Gefitinib Versus Adjuvant Chemotherapy in Patients With Stage II-IIIA Non–Small-Cell Lung Cancer Harboring Positive EGFR Mutations: A Single-Center Retrospective Study

Efficacy and safety of adjuvant EGFR TKI alone and in combination with chemotherapy for resected EGFR mutation-positive non-small cell lung cancer: A Bayesian network meta-analysis

Adjuvant therapy with epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (TKI), alone or with chemotherapy, is used for early-stage non-small cell lung cancer (NSCLC) with EGFR mutations. A Bayesian meta-analysis was conducted to compare the efficacy and safety of adjuvant EGFR-TKI and adjuvant chemotherapy plus EGFR-TKI to determine whether additional adjuvant chemotherapy is beneficial. Randomised controlled trials and retrospective comparative studies examining the efficacy of adjuvant EGFR-TKI were searched from inception to July 2022. Ten studies (1344 patients) were analysed. Disease-free survival (DFS), overall survival (OS), and adverse events (AEs) were the endpoints. Our network meta-analysis demonstrated that EGFR-TKI monotherapy is noninferior to chemotherapy plus EGFR-TKI for DFS and OS in the adjuvant setting. However, combination treatment was associated with a higher AE incidence and severity. Adjuvant EGFR-TKI monotherapy seems a viable alternative to chemotherapy plus EGFR-TKI in patients with resected EGFR mutation-positive NSCLC.

Clinical Relevance of Targeted Therapy and Immune-Checkpoint Inhibition in Lung Cancer

Lung cancer (LC) represents the second most diagnosed tumor and the malignancy with the highest mortality rate. In recent years, tremendous progress has been made in the treatment of this tumor thanks to the discovery, testing, and clinical approval of novel therapeutic approaches. Firstly, targeted therapies aimed at inhibiting specific mutated tyrosine kinases or downstream factors were approved in clinical practice. Secondly, immunotherapy inducing the reactivation of the immune system to efficiently eliminate LC cells has been approved. This review describes in depth both current and ongoing clinical studies, which allowed the approval of targeted therapies and immune-checkpoint inhibitors as standard of care for LC. Moreover, the present advantages and pitfalls of new therapeutic approaches will be discussed. Finally, the acquired importance of human microbiota as a novel source of LC biomarkers, as well as therapeutic targets to improve the efficacy of available therapies, was analyzed. Therapy against LC is increasingly becoming holistic, taking into consideration not only the genetic landscape of the tumor, but also the immune background and other individual variables, such as patient-specific gut microbial composition. On these bases, in the future, the research milestones reached will allow clinicians to treat LC patients with tailored approaches.

Comparing Gefitinib and Traditional Chemotherapy for Better Survival in Patients With Non-Small Cell Lung Cancer: A Systematic Review

Current non-small cell lung cancer (NSCLC) treatment consists of various combinations of surgery, chemotherapy, and/or radiation, depending on the tumor stage. Individuals with stage II-IIIa NSCLC undergo surgery, followed by combination chemotherapy containing cisplatin, such as vinorelbine + cisplatin. Epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs), such as gefitinib, act by inhibiting any signaling pathway containing the EGFR mutation and inhibiting the growth of NSCLC. TKI is a treatment option in advanced NSCLC, resulting in more prolonged progression-free survival (PFS). This manuscript aims to evaluate the influence of utilizing gefitinib - either alone or in combination with conventional chemotherapeutic drug regimens upon NSCLC patient profile survival parameters. A systematic literature review was conducted across multiple scientific literature repositories. The review was performed using the preferred reporting items for systematic reviews and meta-analyses (PRISMA) 2020. There were six randomized clinical trials (RCT) and five retrospective studies. The overall consensus based on the end outcome of each published journal on the effectiveness of gefitinib as a treatment option for NSCLC indicated that there was a notable difference in overall survival (OS) and progression-free survival (PFS) and disease-free survival (DFS) datasets. Gefitinib use correlated with increased timeframes for multiple patient survival parameters within articles shortlisted in this investigation. However, more comprehensive investigations are required to validate such correlations. Gefitinib did demonstrate the potential to provide beneficial effects and counteract NSCLC within such patients.

A meta-analysis of adjuvant EGFR-TKIs for patients with EGFR mutation of resected non-small cell lung cancer

BACKGROUND

The role of epidermal growth factor receptor (EGFR)-tyrosine kinase inhibitor (TKIs) in improving the prognostic outcome of non-small cell lung cancer (NSCLC) cases harboring EGFR mutation following radical surgery is still controversial. This work focused on comparing EGFR-TKIs and adjuvant chemotherapy (ACT) or placebo in treating NSCLC cases, specifically on those with EGFR-mutant, being in the stage of IB-IIIA and possibly gained benefits from the above treatment after radical resection.

METHODS

The Cochrane Library, MEDLINE, and Embase databases were searched to identify eligible clinical trials; two authors were responsible for screening the results. The primary outcomes were evaluated by disease-free survival (DFS) and overall survival (OS) based on hazard ratios (HRs) and a relevant 95% confidence interval (CI).

RESULTS

The literature search yielded twelve eligible studies, including four retrospective cohort studies and eight randomized controlled trials (RCTs) that enrolled 1694 cases and were of acceptable quality. In patients receiving adjuvant EGFR-TKIs compared with ACT or placebo treatment, HR regarding DFS was 0.47 (95% CI: 0.40, 0.55), whereas the OS rate was 0.74 (95% CI: 0.58, 0.95). For patients who received adjuvant EGFR-TKIs in combination with conventional chemotherapy compared to chemotherapy, the efficiency was significantly enhanced, with the HR for DFS being 0.29 (95% CI: 0.15, 0.58) and that for OS being 0.51 (95% CI: 0.25, 1.04), separately.

CONCLUSION

For NSCLC cases who had EGFR mutations and surgery, adjuvant EGFR-TKI combined with chemotherapy achieved superior effect over chemotherapy or placebo with reference to DFS and may prolong the OS up to some extent.

EGFR-Mutant Non-Small-Cell Lung Cancer at Surgical Stages: What Is the Place for Tyrosine Kinase Inhibitors?

Simple Summary

Tyrosine kinase inhibitors are drugs targeting the epidermal growth factor receptor. In lung cancer, they are used to treat advanced EGFR-mutant diseases, and more recently, one has been approved for adjuvant therapy. Even though publications on the topic are numerous, conclusions are difficult to interpret and are sometimes contradictory. We therefore reviewed the literature in order to present an overview of up-to-date data regarding the adjuvant and neoadjuvant use of tyrosine kinase inhibitors, with particular attention given to their benefits, proven or expected, as well as what challenges could be faced when entering them as protocols in standard care.

Abstract

The ADAURA trial has been significant for the perception of EGFR tyrosine kinase inhibitors (TKIs) as a tool for early stage non-small-cell lung cancer (NSCLC). It produced such great insight that the main TKI, Osimertinib, was rapidly integrated into international guidelines for adjuvant use. However, EGFR-mutant NSCLC is a complex entity and has various targeting drugs, and the benefits for patients might not be as clear as they seem. We reviewed trials and meta-analyses considering TKI adjuvant and neoadjuvant use. We also explored the influence of mutation variability and financial evaluations. We found that TKIs often show disease-free survival (DFS) benefits, yet studies have struggled to improve the overall survival (OS); however, the results from the literature might be confusing because of variability in the stages and mutations. The safety profiles and adverse events are acceptable, but costs remain high and accessibility might not be optimal. TKIs are promising drugs that could allow for tailored treatment designs.

Efficacy and safety of adjuvant EGFR-TKIs for resected non-small cell lung cancer: a systematic review and meta-analysis based on randomized control trials

Background

Postoperative adjuvant cisplatin-based chemotherapy had been the standard care in patients with completely resected high-risk stage IB to IIIA non-small cell lung cancer (NSCLC) for decades. However, the survival benefits were far from satisfactory in clinical practice. Thus, this meta-analysis was performed to compare the efficacy and safety of adjuvant epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) in patients with resected NSCLC based on updated literature and research.

Methods

A systematic literature search based on random control trials (RCTs) was conducted with keywords on PubMed, Embase and the Cochrane library databases. All articles compared EGFR-TKIs to placebo or chemotherapy as adjuvant therapies for early-stage resected NSCLC. A meta-analysis was performed to generate combined hazard ratio (HR) with 95% confidence intervals (CI) for disease-free survival (DFS), overall survival (OS), and risk ratio (RR) with 95% CI for disease recurrence and adverse events (AEs). The Stata statistical software (version 14.0) was used to synthesis the data.

Results

A total of 9 RCTs comprising 3098 patients were included. Adjuvant EGFR-TKIs could significantly prolong DFS in patient with resected NSCLC harboring epidermal growth factor receptor (EGFR) mutations (HR 0.46, 95% CI 0.29–0.72), but had no impact on OS (HR 0.87, 95% CI 0.69–1.11). The subgroup analyses indicated that adjuvant EGFR-TKIs were superior in regard to DFS in most subgroups, including varied smoking status, EGFR mutations type, gender, age, Eastern Cooperative Oncology Group performance status and adenocarcinoma. Osimertinib resulted in decreased brain recurrence than first generation of EGFR-TKIs (RR 0.12, 95% CI 0.04–0.34 vs. RR 1.07, 95% CI 0.64–1.78, respectively). The AEs were generally manageable and tolerable. The incidence of high-grade (≥ 3) AEs including diarrhea (RR 5.68, 95% CI 2.94–10.98) and rash (RR 27.74, 95% CI 11.43–67.30) increased after adjuvant EGFR-TKIs treatment.

Conclusions

Adjuvant EGFR-TKIs therapy could significantly prolong DFS in patients with completely resected early-stage EGFR mutation-positive NSCLC, but had no impact on OS. Adjuvant EGFR-TKIs could be an important treatment option in patients with resected early-stage EGFR-mutant NSCLC.

Mechanism of Lethal Skin Toxicities Induced by Epidermal Growth Factor Receptor Inhibitors and Related Treatment Strategies

Epidermal growth factor receptor (EGFR) inhibitors are widely used to treat various types of cancers such as non-small cell lung cancer, head and neck cancer, breast cancer, pancreatic cancer. Adverse reactions such as skin toxicity, interstitial lung disease, hepatotoxicity, ocular toxicity, hypomagnesemia, stomatitis, and diarrhea may occur during treatment. Because the EGFR signaling pathway is important for maintaining normal physiological skin function. Adverse skin reactions occurred in up to 90% of cancer patients treated with EGFR inhibitors, including common skin toxicities (such as papulopustular exanthemas, paronychia, hair changes) and rare fatal skin toxicities (e.g., Stevens–Johnson syndrome, toxic epidermal necrolysis, acute generalized exanthematous pustulosis). This has led to the dose reduction or discontinuation of EGFR inhibitors in the treatment of cancer. Recently, progress has been made about research on the skin toxicity of EGFR inhibitors. Here, we summarize the mechanism of skin toxicity caused by EGFR inhibitors, measures to prevent severe fatal skin toxicity, and provide reference for medical staff how to give care and treatment after adverse skin reactions.

Efficacy of Epidermal Growth Factor Receptor Tyrosine Kinase Inhibitors in the Adjuvant Setting for Patients with Resected Epidermal Growth Factor Receptor Mutant Non-Small Cell Lung Cancer: A Meta-Analysis with 11 Trials

BACKGROUND

Epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) have recently become the standard first-line therapy for advanced non-small cell lung cancer (NSCLC) patients harboring EGFR mutations. This study aimed to define the role of EGFR-TKI treatment in the adjuvant setting of patients with resected EGFR-mutant NSCLC.

METHODS

Three online databases (PubMed, Embase, and the Cochrane Library) were used to conduct systematic research to search for studies published before June 1, 2020. The disease-free survival (DFS) and overall survival (OS) of patients with resected EGFR-mutant NSCLC after radical surgery treated with EGFR-TKIs versus non-EGFR-TKIs in the adjuvant setting were compared. Based on rigorous self-defined inclusion and exclusion criteria, studies were selected, and a meta-analysis was performed using hazard rate (HR) and 95% CIs as effective measures.

RESULTS

Eleven studies, published between 2011 and 2020, with a total of 1,900 patients, were included in this meta-analysis. EGFR-TKI treatment showed a significant beneficial effect on DFS (HR 0.42; 95% CI 0.31-0.57) and OS (HR 0.62; 95% CI 0.45-0.86) for patients with resected EGFR-mutant NSCLC after radical resection in the adjuvant setting.

CONCLUSION

Our meta-analysis results suggested that EGFR-TKI treatment improved the DFS and OS of completely resected patients with EGFR-mutant NSCLC compared with non-EGFR-TKI treatment in the adjuvant setting. In the future, our conclusion should be confirmed by additional large-scale and well-designed clinical trials.

Quality of life with adjuvant gefitinib versus vinorelbine plus cisplatin in patients with completely resected stage II-IIIA (N1-N2) EGFR-mutant non-small-cell lung cancer: Results from the ADJUVANT (CTONG1104) study

OBJECTIVES

Health-related quality of life (HRQoL) data complement conventional clinical endpoints when comparing adjuvant gefitinib with chemotherapy in patients with early-stage non-small-cell lung cancer (NSCLC) and epidermal growth factor receptor (EGFR) mutations. This study aimed to assess changes in HRQoL with adjuvant gefitinib vs chemotherapy in this patient group.

MATERIALS AND METHODS

In the phase III ADJUVANT trial, patients with completely resected, stage II-IIIA (N1-N2), EGFR-mutant NSCLC were randomized (1:1) to receive either gefitinib for 24 months or vinorelbine plus cisplatin (VP) every 3 weeks for four cycles. HRQoL was assessed as a secondary endpoint using the Functional Assessment of Cancer Therapy-Lung Cancer (FACT-L), Lung Cancer Symptom Scale (LCSS) questionnaires, and Trial Outcome Index (TOI) composite score. HRQoL dynamics, improvements, and time to deterioration were compared between groups.

RESULTS

At baseline, 104 of 106, and 80 of 87 patients receiving gefitinib and VP, respectively, completed two questionnaires (FACT-L and LCSS). Baseline scores were balanced between groups. Although HRQoL fluctuated and gradually improved in both groups, longitudinally higher scores were reported with gefitinib than VP (FACT-L, odds ratio 418.16, 95 % confidence interval [CI] 2.75-63509.05, p =  0.019; LCSS, 1.13, 1.04-1.22, p =  0.003; TOI, 88.39, 4.40-1775.05, p =  0.003). Time to deterioration in HRQoL was delayed with gefitinib compared with VP (FACT-L, median 69 vs 6 weeks, hazard ratio 0.62, 95 % CI 0.42-0.90, p =  0.013; LCSS, median 45 vs 6 weeks, 0.63, 0.43-0.93, p =  0.020; TOI, median 164 vs 9 weeks, 0.51, 0.33-0.77, p =  0.001).

CONCLUSION

Adjuvant gefitinib is associated with improved HRQoL over VP, supporting its use in patients with stage II-IIIA (N1-N2), EGFR-mutant NSCLC.

An Activatable Nano-Prodrug for Treating Tyrosine-Kinase-Inhibitor-Resistant Non-Small Cell Lung Cancer and for Optoacoustic and Fluorescent Imaging

Non-small cell lung cancer (NSCLC) is the most common type of lung cancer and the cause of high rate of mortality. The epidermal growth factor receptor (EGFR)-targeted tyrosine kinase inhibitors are used to treat NSCLC, yet their curative effects are usually compromised by drug resistance. This study demonstrates a nanodrug for treating tyrosine-kinase-inhibitor-resistant NSCLC through inhibiting upstream and downstream EGFR signaling pathways. The main molecule of the nanodrug is synthesized by linking a tyrosine kinase inhibitor gefitinib and a near-infrared dye (NIR) on each side of a disulfide via carbonate bonds, and the nanodrug is then obtained through nanoparticle formation of the main molecule in aqueous medium and concomitant encapsulation of a serine threonine protein kinase (Akt) inhibitor celastrol. Upon administration, the nanodrug accumulates at the tumor region of NSCLC-bearing mice and releases the drugs for tumor inhibition, and the dye for fluorescence and optoacoustic imaging. Through suppressing the phosphorylation of upstream EGFR and downstream Akt in the EGFR pathway by gefitinib and celastrol, respectively, the nanodrug exhibits high inhibition efficacy against orthotopic NSCLC in mouse models.

Differences in Stage of Cancer at Diagnosis, Treatment, and Survival by Race and Ethnicity Among Leading Cancer Types

IMPORTANCE

Information about stage of cancer at diagnosis, use of therapy, and survival among patients from different racial/ethnic groups with 1 of the most common cancers is lacking.

OBJECTIVE

To assess stage of cancer at diagnosis, use of therapy, overall survival (OS), and cancer-specific survival (CSS) in patients with cancer from different racial/ethnic groups.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included 950 377 Asian, black, white, and Hispanic patients who were diagnosed with prostate, ovarian, breast, stomach, pancreatic, lung, liver, esophageal, or colorectal cancers from January 2004 to December 2010. Data were collected using the Surveillance, Epidemiology, and End Results (SEER) database, and patients were observed for more than 5 years. Data analysis was conducted in July 2018.

MAIN OUTCOMES AND MEASURES

Multivariable logistic and Cox regression were used to evaluate the differences in stage of cancer at diagnosis, treatment, and survival among patients from different racial/ethnic groups.

RESULTS

A total of 950 377 patients (499 070 [52.5%] men) were included in the study, with 681 251 white patients (71.7%; mean [SD] age, 65 [12] years), 116 015 black patients (12.2%; mean [SD] age, 62 [12] years), 65 718 Asian patients (6.9%; mean [SD] age, 63 [13] years), and 87 393 Hispanic patients (9.2%; mean [SD] age, 61 [13] years). Compared with Asian patients, black patients were more likely to have metastatic disease at diagnosis (odds ratio [OR], 1.144; 95% CI, 1.109-1.180; P < .001). Black and Hispanic patients were less likely to receive definitive treatment than Asian patients (black: adjusted OR, 0.630; 95% CI, 0.609-0.653; P < .001; Hispanic: adjusted OR, 0.751; 95% CI, 0.724-0.780; P < .001). White, black, and Hispanic patients were more likely to have poorer CSS and OS than Asian patients (CSS, white: adjusted HR, 1.310; 95% CI, 1.283-1.338; P < .001; black: adjusted HR, 1.645; 95% CI, 1.605-1.685; P < .001; Hispanic: adjusted HR, 1.300; 95% CI, 1.266-1.334; P < .001; OS, white: adjusted HR, 1.333; 95% CI, 1.310-1.357; P < .001; black: adjusted HR, 1.754; 95% CI, 1.719-1.789; P < .001; Hispanic: adjusted HR, 1.279; 95% CI, 1.269-1.326; P < .001).

CONCLUSIONS AND RELEVANCE

In this study of patients with 1 of 9 leading cancers, stage at diagnosis, treatment, and survival were different by race and ethnicity. These findings may help to optimize treatment and improve outcomes.

Cordycepin Inhibits Drug-resistance Non-small Cell Lung Cancer Progression by Activating AMPK Signaling Pathway

Lung cancer is the most commonly diagnosed cancer worldwide and it is also the most leading cause of cancer-related deaths. Although multiple generations of targeted therapeutic drugs such as gefitinib and afatinib specifically targeting the epidermal growth factor receptor (EGFR) pathway are currently available for lung cancer treatment, none of them can escape their eventual drug-resistance. As a key component of Cordyceps Sinensis and widely used in traditional Chinese medicines (TCM), cordycepin (CD) has attracted increasing attention to both scientists and clinicians. We aimed to explore the potential in developing cordycepin (CD) as an anti-lung cancer drug. A systematic analysis was conducted on a panel of non-small cell lung cancer (NSCLC) cell lines to identify the cells sensitive to CD. We found that CD can affect different aspects of lung cancer development including proliferation, migration, invasion, cell cycle, and apoptosis. We then explored the underlying molecular mechanisms of CD-mediated NSCLC cell apoptosis by conducting a series of in vitro and in vivo experiments. We found that in addition to affecting different stages of NSCLC development including tumor growth, migration, and invasion, the CD is capable of inhibiting NSCLC cell cycle progression and inducing cancer cell apoptosis without apparent adverse effect on normal lung cells. Furthermore, we found that the cells containing EGFR mutations are more sensitive to CD treatment than those without. Mechanistically, CD induces NSCLC cell apoptosis by interacting with and activating AMP-activated protein kinase (AMPK). More importantly, we found that the potency of CD's anticancer effect both in vitro and in vivo is comparable to afatinib and even better than gefitinib. Our findings suggest that CD either by itself or in combination with the currently available targeted therapeutic drugs might be additional therapeutic options for drug-resistance NSCLC treatment.