD-1)/programmed death-ligand 1 (PD-L1) inhibitor monotherapy and PD-1/PD-L1 inhibitor plus chemotherapy have become a standard of care for advanced NSCLC in China. In the Chinese Society of Clinical Oncology's guidelines for NSCLC, maintenance immunotherapy is recommended for locally advanced NSCLC after chemoradiotherapy. Adjuvant immunotherapy and neoadjuvant chemoimmunotherapy will be approved for resectable NSCLC. In this review, we summarized recent advances in NSCLC in China in terms of epidemiology, biology, molecular pathology, pathogenesis, screening, diagnosis, targeted therapy, and immunotherapy.
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Affiliation(s)
- Peixin Chen
- School of MedicineTongji UniversityShanghai200092P. R. China
- Department of Medical OncologyShanghai Pulmonary HospitalSchool of MedicineTongji UniversityShanghai200433P. R. China
| | - Yunhuan Liu
- Department of Respiratory and Critical Care MedicineHuadong HospitalFudan UniversityShanghai200040P. R. China
| | - Yaokai Wen
- School of MedicineTongji UniversityShanghai200092P. R. China
- Department of Medical OncologyShanghai Pulmonary HospitalSchool of MedicineTongji UniversityShanghai200433P. R. China
| | - Caicun Zhou
- School of MedicineTongji UniversityShanghai200092P. R. China
- Department of Medical OncologyShanghai Pulmonary HospitalSchool of MedicineTongji UniversityShanghai200433P. R. China
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Peng L, Zhu L, Sun Y, Stebbing J, Selvaggi G, Zhang Y, Yu Z. Targeting ALK Rearrangements in NSCLC: Current State of the Art. Front Oncol 2022; 12:863461. [PMID: 35463328 PMCID: PMC9020874 DOI: 10.3389/fonc.2022.863461] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 03/08/2022] [Indexed: 12/25/2022] Open
Abstract
Anaplastic lymphoma kinase (ALK) alterations in non-small cell lung cancer (NSCLC) can be effectively treated with a variety of ALK-targeted drugs. After the approval of the first-generation ALK inhibitor crizotinib which achieved better results in prolonging the progression-free survival (PFS) compared with chemotherapy, a number of next-generation ALK inhibitors have been developed including ceritinib, alectinib, brigatinib, and ensartinib. Recently, a potent, third-generation ALK inhibitor, lorlatinib, has been approved by the Food and Drug Administration (FDA) for the first-line treatment of ALK-positive (ALK+) NSCLC. These drugs have manageable toxicity profiles. Responses to ALK inhibitors are however often not durable, and acquired resistance can occur as on-target or off-target alterations. Studies are underway to explore the mechanisms of resistance and optimal treatment options beyond progression. Efforts have also been undertaken to develop further generations of ALK inhibitors. This review will summarize the current situation of targeting the ALK signaling pathway.
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Affiliation(s)
- Ling Peng
- Cancer Center, Department of Pulmonary and Critical Care Medicine, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, China
| | - Liping Zhu
- Department of Medical Oncology, Shouguang Hospital of Traditional Chinese Medicine, Shouguang, China
| | - Yilan Sun
- Cancer Center, Department of Pulmonary and Critical Care Medicine, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, China
| | - Justin Stebbing
- Division of Cancer, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | | | - Yongchang Zhang
- Department of Medical Oncology, Lung Cancer and Gastrointestinal Unit, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Changsha, China
| | - Zhentao Yu
- Department of Thoracic Surgery, National Cancer Center, National Clinical Research Center for Cancer, Cancer Hospital and Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China
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Gao T, Li C, He X, Zhang T. Chemotherapy versus alectinib for the treatment of crizotinib-pretreated ALK-positive patients with non small cell lung cancer: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2022; 101:e29064. [PMID: 35356928 PMCID: PMC10684200 DOI: 10.1097/md.0000000000029064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 02/24/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND There are no evidence-based data in the literature to demonstrate that alectinib shows a clinically relevant advantage over chemotherapy in anaplastic lymphoma kinase-positive non-small cell lung cancer pretreated with crizotinib. Therefore, we designed this systematic review and meta-analysis protocol to reveal whether the safety and efficacy of alectinib are indeed superior to chemotherapy alone in this special group of patients. METHODS This protocol will be written following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols statement guidelines. We will search databases from Web of Science, Embase, PubMed, Wanfang Data, Scopus, Science Direct, Cochrane Library from their inception to June 2022, restricting them to human subjects and clinical trials. Outcomes include progression-free survival, central nervous system progression, and incidence of adverse events. Pooled analyses will be calculated using fixed-effect models, whereas random-effect models will be applied in case of significant heterogeneity across studies. Any disagreements will be discussed and resolved in discussions with the third reviewer. RESULTS We hypothesized that alectinib would be superior to chemotherapy in patients with anaplastic lymphoma kinase-positive non-small cell lung cancer pretreated with crizotinib. CONCLUSIONS The review will add to the existing literature by showing compelling evidence and improved guidance in clinic settings. OSF REGISTRATION NUMBER 10.17605/OSF.IO/PQF53.
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Affiliation(s)
| | | | | | - Tao Zhang
- Correspondence: Tao Zhang, Department of Chest Surgery, XianYang Central Hospital, Shaanxi, 712000, China (e-mail: ).
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Gupta N, Reckamp KL, Camidge DR, Kleijn HJ, Ouerdani A, Bellanti F, Maringwa J, Hanley MJ, Wang S, Zhang P, Venkatakrishnan K. Population Pharmacokinetic and Exposure-Response Analyses From ALTA-1L: Model-Based Analyses Supporting the Brigatinib Dose in ALK-Positive NSCLC. Clin Transl Sci 2022; 15:1143-1154. [PMID: 35041775 PMCID: PMC9099121 DOI: 10.1111/cts.13231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 12/02/2021] [Accepted: 12/24/2021] [Indexed: 11/29/2022] Open
Abstract
The ALK in Lung Cancer Trial of brigAtinib in 1st Line (ALTA-1L) compared brigatinib versus crizotinib in ALK inhibitor-naive patients with ALK+ NSCLC. A population pharmacokinetic (PK) model was used to estimate brigatinib exposures for exposure-efficacy and exposure-safety analyses in ALTA-1L. A previously developed population PK model for brigatinib was applied to estimate brigatinib PK parameters. Relationships between static (time-independent) and dynamic (time-varying) exposure metrics and efficacy (progression-free survival [PFS], objective response rate [ORR], and intracranial ORR) and safety outcomes (selected grade ≥ 2 and grade ≥ 3 adverse events) were evaluated using logistic regression and time-to-event analyses. There were no meaningful differences in brigatinib PK in the first-line and second-line settings, supporting use of the previous population PK model for the first-line population. Exposure-response analyses showed no significant effect of time-varying brigatinib exposure on PFS. Brigatinib exposure was not significantly related to ORR, but higher exposure was associated with higher intracranial ORR (odds ratio: 1.13; 95% confidence interval: 1.01-1.28; P = 0.049). Across the observed median exposure (5th-95th percentile) at steady state for 180 mg once daily, the predicted probability of intracranial ORR was 0.83 (0.58-0.99). Adverse events significantly associated with higher exposure were elevated lipase (grade ≥ 3) and amylase (grade ≥ 2). Time to first brigatinib dose reduction was not related to exposure. These results support the benefit-risk profile of first-line brigatinib 180 mg once daily (7-day lead-in dose at 90 mg once daily) in patients with ALK+ NSCLC.
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Affiliation(s)
- Neeraj Gupta
- Takeda Development Center Americas, Inc., Lexington, MA, USA
| | - Karen L Reckamp
- Samuel Oschin Cancer Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | | | | | | | | | | | - Shining Wang
- Takeda Development Center Americas, Inc., Lexington, MA, USA
| | - Pingkuan Zhang
- Takeda Development Center Americas, Inc., Lexington, MA, USA
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11
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Late phase 1 studies: concepts and outcomes. Lancet Oncol 2021; 22:e446-e455. [PMID: 34592194 DOI: 10.1016/s1470-2045(21)00467-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 07/27/2021] [Accepted: 08/04/2021] [Indexed: 12/13/2022]
Abstract
Over the past two decades, targeted therapies have become cornerstone treatments for numerous cancers with oncogene addiction. Unfortunately, their effectiveness reduces over time and most patients who receive targeted therapies relapse within 12 months. The emergence of drug-resistance mechanisms in tumours paved the way for next-generation inhibitors. However, insufficient concentration of targeted therapy is a frequent but poorly explored mechanism of treatment failure. Additionally, the maximum tolerated dose (MTD) is not always reached in phase studies, and the recommended phase 2 dose is mostly based on benefit-risk ratio and pharmacokinetic considerations, which could result in a suboptimal dose. This scenario has led us to propose a new concept in clinical drug development: the late phase 1 study. The primary goal of this type of trial is to define an alternative MTD of a drug in patients who are chronically exposed and had an initial benefit from targeted therapy but subsequently progressed without an identified resistance alteration. Intrapatient dose escalation might increase drug concentration and restore drug activity or efficacy.
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12
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Fahmy A, Hopkins AM, Sorich MJ, Rowland A. Evaluating the utility of therapeutic drug monitoring in the clinical use of small molecule kinase inhibitors: a review of the literature. Expert Opin Drug Metab Toxicol 2021; 17:803-821. [PMID: 34278936 DOI: 10.1080/17425255.2021.1943357] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Introduction: Orally administered small molecule kinase inhibitors (KI) are a key class of targeted anti-cancer medicines that have contributed substantially to improved survival outcomes in patients with advanced disease. Since the introduction of KIs in 2001, there has been a building body of evidence that the benefit derived from these drugs may be further enhanced by individualizing dosing on the basis of concentration.Areas covered: This review considers the rationale for individualized KI dosing and the requirements for robust therapeutic drug monitoring (TDM). Current evidence supporting TDM-guided KI dosing is presented and critically evaluated, and finally potential approaches to address translational challenges for TDM-guided KI dosing and alternate approaches to support individualization of KI dosing are discussed.Expert opinion: Intuitively, the individualization of KI dosing through an approach such as TDM-guided dosing has great potential to enhance the effectiveness and tolerability of these drugs. However, based on current literature evidence it is unrealistic to propose that TDM-guided KI dosing should be routinely implemented into clinical practice.
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Affiliation(s)
- Alia Fahmy
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Ashley M Hopkins
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Michael J Sorich
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Andrew Rowland
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
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13
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Chen J, Ruiz-Garcia A, James LP, Peltz G, Thurm H, Clancy J, Hibma J. Lorlatinib Exposure-Response Analyses for Safety and Efficacy in a Phase I/II Trial to Support Benefit-Risk Assessment in Non-Small Cell Lung Cancer. Clin Pharmacol Ther 2021; 110:1273-1281. [PMID: 33973232 PMCID: PMC9290079 DOI: 10.1002/cpt.2228] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 02/23/2021] [Indexed: 11/07/2022]
Abstract
Lorlatinib is a small molecule inhibitor of anaplastic lymphoma kinase (ALK) and c-ROS oncogene 1 (ROS1) tyrosine kinases and is approved for the treatment of patients with ALK-positive advanced non-small cell lung cancer (NSCLC). In the phase I/II study (NCT01970865), potential exposure-response (E-R) relationships between lorlatinib and selected safety and efficacy end points were evaluated in patients with NSCLC. E-R relationships were assessed for safety end points with incidence > 10% in all treated patients (n = 328). In total, 4 safety end points were assessed: hypercholesterolemia grade ≥ 3, hypertriglyceridemia grade ≥ 3, weight gain grade ≥ 2, and treatment-emergent adverse events (TEAEs) grade ≥ 3. Using logistic regression, significant relationships were identified between lorlatinib plasma exposure and risk of hypercholesterolemia grade ≥ 3 (odds ratio (OR) 5.256) and risk of TEAE grade ≥ 3 (OR 3.214). The covariates baseline cholesterol and time on study prior to the event (TE) were associated with the probability of hypercholesterolemia grade ≥ 3. Baseline cholesterol and TE were found to have a statistically significant correlation with TEAE grade ≥ 3. Exposure-efficacy relationships were assessed for objective response rate (ORR; n = 197) and intracranial objective response rate (IC-ORR; n = 132). Lorlatinib plasma exposure was not identified as a statistically significant factor related to either efficacy end point. The only significant E-R relationships identified for efficacy were between baseline alkaline phosphatase and baseline amylase with IC-ORR (ORs 0.363 and 1.015, respectively). These findings support the lorlatinib indicated dose and dose modification guidelines regarding the management of lorlatinib-related AEs.
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Mueller-Schoell A, Groenland SL, Scherf-Clavel O, van Dyk M, Huisinga W, Michelet R, Jaehde U, Steeghs N, Huitema ADR, Kloft C. Therapeutic drug monitoring of oral targeted antineoplastic drugs. Eur J Clin Pharmacol 2021; 77:441-464. [PMID: 33165648 PMCID: PMC7935845 DOI: 10.1007/s00228-020-03014-8] [Citation(s) in RCA: 111] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 10/01/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE This review provides an overview of the current challenges in oral targeted antineoplastic drug (OAD) dosing and outlines the unexploited value of therapeutic drug monitoring (TDM). Factors influencing the pharmacokinetic exposure in OAD therapy are depicted together with an overview of different TDM approaches. Finally, current evidence for TDM for all approved OADs is reviewed. METHODS A comprehensive literature search (covering literature published until April 2020), including primary and secondary scientific literature on pharmacokinetics and dose individualisation strategies for OADs, together with US FDA Clinical Pharmacology and Biopharmaceutics Reviews and the Committee for Medicinal Products for Human Use European Public Assessment Reports was conducted. RESULTS OADs are highly potent drugs, which have substantially changed treatment options for cancer patients. Nevertheless, high pharmacokinetic variability and low treatment adherence are risk factors for treatment failure. TDM is a powerful tool to individualise drug dosing, ensure drug concentrations within the therapeutic window and increase treatment success rates. After reviewing the literature for 71 approved OADs, we show that exposure-response and/or exposure-toxicity relationships have been established for the majority. Moreover, TDM has been proven to be feasible for individualised dosing of abiraterone, everolimus, imatinib, pazopanib, sunitinib and tamoxifen in prospective studies. There is a lack of experience in how to best implement TDM as part of clinical routine in OAD cancer therapy. CONCLUSION Sub-therapeutic concentrations and severe adverse events are current challenges in OAD treatment, which can both be addressed by the application of TDM-guided dosing, ensuring concentrations within the therapeutic window.
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Affiliation(s)
- Anna Mueller-Schoell
- Dept. of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
- Graduate Research Training Program, PharMetrX, Berlin/Potsdam, Germany
| | - Stefanie L Groenland
- Department of Clinical Pharmacology, Division of Medical Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Oliver Scherf-Clavel
- Institute of Pharmacy and Food Chemistry, Julius-Maximilians-Universität Würzburg, Würzburg, Germany
| | - Madelé van Dyk
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Wilhelm Huisinga
- Institute of Mathematics, University of Potsdam, Potsdam, Germany
| | - Robin Michelet
- Dept. of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
| | - Ulrich Jaehde
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Bonn, Bonn, Germany
| | - Neeltje Steeghs
- Department of Clinical Pharmacology, Division of Medical Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Alwin D R Huitema
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
- Department of Clinical Pharmacy, University Medical Center, Utrecht University, Utrecht, The Netherlands
| | - Charlotte Kloft
- Dept. of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany.
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15
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Hohmann N, Bozorgmehr F, Christopoulos P, Mikus G, Blank A, Burhenne J, Thomas M, Haefeli WE. Pharmacoenhancement of Low Crizotinib Plasma Concentrations in Patients with Anaplastic Lymphoma Kinase-Positive Non-Small Cell Lung Cancer using the CYP3A Inhibitor Cobicistat. Clin Transl Sci 2021; 14:487-491. [PMID: 33222380 PMCID: PMC7993319 DOI: 10.1111/cts.12921] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 08/03/2020] [Indexed: 12/01/2022] Open
Abstract
The inhibitor of anaplastic lymphoma kinase (ALK) crizotinib significantly increases survival in patients with ALK-positive non-small cell lung cancer (NSCLC). When evaluating crizotinib pharmacokinetics (PKs) in patients taking the standard flat oral dose of 250 mg b.i.d., interindividual PK variability is substantial and patient survival is lower in the quartile with the lowest steady-state trough plasma concentrations (Cmin,ss ), suggesting that concentrations should be monitored and doses individualized. We investigated whether the CYP3A inhibitor cobicistat increases Cmin,ss of the CYP3A substrate crizotinib in patients with low exposure. Patients with ALK-positive NSCLC of our outpatient clinic treated with crizotinib were enrolled in a phase I trial (EudraCT 2016-002187-14, DRKS00012360) if crizotinib Cmin,ss was below 310 ng/mL and treated with cobicistat for 14 days. Crizotinib plasma concentration profiles were established before and after a 14-day co-administration of cobicistat to construct the area under the plasma concentration-time curve in the dosing interval from zero to 12 hours (AUC0-12 ). Patients were also monitored for adverse events by physical examination, laboratory tests, and 12-lead echocardiogram. Enrolment was prematurely stopped because of the approval of alectinib, a next-generation ALK-inhibitor with superior efficacy. In the only patient enrolled, cobicistat increased Cmin,ss from 158 ng/mL (before cobicistat) to 308 ng/mL (day 8) and 417 ng/mL (day 14 on cobicistat), concurrently the AUC0-12 increased by 78% from 2,210 ng/mL*h to 3,925 ng/mL*h. Neither safety signals nor serious adverse events occurred. Pharmacoenhancement with cobicistat as an alternative for dose individualisation for patients with NSCLC with low crizotinib exposure appears to be safe and is cost-effective and feasible.
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Affiliation(s)
- Nicolas Hohmann
- Department Clinical Pharmacology and PharmacoepidemiologyUniversity Hospital HeidelbergHeidelbergGermany
- Department of Medical OncologyNational Center for Tumor DiseasesHeidelbergGermany
| | - Farastuk Bozorgmehr
- Department of Thoracic OncologyGerman Center for Lung Research (DZL)Thorax Clinic at Heidelberg University HospitalHeidelbergGermany
| | - Petros Christopoulos
- Department of Thoracic OncologyGerman Center for Lung Research (DZL)Thorax Clinic at Heidelberg University HospitalHeidelbergGermany
| | - Gerd Mikus
- Department Clinical Pharmacology and PharmacoepidemiologyUniversity Hospital HeidelbergHeidelbergGermany
| | - Antje Blank
- Department Clinical Pharmacology and PharmacoepidemiologyUniversity Hospital HeidelbergHeidelbergGermany
| | - Jürgen Burhenne
- Department Clinical Pharmacology and PharmacoepidemiologyUniversity Hospital HeidelbergHeidelbergGermany
| | - Michael Thomas
- Department of Thoracic OncologyGerman Center for Lung Research (DZL)Thorax Clinic at Heidelberg University HospitalHeidelbergGermany
| | - Walter E. Haefeli
- Department Clinical Pharmacology and PharmacoepidemiologyUniversity Hospital HeidelbergHeidelbergGermany
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16
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Gupta N, Wang X, Offman E, Rich B, Kerstein D, Hanley M, Diderichsen PM, Zhang P, Venkatakrishnan K. Brigatinib Dose Rationale in Anaplastic Lymphoma Kinase-Positive Non-Small Cell Lung Cancer: Exposure-Response Analyses of Pivotal ALTA Study. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2020; 9:718-730. [PMID: 33185028 PMCID: PMC7762810 DOI: 10.1002/psp4.12569] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 10/25/2020] [Indexed: 01/08/2023]
Abstract
Brigatinib is a kinase inhibitor indicated for patients with advanced anaplastic lymphoma kinase–positive non‐small cell lung cancer who progressed on or are intolerant to crizotinib. Approval was based on results from a randomized, dose‐ranging phase II study (ALK in Lung Cancer Trial of AP26113 (ALTA)). Despite an apparent dose–response relationship for efficacy in ALTA, an exposure–response relationship was not discernable using static models driven by time‐averaged exposure. However, exposure–response modeling using daily time‐varying area under the concentration curve as the predictor in time‐to‐event models predicted that increasing the dose of brigatinib (range, 30 mg once daily (q.d.) to 240 mg q.d.) would result in clinically meaningful improvements in progression‐free survival (PFS), intracranial PFS, and overall survival. Grade ≥ 2 rash and amylase elevation were predicted to significantly increase with brigatinib exposure. These results provided support for a favorable benefit‐risk profile with the approved dosing regimen (180 mg q.d. with 7‐day lead‐in at 90 mg) versus 90 mg q.d.
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Affiliation(s)
- Neeraj Gupta
- Millennium Pharmaceuticals, Inc., Cambridge, Massachusetts, USA
| | | | | | | | - David Kerstein
- Millennium Pharmaceuticals, Inc., Cambridge, Massachusetts, USA
| | - Michael Hanley
- Millennium Pharmaceuticals, Inc., Cambridge, Massachusetts, USA
| | | | - Pingkuan Zhang
- Millennium Pharmaceuticals, Inc., Cambridge, Massachusetts, USA
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17
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Lee S, Nath CE, Balzer BWR, Lewis CR, Trahair TN, Anazodo AC, Shaw PJ. An HPLC–PDA method for determination of alectinib concentrations in the plasma of an adolescent. ACTA CHROMATOGR 2020. [DOI: 10.1556/1326.2019.00578] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Alectinib is a central nervous system-active small molecule anaplastic lymphoma kinase (ALK) inhibitor that is effective in the treatment of patients with ALK positive tumors, including advanced non-small cell lung cancers and lymphomas. A simple, isocratic high-performance liquid chromatography–photo diode array detection (HPLC–PDA) assay for measurement of alectinib in human plasma is described. Alectinib is extracted from the plasma matrix by addition of methanol, followed by centrifugation and acidification with 0.1% formic acid. It elutes with a run time of 4.6 min using a 250 mm × 4.6 mm RP-C18 column with 0.1% aqueous formic acid and methanol (35:65, v/v) and a flow rate of 1 mL/min. Detection was at 339 nm. Linear calibration plots were achieved in the range of 0.1–20 μg/mL for alectinib (r2 = 0.9996). With limits of detection and quantification of 0.05 and 0.1 μg/mL, respectively, and excellent precision (%CV < 10%), accuracy (bias < ±12%), and recovery (>97%) within the 1–20 μg/mL concentration range, this assay was suitable for measuring pre-dose alectinib concentrations in an adolescent receiving 600-mg doses twice daily.
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Affiliation(s)
- Samiuela Lee
- 1 Department of Biochemistry, The Children’s Hospital at Westmead, Australia
| | - Christa E. Nath
- 1 Department of Biochemistry, The Children’s Hospital at Westmead, Australia
- 2 Faculty of Pharmacy, University of Sydney, Australia
| | - Ben W. R. Balzer
- 3 Sydney Children's Hospital, Randwick NSW 2031, Australia
- 4 School of Women's and Children's Health, University of New South Wales, Randwick NSW 2031, Australia
| | - Craig R. Lewis
- 5 Nelune Comprehensive Cancer Centre, Prince of Wales Hospital, Randwick NSW 2031, Australia
- 6 Prince of Wales Clinical School, University of New South Wales, Randwick NSW 2031, Australia
| | - Toby N. Trahair
- 4 School of Women's and Children's Health, University of New South Wales, Randwick NSW 2031, Australia
- 7 Kids Cancer Centre, Sydney Children's Hospital, Randwick NSW 2031, Australia
| | - Antoinette C. Anazodo
- 4 School of Women's and Children's Health, University of New South Wales, Randwick NSW 2031, Australia
- 5 Nelune Comprehensive Cancer Centre, Prince of Wales Hospital, Randwick NSW 2031, Australia
- 7 Kids Cancer Centre, Sydney Children's Hospital, Randwick NSW 2031, Australia
| | - Peter J. Shaw
- 8 Cancer Centre for Children, The Children's Hospital at Westmead, Australia
- 9 Discipline of Child and Adolescent Health, University of Sydney, Australia
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18
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Groenland SL, Geel DR, Janssen JM, de Vries N, Rosing H, Beijnen JH, Burgers JA, Smit EF, Huitema ADR, Steeghs N. Exposure-Response Analyses of Anaplastic Lymphoma Kinase Inhibitors Crizotinib and Alectinib in Non-Small Cell Lung Cancer Patients. Clin Pharmacol Ther 2020; 109:394-402. [PMID: 32686074 PMCID: PMC7891593 DOI: 10.1002/cpt.1989] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 06/30/2020] [Indexed: 12/19/2022]
Abstract
Crizotinib and alectinib are anaplastic lymphoma kinase (ALK)-inhibitors indicated for the treatment of ALK-positive metastatic non-small cell lung cancer (NSCLC). At the currently used fixed doses, interindividual variability in exposure is high. The aim of this study was to investigate whether minimum plasma concentrations (Cmin ) of crizotinib and alectinib are related to efficacy and toxicity. An observational study was performed, in which ALK-positive NSCLC patients who were treated with crizotinib and alectinib and from whom pharmacokinetic samples were collected in routine care, were included in the study. Exposure-response analyses were explored using previously proposed Cmin thresholds of 235 ng/mL for crizotinib and 435 ng/mL for alectinib. Forty-eight crizotinib and 52 alectinib patients were included. For crizotinib, median progression-free survival (mPFS) was 5.7 vs. 17.4 months for patients with Cmin < 235 ng/mL (48%) and ≥ 235 ng/mL, respectively (P = 0.08). In multivariable analysis, Cmin < 235 ng/mL resulted in a hazard ratio (HR) of 1.79 (95% confidence interval (CI), 0.90-3.59, P = 0.100). In a pooled analysis of all crizotinib patients (not only ALK-positive, n = 79), the HR was 2.15 (95% CI, 1.21-3.84, P = 0.009). For alectinib, mPFS was 12.6 months vs. not estimable (95% CI, 19.8-not estimable) for patients with Cmin < 435 ng/mL (37%) and ≥ 435 ng/mL, respectively (P = 0.04). Multivariable analysis resulted in an HR of 4.29 (95% CI, 1.33-13.90, P = 0.015). In conclusion, PFS of crizotinib and alectinib treated NSCLC patients is prolonged in patients with Cmin ≥ 235 ng/mL and 435 ng/mL, respectively. Therefore, therapeutic drug monitoring should be part of routine clinical management for these agents.
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Affiliation(s)
- Stefanie L Groenland
- Department of Clinical Pharmacology, Division of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Dieuwertje R Geel
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Julie M Janssen
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Niels de Vries
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Hilde Rosing
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Jos H Beijnen
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.,Department of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Jacobus A Burgers
- Department of Thoracic Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Egbert F Smit
- Department of Thoracic Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Alwin D R Huitema
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.,Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Neeltje Steeghs
- Department of Clinical Pharmacology, Division of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
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Assessing the translational value of pre-clinical studies for clinical response rate in oncology: an exploratory investigation of 42 FDA-approved small-molecule targeted anticancer drugs. Cancer Chemother Pharmacol 2020; 85:1015-1027. [PMID: 32424570 DOI: 10.1007/s00280-020-04076-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 04/24/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE To assess the translational value of anticancer preclinical models, we retrospectively investigated the relationships between preclinical data and clinical response rate for 42 small-molecule targeted anticancer drugs approved by the US FDA from 2001 to 2018. METHODS For 42 FDA-approved drugs, relevant pre-clinical (IC50, mouse PK/efficacy) and clinical (overall response rates [ORR], PK) data were extracted from the public domain. Relationships were investigated overall and separately by mechanism of action and solid vs liquid tumors. Binomial-normal regression analysis was performed using R. RESULTS A significant correlation was found between the ratio of free human average plasma concentration (hCave) at the approved clinical dose to biochemical IC50 and ORR for kinase inhibitors with solid tumor indications (KIST). We also identified that, for KIST, the ratios of (i) total and (ii) free human-to-mouse average plasma concentration at efficacious doses were correlated to ORR ((i) R2 = 0.72, n = 10; (ii) R2 = 0.78, n = 10)). CONCLUSION Relationships were identified for ratios of efficacious clinical exposures to typical preclinical pharmacology data and ORR for KIST in this retrospective analysis. Although the obtained datasets are limited, the relationships demonstrate that a systemic exposure relative to established pre-clinical pharmacology experiments for an investigational KIST could be used as a reference to assess if desired efficacy could be achieved. This approach may assist selection of the recommended phase 2 dose (RP2D) of an investigational drug.
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20
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Liu WJ, Du Y, Wen R, Yang M, Xu J. Drug resistance to targeted therapeutic strategies in non-small cell lung cancer. Pharmacol Ther 2019; 206:107438. [PMID: 31715289 DOI: 10.1016/j.pharmthera.2019.107438] [Citation(s) in RCA: 102] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 11/06/2019] [Indexed: 02/07/2023]
Abstract
Rapidly developing molecular biology techniques have been employed to identify cancer driver genes in specimens from patients with non-small cell lung cancer (NSCLC). Inhibitors and antibodies that specifically target driver gene-mediated signaling pathways to suppress tumor growth and progression are expected to extend the survival time and further improve the quality of life of patients. However, the health of patients with advanced and metastatic NSCLC presents significant challenges due to treatment resistance, mediated by cancer driver gene alteration, epigenetic alteration, and tumor heterogeneity. In this review, we discuss two different resistance mechanisms in NSCLC targeted therapies, namely changes in the targeted oncogenes (on-target resistance) and changes in other related signaling pathways (off-target resistance) in tumor cells. We highlight the conventional mechanisms of drug resistance elicited by the complex heterogeneous microenvironment of NSCLC during targeted therapy, including mutations in epidermal growth factor receptor (EGFR), anaplastic lymphoma kinase (ALK), the receptor tyrosine kinase ROS proto-oncogene 1 (ROS1), and the serine/threonine-protein kinase BRAF (v-Raf murine sarcoma viral oncogene homolog B). We also discuss the mechanism of action of less common oncoproteins, as in-depth understanding of these molecular mechanisms is important for optimizing treatment strategies.
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Affiliation(s)
- Wen-Juan Liu
- Shandong Provincial Key Laboratory of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, China
| | - Yue Du
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Ru Wen
- Department of Medicine, Stanford University School of Medicine, California, USA
| | - Ming Yang
- Shandong Provincial Key Laboratory of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, China.
| | - Jian Xu
- Laboratory of Molecular Biology, Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA.
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21
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Pooled overall survival and safety data from the pivotal phase II studies (NP28673 and NP28761) of alectinib in ALK-positive non-small-cell lung cancer. Lung Cancer 2019; 139:22-27. [PMID: 31706099 DOI: 10.1016/j.lungcan.2019.10.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 10/11/2019] [Accepted: 10/13/2019] [Indexed: 11/23/2022]
Abstract
OBJECTIVES A pooled analysis of two open-label phase II studies of alectinib (NP28673 [NCT01801111] and NP28761 [NCT01871805]) demonstrated clinical activity in patients with advanced, anaplastic lymphoma kinase-positive (ALK+) non-small-cell lung cancer (NSCLC) previously treated with crizotinib. Longer-term and final pooled analyses of overall survival (OS) and safety data from the two studies are presented here. PATIENTS AND METHODS The pooled population totaled 225 patients (NP28673: n = 138, NP28761: n = 87) who received 600 mg oral alectinib twice daily until disease progression, death, or withdrawal. OS was defined as the time from date of first treatment to date of death, regardless of cause. OS was estimated using Kaplan-Meier methodology, with 95% confidence intervals (CIs) determined using the Brookmeyer-Crowley method. Safety was assessed through adverse event (AE) reporting. RESULTS Baseline characteristics were generally comparable between the studies. At final data cutoff (October 27, 2017 [NP28673], October 12, 2017 [NP28761]; median pooled follow-up time, ∼21 months), 53.3% of patients had died, 39.1% were alive and in follow-up, and 7.6% had withdrawn consent or were lost to follow-up. Alectinib demonstrated a median OS of 29.1 months (95% CI 21.3-39.0). No new or unexpected safety findings were observed. The most common all-grade AEs included constipation (39.1%), fatigue (35.1%), peripheral edema (28.4%), myalgia (26.2%), and nausea (24.0%). CONCLUSION Updated results from this pooled analysis further demonstrate that alectinib has robust clinical activity and a manageable safety profile in patients with advanced, ALK+ NSCLC pretreated with crizotinib.
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Morcos PN, Liu J, Blumenthal GM, Zhao H. Model‐Informed Drug Development Approach to Expedite Approval: Case of Alectinib in First‐Line Anaplastic Lymphoma Kinase + Non‐Small Cell Lung Cancer. Clin Pharmacol Ther 2019; 105:826-828. [DOI: 10.1002/cpt.1340] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 12/08/2018] [Indexed: 11/07/2022]
Affiliation(s)
- Peter N. Morcos
- Clinical Pharmacology, Pharmaceutical Sciences, Pharma Research and Early Development (pRED)Roche Innovation Center New York New York USA
| | - Jiang Liu
- Office of Clinical Pharmacology, Food and Drug Administration Silver Spring Maryland USA
| | - Gideon M. Blumenthal
- Office of Hematology and Oncology Products, Food and Drug Administration Silver Spring Maryland USA
| | - Hong Zhao
- Office of Clinical Pharmacology, Food and Drug Administration Silver Spring Maryland USA
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Balzer BWR, Loo C, Wegner EA, Nath CE, Lee S, Smith C, Lewis CR, Trahair TN, Anazodo AC. Alectinib is effective, safe and tolerable in an adolescent with stage IVB ALK-rearranged adenocarcinoma of the lung. Pediatr Hematol Oncol 2018; 35:415-421. [PMID: 30526220 DOI: 10.1080/08880018.2018.1541492] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Anaplastic lymphoma kinase (ALK) inhibitors such as crizotinib and alectinib have been shown to have significant activity in ALK-rearranged non-small cell lung cancers (NSCLC). There are no data for alectinib's safety or efficacy in younger patients, though it is superior to crizotinib in adult trials. We present a 14-year old girl diagnosed with stage IV-B ALK-positive adenocarcinoma of the lung after presenting with cough and fever. She was commenced on alectinib at adult dose and has had sustained complete metabolic remission for 9 months. She is the youngest patient with lung adenocarcinoma to be treated with alectinib.
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Affiliation(s)
- Ben W R Balzer
- a Sydney Children's Hospital , Randwick , New South Wales , Australia.,b School of Women's and Children's Health , University of New South Wales , Randwick , New South Wales , Australia
| | - Christine Loo
- c Department of Anatomical Pathology , NSW Health Pathology, Prince of Wales Hospital , Randwick , New South Wales , Australia
| | - Eva A Wegner
- d Department of Nuclear Medicine and PET , Prince of Wales Hospital , Randwick , New South Wales , Australia.,e Prince of Wales Clinical School , University of New South Wales , Randwick , New South Wales , Australia
| | - Christa E Nath
- f Department of Biochemistry , The Children's Hospital at Westmead , Westmead , New South Wales , Australia.,g Faculty of Pharmacy , University of Sydney , Camperdown , New South Wales , Australia
| | - Samiuela Lee
- f Department of Biochemistry , The Children's Hospital at Westmead , Westmead , New South Wales , Australia
| | - Chantelle Smith
- h Pharmacy Department , Sydney Children's Hospital , Randwick , New South Wales , Australia
| | - Craig R Lewis
- e Prince of Wales Clinical School , University of New South Wales , Randwick , New South Wales , Australia.,i Department of Medical Oncology , Prince of Wales Hospital , Randwick , New South Wales , Australia
| | - Toby N Trahair
- a Sydney Children's Hospital , Randwick , New South Wales , Australia.,b School of Women's and Children's Health , University of New South Wales , Randwick , New South Wales , Australia.,j Sydney Children's Hospital , Kids Cancer Centre , Randwick , New South Wales , Australia
| | - Antoinette C Anazodo
- a Sydney Children's Hospital , Randwick , New South Wales , Australia.,b School of Women's and Children's Health , University of New South Wales , Randwick , New South Wales , Australia.,j Sydney Children's Hospital , Kids Cancer Centre , Randwick , New South Wales , Australia.,k Prince of Wales Hospital , Nelune Comprehensive Cancer Centre , Randwick , New South Wales , Australia
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24
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Vavalà T, Novello S. Alectinib in the treatment of ALK-positive non-small cell lung cancer: an update on its properties, efficacy, safety and place in therapy. Ther Adv Med Oncol 2018; 10:1758835918789364. [PMID: 30090122 PMCID: PMC6077883 DOI: 10.1177/1758835918789364] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Accepted: 06/19/2018] [Indexed: 01/01/2023] Open
Abstract
Anaplastic lymphoma kinase (ALK) rearrangement is identified in 3–7% of advanced non-small cell lung cancer (NSCLC) cases, and ALK tyrosine kinase inhibitors (TKIs) have revolutionized the management of this subset of NSCLC patients. ALK–TKIs have been proven highly effective in ALK-rearranged advanced NSCLC patients, but after initial responses and benefit, a subsequent progression inevitably occurs. Understanding acquired-resistance mechanisms and defining an appropriate algorithm is becoming even more essential, particularly considering the availability of extremely efficacious next-generation ALK inhibitors. The aim of this review is the analysis of current data about ALK inhibition as a therapeutic strategy in ALK-rearranged NSCLC management, with a focus on a specific ALK–TKI, alectinib. Alectinib is a highly selective inhibitor of ALK and showed systemic and central nervous system (CNS) efficacy in the treatment of this particular population. The change of first-line approach, and consequently of further lines of therapy, in ALK-rearranged NSCLC patients is still a matter of debate. A summary of evidence from randomized trials evaluating alectinib will be presented in order to discuss the available clinical evidence, safety and place in therapy.
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Affiliation(s)
- Tiziana Vavalà
- SC of Oncology at ASL CN1, Ospedale Civile di Saluzzo, Cuneo, Italy
| | - Silvia Novello
- Department of Oncology, University of Torino, AOU S. Luigi Gonzaga, Regione Gonzole 10, Orbassano (TO), Turin, Orbassano 10043, Italy
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