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Kozono D, Hua X, Wu MC, Tolba KA, Waqar SN, Dragnev KH, Cheng H, Hirsch FR, Mack PC, Gray JE, Kelly K, Borghaei H, Herbst RS, Gandara DR, Redman MW. Lung-MAP Next-Generation Sequencing Analysis of Advanced Squamous Cell Lung Cancers (SWOG S1400). J Thorac Oncol 2024:S1556-0864(24)00751-2. [PMID: 39111731 DOI: 10.1016/j.jtho.2024.07.024] [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: 03/13/2024] [Revised: 07/24/2024] [Accepted: 07/27/2024] [Indexed: 08/27/2024]
Abstract
INTRODUCTION Squamous cell cancer (SqCC) is a lung cancer subtype with few targeted therapy options. Molecular characterization, that is, by next-generation sequencing (NGS), is needed to identify potential targets. Lung Cancer Master Protocol Southwest Oncology Group S1400 enrolled patients with previously treated stage IV or recurrent SqCC to assess NGS biomarkers for therapeutic sub-studies. METHODS Tumors underwent NGS using Foundation Medicine's FoundationOne research platform, which sequenced the exons and/or introns of 313 cancer-related genes. Mutually exclusive gene set analysis and Selected Events Linked by Evolutionary Conditions across Human Tumors were performed to identify mutually exclusive and co-occurring gene alterations. Comparisons were performed with data on 495 lung SqCC downloaded from The Cancer Genome Atlas. Cox proportional hazards models were used to assess associations between genetic variants and survival. RESULTS NGS data are reported for 1672 patients enrolled on S1400 between 2014 and 2019. Mutually exclusive gene set analysis identified two non-overlapping sets of mutually exclusive alterations with a false discovery rate of less than 15%: NFE2L2, KEAP1, and PARP4; and CDKN2A and RB1. PARP4, a relatively uncharacterized gene, showed three frequent mutations suggesting functional significance: 3116T>C (I1039T), 3176A>G (Q1059R), and 3509C>T (T1170I). When taken together, NFE2L2 and KEAP1 alterations were associated with poorer survival. CONCLUSIONS As the largest dataset to date of lung SqCC profiled on a clinical trial, the S1400 NGS dataset establishes a rich resource for biomarker discovery. Mutual exclusivity of PARP4 and NFE2L2 or KEAP1 alterations suggests that PARP4 may have an uncharacterized role in a key pathway known to impact oxidative stress response and treatment resistance.
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Affiliation(s)
- David Kozono
- Department of Radiation Oncology, Dana-Farber Brigham Cancer Center, Boston, Massachusetts.
| | - Xing Hua
- SWOG Statistics and Data Management Center, Seattle, Washington; Biostatistics Program, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Michael C Wu
- SWOG Statistics and Data Management Center, Seattle, Washington; Biostatistics Program, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | - Saiama N Waqar
- Division of Oncology, Washington University School of Medicine, St. Louis, Missouri
| | | | - Haiying Cheng
- Department of Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Fred R Hirsch
- Mt. Sinai Health System Center for Thoracic Oncology, Tisch Cancer Institute, New York, New York
| | - Philip C Mack
- Mt. Sinai Health System Center for Thoracic Oncology, Tisch Cancer Institute, New York, New York
| | - Jhanelle E Gray
- Department of Thoracic Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Karen Kelly
- Division of Hematology and Oncology, UC Davis Comprehensive Cancer Center, Sacramento, California
| | - Hossein Borghaei
- Department of Hematology/Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Roy S Herbst
- Section of Medical Oncology, Yale University, New Haven, Connecticut
| | - David R Gandara
- Division of Hematology and Oncology, UC Davis Comprehensive Cancer Center, Sacramento, California
| | - Mary W Redman
- SWOG Statistics and Data Management Center, Seattle, Washington; Biostatistics Program, Fred Hutchinson Cancer Research Center, Seattle, Washington
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XIONG B, KE W, JIANG W. [Advances of Molecular Targeted Therapy in EGFR-mutated Squamous Cell Lung Cancer]. ZHONGGUO FEI AI ZA ZHI = CHINESE JOURNAL OF LUNG CANCER 2024; 27:283-290. [PMID: 38769831 PMCID: PMC11110274 DOI: 10.3779/j.issn.1009-3419.2024.101.07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Indexed: 05/22/2024]
Abstract
Non-small cell lung cancer (NSCLC) is a prevalent tumour type in our country, with lung squamous carcinoma being a commonly observed NSCLC subtype besides lung adenocarcinoma. Epidermal growth factor receptor (EGFR) is a significant driver gene in lung cancer, and EGFR mutation frequency is considerably lower in lung squamous carcinoma in comparison to lung adenocarcinoma. Although targeted therapy against EGFR has demonstrated significant advancements in lung adenocarcinoma, while progress in lung squamous carcinoma has been relatively sluggish. This paper reviews recent studies on molecular targeted therapy for EGFR-mutated lung squamous carcinoma and summarises the efficacy of EGFR-tyrosine kinase inhibitors (TKIs) in treating squamous carcinoma of the lung, in order to provide a reference for treating patients with EGFR-mutated squamous carcinoma of the lung.
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Razzaq A, Disoma C, Zhou Y, Tao S, Chen Z, Liu S, Zheng R, Zhang Y, Liao Y, Chen X, Liu S, Dong Z, Xu L, Deng X, Li S, Xia Z. Targeting epidermal growth factor receptor signalling pathway: A promising therapeutic option for COVID-19. Rev Med Virol 2024; 34:e2500. [PMID: 38126937 DOI: 10.1002/rmv.2500] [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: 08/14/2023] [Revised: 11/20/2023] [Accepted: 12/10/2023] [Indexed: 12/23/2023]
Abstract
The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is continuously producing new variants, necessitating effective therapeutics. Patients are not only confronted by the immediate symptoms of infection but also by the long-term health issues linked to long COVID-19. Activation of epidermal growth factor receptor (EGFR) signalling during SARS-CoV-2 infection promotes virus propagation, mucus hyperproduction, and pulmonary fibrosis, and suppresses the host's antiviral response. Over the long term, EGFR activation in COVID-19, particularly in COVID-19-induced pulmonary fibrosis, may be linked to the development of lung cancer. In this review, we have summarised the significance of EGFR signalling in the context of SARS-CoV-2 infection. We also discussed the targeting of EGFR signalling as a promising strategy for COVID-19 treatment and highlighted erlotinib as a superior option among EGFR inhibitors. Erlotinib effectively blocks EGFR and AAK1, thereby preventing SARS-CoV-2 replication, reducing mucus hyperproduction, TNF-α expression, and enhancing the host's antiviral response. Nevertheless, to evaluate the antiviral efficacy of erlotinib, relevant clinical trials involving an appropriate patient population should be designed.
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Affiliation(s)
- Aroona Razzaq
- Department of Cell Biology, School of Life Sciences, Central South University, Changsha, China
| | - Cyrollah Disoma
- Department of Cell Biology, School of Life Sciences, Central South University, Changsha, China
- Department of Biology, College of Natural Sciences and Mathematics, Mindanao State University, Marawi City, Philippines
| | - Yuzheng Zhou
- Department of Cell Biology, School of Life Sciences, Central South University, Changsha, China
- Institute for Hepatology, National Clinical Research Center for Infectious Disease, Shenzhen Third People's Hospital, Southern University of Science and Technology, Shenzhen, China
| | - Siyi Tao
- Department of Cell Biology, School of Life Sciences, Central South University, Changsha, China
| | - Zongpeng Chen
- Department of Cell Biology, School of Life Sciences, Central South University, Changsha, China
| | - Sixu Liu
- Department of Cell Biology, School of Life Sciences, Central South University, Changsha, China
| | - Rong Zheng
- Department of Cell Biology, School of Life Sciences, Central South University, Changsha, China
| | - Yongxing Zhang
- Department of Cell Biology, School of Life Sciences, Central South University, Changsha, China
| | - Yujie Liao
- Department of Cell Biology, School of Life Sciences, Central South University, Changsha, China
| | - Xuan Chen
- Department of Cell Biology, School of Life Sciences, Central South University, Changsha, China
| | - Sijie Liu
- Department of Cell Biology, School of Life Sciences, Central South University, Changsha, China
| | - Zijun Dong
- Department of Cell Biology, School of Life Sciences, Central South University, Changsha, China
| | - Liangtao Xu
- Department of Cell Biology, School of Life Sciences, Central South University, Changsha, China
| | - Xu Deng
- Xiangya School of Pharmaceutical Science, Central South University, Changsha, China
| | - Shanni Li
- Department of Cell Biology, School of Life Sciences, Central South University, Changsha, China
| | - Zanxian Xia
- Department of Cell Biology, School of Life Sciences, Central South University, Changsha, China
- Hunan Key Laboratory of Animal Models for Human Diseases, School of Life Sciences, Central South University, Changsha, China
- Hunan Key Laboratory of Medical Genetics, School of Life Sciences, Central South University, Changsha, China
- Centre for Medical Genetics, School of Life Sciences, Central South University, Changsha, China
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Hsu EC, Wu KL, Tsai YM, Lee MH, Tsai MJ, Kuo CY, Liu YC, Liang FW, Yang CJ, Hung JY. Real-world treatment pattern and prognostic factors of stage IV lung squamous cell carcinoma patients. Kaohsiung J Med Sci 2022; 38:1001-1011. [PMID: 36214468 DOI: 10.1002/kjm2.12599] [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: 04/13/2022] [Revised: 08/26/2022] [Accepted: 08/30/2022] [Indexed: 06/16/2023] Open
Abstract
Lung squamous cell carcinoma (LUSC) represents a minor proportion of nonsmall cell lung cancer (NSCLC) harboring a poor prognosis. Herein, retrospective medical record research was performed to investigate real-world treatment patterns and identify the prognostic factors among LUSC patients. A total of 173 patients with a median age of 68 years were enrolled for analysis. Males were predominant (n = 143, 83%) and current or ex-smokers contributed to 78% of the entire cohort. Pleura and lung were the most common metastatic sites, whereas brain metastasis was only 7%. After diagnosis, however, only 107 patients (62%) had received first-line chemotherapy. In the chemotherapy cohort, median progression-free survival (PFS) and overall survival (OS) were 3.9 and 11.1 months, respectively. After multivariable analysis, bone metastasis and the use of first-line single-agent chemotherapy independently predicted shorter PFS. For baseline characteristics, male sex, metastasis to lung, pleura, liver, and bone independently predicted worse OS. Regarding the treatment pattern, patients who had undergone standard first-line doublet therapy and employed targeted therapies after disease progression linked to longer OS. In the real world, even those who underwent chemotherapy still had poor outcome. The findings may help clinicians to orchestrate the treatment strategies for LUSC patients and provide further direction of large-scale studies.
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Affiliation(s)
- En-Chi Hsu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Kuan-Li Wu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ying-Ming Tsai
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Mei-Hsuan Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ming-Ju Tsai
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chia-Yu Kuo
- Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yu-Chuan Liu
- Clinical Trial Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Fu-Wen Liang
- Department of Public Health, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chih-Jen Yang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jen-Yu Hung
- School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
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Qian J, Ye X, Huang A, Qin R, Cai Y, Xue Y, Zhang S, Wang W, Xiong L, Gu A. Afatinib 30 mg in the treatment of common and uncommon EGFR-mutated advanced lung adenocarcinomas: a retrospective, single-center, longitudinal study. J Thorac Dis 2022; 14:2169-2177. [PMID: 35813735 PMCID: PMC9264103 DOI: 10.21037/jtd-22-507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 06/09/2022] [Indexed: 11/06/2022]
Abstract
Background Afatinib 30 mg has been proved to be with comparable efficacy but more tolerable than the dose of 40 mg for Asian patients with non-small cell lung cancer (NSCLC). This study aimed to investigate the clinical outcomes of afatinib at 30 mg/d in the treatment of advanced lung adenocarcinomas (LAD) with common and uncommon epidermal growth factor receptor (EGFR) mutations. Methods EGFR-mutated advanced LAD patients receiving afatinib (30 mg/d) from January 2017 to November 2021 were retrospectively included. EGFR status was classified into three subtypes, namely common mutations including exon 19 deletions (19del) and exon 21 L858R (21L858R), uncommon mutations including G719X, L861Q, S768I, and complex mutations, and separately exon 20 insertions (20ins). Progression-free survival (PFS), objective response rate (ORR), disease control rate (DCR) and adverse events (AEs) were analyzed during regular follow-up. Results The overall median PFS of totally 58 included patients was 9.83 [95% confidence index (CI): 5.76–13.91] months. The number of patients with common, uncommon, and 20ins mutations was 32 (55.2%), 19 (32.8%) and 7 (12.1%), respectively. Baseline characteristics did not differ significantly among the three subtypes. The corresponding median PFS was 13.97 (12.06–15.89), 8.48 (0.32–16.64), and 3.78 (1.93–5.64) months, respectively (P=0.002). In the first-line setting, patients with common and uncommon mutations had a significantly longer PFS compared to those with 20ins [14.53 (13.53–15.53) vs. 10.39 (4.87–15.91) vs. 2.37 (0.00–5.11) months, P<0.001]. The first-line ORR showed significant differences among the three subtypes (60% vs. 80% vs. 0.0%, P=0.023). All-grade AEs occurred in 22 patients (37.9%). AEs ≥ grade 3 mainly included diarrhea (8.6%), and none of the patients discontinued treatment due to severe AEs. Conclusions Afatinib at 30 mg/d is associated with a favorable efficacy and tolerability in the treatment of advanced LAD with common and major uncommon EGFR mutations except 20ins. Further large-scale prospective studies are warranted to confirm our findings.
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Affiliation(s)
- Jie Qian
- Department of Emergency Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Xuanting Ye
- Department of Oncology, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Aimi Huang
- Department of Pulmonary Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Ruoyan Qin
- Department of Oncology, Longhua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yuqing Cai
- Department of Oncology, Longhua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yiqian Xue
- Department of Oncology, Longhua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Shi Zhang
- Department of Oncology, Longhua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Weimin Wang
- Department of Pulmonary Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Liwen Xiong
- Department of Pulmonary Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Aiqin Gu
- Department of Pulmonary Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
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Santos ES, Rodriguez E. Treatment Considerations for Patients with Advanced Squamous Cell Carcinoma of the Lung. Clin Lung Cancer 2022; 23:457-466. [DOI: 10.1016/j.cllc.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 06/10/2022] [Accepted: 06/12/2022] [Indexed: 11/27/2022]
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Effect of Family Participatory Nursing Model Based on WeChat Platform on Psychological Elasticity and Quality of Life of Patients with Lung Cancer. BIOMED RESEARCH INTERNATIONAL 2022; 2022:4704107. [PMID: 35578722 PMCID: PMC9107353 DOI: 10.1155/2022/4704107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 03/22/2022] [Accepted: 03/28/2022] [Indexed: 11/24/2022]
Abstract
Objective To explore the effect of family participatory nursing model based on WeChat platform on psychological elasticity and life quality of patients with lung cancer. Methods One hundred patients with lung cancer treated in our hospital from February 2019 to April 2021 were enrolled. The patients were randomly assigned into control group and study group. The control group received routine nursing and the study group received family participatory nursing model based on WeChat platform. The scores of nursing satisfaction, self-feeling burden, symptom group assessment scale, family care index, and compliance and life quality were compared. Results First of all, we compared the nursing satisfaction: the study group was very satisfied in 25 cases, satisfactory in 20 cases, general in 5 cases, the satisfaction rate was 100.00%; the control group was very satisfied in 14 cases, satisfactory in 17 cases, general in 13 cases, dissatisfied in 6 cases, and the satisfaction rate was 88.00%. Compared between the two groups, the nursing satisfaction in the study group was higher compared to the control group (P < 0.05). Secondly, we compared the self-perceived burden, the emotional burden, physical burden, and economic burden and total scores of the study group were lower compared to the control group (P < 0.05). Comparing the scores of symptom group evaluation scale, the scores of respiratory symptoms, fatigue symptoms, psychological and emotional symptoms, digestive tract symptoms, and nervous system symptoms in the study group were lower compared to the control group (P < 0.05). In terms of the family care index of the two groups, the scores of fitness, cooperation, length, emotion, and intimacy in the study group were higher compared to the control group (P < 0.05). Comparison of compliance, the study group was very compliant in 42 cases, compliant in 7 cases, noncompliant in 1 case, the compliance rate was 98.00%; the control group was very compliant in 24 cases, compliant in 20 cases, noncompliant in 6 cases, the compliance rate was 88.00%. The compliance rate in the study group was higher compared to the control group (P < 0.05). Finally, we compared the scores of qualities of life. Before nursing, there exhibited no significant difference (P > 0.05). The scores of physiological function, psychological function, social function, and health self-cognition in the study group were lower compared to the control group (P < 0.05). Conclusion The family participatory nursing model based on WeChat platform helps to facilitate the psychological elasticity and quality of life of patients with lung cancer and further promote patients' self-care ability and compliance with lung cancer. It can also effectively enhance family care and nursing satisfaction; the nursing model is worth popularizing and applying in clinic.
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Chen YY, Chang SC, Chang CY, Chang CF, Lai YC, Wei YF, Chen CY. Real-world effectiveness of second-line Afatinib versus chemotherapy for the treatment of advanced lung squamous cell carcinoma in immunotherapy-naïve patients. BMC Cancer 2021; 21:1225. [PMID: 34781919 PMCID: PMC8594240 DOI: 10.1186/s12885-021-08920-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 10/25/2021] [Indexed: 11/22/2022] Open
Abstract
Background Limited treatment options exist for relapsed advanced lung squamous cell carcinoma (SCC), leading to poor outcomes compared with adenocarcinoma. This study aimed to investigate the efficacy of second-line afatinib versus chemotherapy in patients with advanced lung SCC who progressed after first-line chemotherapy. Methods In this retrospective, multisite cohort study, we recruited patients with initial locally advanced or metastatic lung SCC from four institutes in Taiwan between June 2014 and October 2020. The primary endpoint of this study was progression-free survival (PFS), and the secondary endpoints were the objective response rate (ORR), disease control rate (DCR), and overall survival (OS). Results The present study enrolled 108 patients: 19 received second-line afatinib, and 89 received second-line chemotherapy. The median ages were 71 and 67 years, respectively. PFS was significantly longer among patients who received afatinib than among those who received chemotherapy (median 4.7 months [95% confidence interval (CI), 0.1–7.5] vs. 2.6 months [95% CI, 0.9–6.7]; hazard ratio (HR) 0.53 [95% CI 0.32–0.88], p = 0.013). Compared with the chemotherapy group, OS was longer in the afatinib group but did not reach significance (median 16.0 months [95% CI, 6.1–22.0] vs. 12.3 months [6.2–33.9]; HR 0.65 [95% CI 0.38–1.11], p = 0.112). Conclusions Afatinib offered a longer PFS and comparable OS to chemotherapy in advanced lung SCC patients in a real-world setting, it may be considered as a 2nd line alternative treatment choice for immunotherapy unfit advanced lung SCC patients. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-021-08920-3.
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Affiliation(s)
- You-Yi Chen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital Yunlin Branch, Yunlin Count, Douliu City, Taiwan, Republic of China.,College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Shih-Chieh Chang
- Division of Chest Medicine, Department of Internal Medicine, National Yang Ming Chiao Tung University Hospital, Yilan County, Taiwan
| | - Cheng-Yu Chang
- Division of Pulmonary Medicine, Department of Internal Medicine, Far Eastern Memorial Hospital, and Department of Nursing, Cardinal Tien College of Healthcare and Management, New Taipei City, Taiwan
| | - Chun-Fu Chang
- Division of Chest Medicine, Department of Internal Medicine, National Yang Ming Chiao Tung University Hospital, Yilan County, Taiwan
| | - Yi-Chun Lai
- Division of Chest Medicine, Department of Internal Medicine, National Yang Ming Chiao Tung University Hospital, Yilan County, Taiwan
| | - Yu-Feng Wei
- Department of Internal Medicine, E-Da Cancer Hospital, Kaohsiung, Taiwan.,School of Medicine for International Students, College of Medicine, and Institute of Biotechnology and Chemical Engineering, I-Shou University, Kaohsiung, Taiwan
| | - Chung-Yu Chen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital Yunlin Branch, Yunlin Count, Douliu City, Taiwan, Republic of China. .,College of Medicine, National Taiwan University, Taipei, Taiwan.
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