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Faisal Hamdi AI, How SH, Islam MK, Lim JCW, Stanslas J. Adaptive therapy to circumvent drug resistance to tyrosine kinase inhibitors in cancer: is it clinically relevant? Expert Rev Anticancer Ther 2022; 22:1309-1323. [PMID: 36376248 DOI: 10.1080/14737140.2022.2147671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Cancer is highly adaptable and is constantly evolving against current targeted therapies such as tyrosine kinase inhibitors. Despite advances in recent decades, the emergence of drug resistance to tyrosine kinase inhibitors constantly hampers therapeutic efficacy of cancer treatment. Continuous therapy versus intermittent clinical regimen has been a debate in drug administration of cancer patients. An ecologically-inspired shift in cancer treatment known as 'adaptive therapy' intends to improve the drug administration of drugs to cancer patients that can delay emergence of drug resistance. AREAS COVERED We discuss improved understanding of the concept of drug resistance, the basis of continuous therapy, intermittent clinical regimens, and adaptive therapy will be reviewed. In addition, we discuss how adaptive therapy provides guidance for future cancer treatment. EXPERT OPINION The current understanding of drug resistance in cancer leads to poor prognosis and limited treatment options in patients. Fighting drug resistance mutants is constantly followed by new forms of resistance. In most reported cases, continuous therapy leads to drug resistance and an intermittent clinical regimen vaguely delays it. However, adaptive therapy, conceptually, exploits multiple parameters that can suppress the growth of drug resistance and provides safe treatment for cancer patients in the future.
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Affiliation(s)
- Amir Imran Faisal Hamdi
- Pharmacotherapeutics Unit, Department of Medicine, Universiti Putra MalaysiaMedicine, 43400, Serdang, Malaysia
| | - Soon Hin How
- Kuliyyah of Medicine, International Islamic University Malaysia, Kuantan Campus, Kuliyyah of Medicine, 25200, Kuantan, Malaysia
| | | | - Jonathan Chee Woei Lim
- Pharmacotherapeutics Unit, Department of Medicine, Universiti Putra MalaysiaMedicine, 43400, Serdang, Malaysia
| | - Johnson Stanslas
- Pharmacotherapeutics Unit, Department of Medicine, Universiti Putra MalaysiaMedicine, 43400, Serdang, Malaysia
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Piper-Vallillo A, Rotow JK, Aredo JV, Shaverdashvili K, Luo J, Carlisle JW, Husain H, Muzikansky A, Heist RS, Rangachari D, Ramalingam SS, Wakelee HA, Yu HA, Sequist LV, Bauml JM, Neal JW, Piotrowska Z. High-Dose Osimertinib for CNS Progression in EGFR+ NSCLC: A Multi-Institutional Experience. JTO Clin Res Rep 2022; 3:100328. [PMID: 35637759 PMCID: PMC9142556 DOI: 10.1016/j.jtocrr.2022.100328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 04/07/2022] [Accepted: 04/09/2022] [Indexed: 11/28/2022] Open
Abstract
Introduction This multicenter review evaluated the efficacy and safety of osimertinib dose escalation for central nervous system (CNS) progression developing on osimertinib 80 mg in EGFR-mutant NSCLC. Methods Retrospective review identified 105 patients from eight institutions with advanced EGFR-mutant NSCLC treated with osimertinib 160 mg daily between October 2013 and January 2020. Radiographic responses were clinically assessed, and Kaplan-Meier analyses were used. We defined CNS disease control as the interval from osimertinib 160 mg initiation to CNS progression or discontinuation of osimertinib 160 mg. Results Among 105 patients treated with osimertinib 160 mg, 69 were escalated for CNS progression, including 24 treated with dose escalation alone (cohort A), 34 who received dose-escalated osimertinib plus concurrent chemotherapy and/or radiation (cohort B), and 11 who received osimertinib 160 mg without any prior 80 mg exposure. The median duration of CNS control was 3.8 months (95% confidence interval [CI], 1.7-5.8) in cohort A, 5.1 months (95% CI, 3.1-6.5) in cohort B, and 4.2 months (95% CI 1.6-not reached) in cohort C. Across all cohorts, the median duration of CNS control was 6.0 months (95% CI, 5.1-9.0) in isolated leptomeningeal progression (n = 27) and 3.3 months (95% CI, 1.0-3.1) among those with parenchymal-only metastases (n = 23). Patients on osimertinib 160 mg experienced no severe or unexpected side effects. Conclusion Among patients with EGFR-mutant NSCLC experiencing CNS progression on osimertinib 80 mg daily, dose escalation to 160 mg provided modest benefit with CNS control lasting approximately 3 to 6 months and seemed more effective in patients with isolated leptomeningeal CNS progression.
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Affiliation(s)
- A.J. Piper-Vallillo
- Massachusetts General Hospital, Boston, Massachusetts
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Julia K. Rotow
- Harvard Medical School, Boston, Massachusetts
- Dana Farber Cancer Institute, Boston, Massachusetts
| | | | | | - Jia Luo
- Harvard Medical School, Boston, Massachusetts
- Dana Farber Cancer Institute, Boston, Massachusetts
- Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Hatim Husain
- University of California San Diego Medical Center, La Jolla, California
| | | | - Rebecca S. Heist
- Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Deepa Rangachari
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | | | | | - Helena A. Yu
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Lecia V. Sequist
- Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Joshua M. Bauml
- Abramson Cancer Center at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joel W. Neal
- Stanford University School of Medicine, Stanford, California
| | - Zofia Piotrowska
- Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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Mathur D, Barnett E, Scher HI, Xavier JB. Optimizing the future: how mathematical models inform treatment schedules for cancer. Trends Cancer 2022; 8:506-516. [PMID: 35277375 DOI: 10.1016/j.trecan.2022.02.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 01/25/2022] [Accepted: 02/14/2022] [Indexed: 11/18/2022]
Abstract
For decades, mathematical models have influenced how we schedule chemotherapeutics. More recently, mathematical models have leveraged lessons from ecology, evolution, and game theory to advance predictions of optimal treatment schedules, often in a personalized medicine manner. We discuss both established and emerging therapeutic strategies that deviate from canonical standard-of-care regimens, and how mathematical models have contributed to the design of such schedules. We first examine scheduling options for single therapies and review the advantages and disadvantages of various treatment plans. We then consider the challenge of scheduling multiple therapies, and review the mathematical and clinical support for various conflicting treatment schedules. Finally, we propose how a consilience of mathematical and clinical knowledge can best determine the optimal treatment schedules for patients.
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Affiliation(s)
- Deepti Mathur
- Program for Computational and Systems Biology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ethan Barnett
- Genitourinary Oncology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Howard I Scher
- Genitourinary Oncology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Joao B Xavier
- Program for Computational and Systems Biology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Wittlinger F, Laufer SA. The pre-clinical discovery and development of osimertinib used to treat non-small cell lung cancer. Expert Opin Drug Discov 2021; 16:1091-1103. [PMID: 34053372 DOI: 10.1080/17460441.2021.1936496] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Introduction: Osimertinib is currently the only FDA- and EMA-approved third-generation small-molecule epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (TKI). It was initially indicated for second-line treatment of patients with metastatic EGFR T790M mutation-positive non-small cell lung cancer (NSCLC) and got approved for first-line treatment of EGFR activation mutation-positive metastatic NSCLC in 2018. Most recently, the FDA granted approval for the adjuvant treatment of patients with early-stage mutated EGFR NSCLC after tumor resection.Areas covered: This drug discovery case history focuses on the key studies that led to the preclinical discovery and development of osimertinib. The authors focus on published preclinical studies by scientists from AstraZeneca and highlight key events in the clinical development.Expert opinion: Although eventually compromised by the cellular plasticity of the tumor and the inevitable acquisition of drug resistance through the use of osimertinib, its key role in the treatment of NSCLC with specific EGFR mutations will be maintained in the near future. As the genome of EGFR is highly labile and since the rapid development of new mutants remains an issue, there is still room for improvement for the next generation of inhibitors.
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Affiliation(s)
- Florian Wittlinger
- Tuebingen Center for Academic Drug Discovery & Development, Institute of Pharmaceutical Sciences, Eberhard Karls Universität Tübingen, Tübingen, Germany
| | - Stefan A Laufer
- Tuebingen Center for Academic Drug Discovery & Development, Institute of Pharmaceutical Sciences, Eberhard Karls Universität Tübingen, Tübingen, Germany
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Overcoming Intrinsic and Acquired Cetuximab Resistance in RAS Wild-Type Colorectal Cancer: An In Vitro Study on the Expression of HER Receptors and the Potential of Afatinib. Cancers (Basel) 2019; 11:cancers11010098. [PMID: 30650638 PMCID: PMC6357064 DOI: 10.3390/cancers11010098] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 01/08/2019] [Accepted: 01/14/2019] [Indexed: 12/16/2022] Open
Abstract
The epidermal growth factor receptor (EGFR) is an important therapeutic target in colorectal cancer (CRC). After the initial promising results of EGFR-targeted therapies such as cetuximab, therapeutic resistance poses a challenging problem and limits the success of effective anti-EGFR cancer therapies in the clinic. In order to overcome resistance to these EGFR-targeted therapies, new treatment options are necessary. The objective of this study was to investigate the expression of human epidermal growth factor (HER) receptors and the efficacy of afatinib, a second-generation irreversible EGFR-tyrosine kinase inhibitor, in RAS wild-type CRC cell lines with different cetuximab sensitivities. CRC cell lines with different sensitivities to cetuximab showed rather low EGFR expression but high HER2 and HER3 expression. These results were in line with the The Cancer Genome Atlas (TCGA) data from CRC patients, where higher mRNA levels of HER2 and HER3 were also detected compared to EGFR. Therefore, the targets of afatinib were indeed expressed on the CRC cell lines used in this study and in CRC patients. Furthermore, cetuximab resistance had no significant influence on the expression levels of HER receptors in CRC cell lines (p ≥ 0.652). This study also demonstrated that afatinib was able to induce a concentration-dependent cytotoxic effect in RAS wild-type CRC cell lines with different cetuximab sensitivities. Neither cetuximab resistance (p = 0.233) nor hypoxia (p = 0.157) significantly influenced afatinib’s cytotoxic effect. In conclusion, our preclinical data support the hypothesis that treatment with afatinib might be a promising novel therapeutic strategy for CRC patients experiencing intrinsic and acquired cetuximab resistance.
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Tan WL, Ng QS, Lim C, Tan EH, Toh CK, Ang MK, Kanesvaran R, Jain A, Tan DSW, Lim DWT. Influence of afatinib dose on outcomes of advanced EGFR-mutant NSCLC patients with brain metastases. BMC Cancer 2018; 18:1198. [PMID: 30509246 PMCID: PMC6276185 DOI: 10.1186/s12885-018-5110-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 11/20/2018] [Indexed: 12/12/2022] Open
Abstract
Background Afatinib is an oral irreversible epidermal growth factor receptor (EGFR) tyrosine-kinase inhibitor (TKI) indicated in first-line treatment of advanced EGFR-mutant (EGFRm+) non-small cell lung cancer (NSCLC). Dose dependent side effects can limit drug exposure, which may impact on extracranial and central nervous system (CNS) disease control. Methods We performed a retrospective study of 125 patients diagnosed with advanced EGFRm+ NSCLC treated with first-line afatinib at a tertiary Asian cancer center, exploring clinicopathological factors that may influence survival outcomes. Median progression free survival (PFS) was estimated using the Kaplan-Meier method. Comparison of PFS between subgroups of patients was done using log-rank tests and Cox proportional hazards models. Results Out of 125 patients, 62 (49.6%) started on 40 mg once daily (OD) afatinib, 61 (48.8%) on 30 mg OD and 1 (0.8%) on 20 mg OD. After median follow-up of 13.8 months from afatinib initiation, the observed response rate was 70.4% and median PFS 11.9 months (95% CI 10.3–19.3). 42 (33.6%) patients had baseline brain metastases (BM) and PFS of those who started on 40 mg OD (n = 17) vs. 30 mg OD (n = 25) was 13.3 months vs. 5.3 months (HR 0.39, 95% CI 0.15–0.99). BM+ patients who started on 40 mg had similar PFS to patients with no BM (13.3 months vs. 15.0 months; HR 0.79, 95% CI 0.34–1.80). Conclusion In patients with advanced EGFRm+ NSCLC with BM+, initiating patients on afatinib 40 mg OD was associated with improved PFS compared to 30 mg OD, underscoring the potential importance of dose intensity in control of CNS disease.
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Affiliation(s)
- Wan-Ling Tan
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore, Singapore
| | - Quan Sing Ng
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore, Singapore
| | - Cindy Lim
- Clinical Trials & Epidemiological Sciences, National Cancer Centre Singapore, Singapore, Singapore
| | - Eng Huat Tan
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore, Singapore
| | - Chee Keong Toh
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore, Singapore
| | - Mei-Kim Ang
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore, Singapore
| | - Ravindran Kanesvaran
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore, Singapore
| | - Amit Jain
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore, Singapore
| | - Daniel S W Tan
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore, Singapore.,Genome Institute of Singapore, A*STAR, Singapore, Singapore
| | - Darren Wan-Teck Lim
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore, Singapore. .,Institute of Molecular and Cell Biology, A*STAR, Singapore, Singapore.
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