Are novel oral oncolytics underdosed in obese patients?

PURPOSE

Data on the effects of obesity on drug exposure of oral targeted oncolytics is scarce. Therefore, the aim of this study was to investigate the influence of body weight and body mass index (BMI) on trough levels of oral oncolytics with an exposure-response relationship. The oral oncolytics of interest were abiraterone, alectinib, cabozantinib, crizotinib, imatinib, pazopanib, sunitinib and trametinib.

METHODS

This retrospective cohort study included patients treated with the selected oral oncolytics at the standard dose, with a measured trough level at steady state and with available body weight. The Spearman's correlation test was used to determine the correlation between body weight and trough levels. The Fisher's exact text was used to compare the frequency of inadequate trough levels between BMI categories.

RESULTS

1265 patients were included across the different oral oncolytics. A negative correlation coefficient was observed between weight and trough levels for crizotinib (n = 75), imatinib (n = 201) and trametinib (n = 310), respectively, ρ = - 0.41, ρ = - 0.24 and ρ = - 0.23, all with a p-value < 0.001. For crizotinib, a higher percentage of patients with a body weight > 100 kg had inadequate trough levels. No statistically significant differences were observed in the frequency of inadequate trough levels between BMI categories.

CONCLUSION

Higher body weight was only correlated with lower plasma trough levels for crizotinib, imatinib, and trametinib. Therefore, patients with a high body weight may require dose escalation to obtain adequate target levels when treated with these oral oncolytics.

Anaplastic Lymphoma Kinase Inhibitor-Induced Neutropenia: A Systematic Review

Lung cancers with ALK rearrangement represent less than 5% of all lung cancers. ALK inhibitors are currently used to treat first-line metastatic non-small cell lung cancer with ALK rearrangement. Compared to chemotherapy, ALK inhibitors have improved progression-free survival, overall survival, and quality of life for patients. The results of several phase 3 studies with a follow-up of over 6 years suggest that the life expectancy of these patients treated with targeted therapies is significantly higher than 5 years and could approach 10 years. Nevertheless, these treatments induce haematological toxicities, including neutropenia. Few data are available on neutropenia induced by ALK inhibitors and on the pathophysiological mechanism and therapeutic adaptations necessary to continue the treatment. Given the high efficacy of these treatments, managing side effects to avoid treatment interruptions is essential. Here, we have reviewed the data from published clinical studies and case reports to provide an overview of neutropenia induced by ALK inhibitors.

Adverse Side Effects of Crizotinib in the Treatment of Anaplastic Lymphoma Kinase-Mutated Non-small Cell Lung Cancer: A Systematic Review

Lung cancer is the leading cause of cancer deaths worldwide, with the majority consisting of non-small cell lung cancer (NSCLC). Genetic mutations present an opportunity for targeted therapy, in addition to current mainstay treatments such as chemotherapy and radiotherapy. Overall, 5% of NSCLCs have an anaplastic lymphoma kinase (ALK) mutation, often prevalent in a younger population. Crizotinib is an ALK inhibitor that was approved to treat ALK-mutated advanced NSCLC. While common side effects such as nausea, fatigue, and diarrhea are mostly well tolerated, adverse side effects can lead to treatment discontinuation or adjustment or can be fatal. This systematic review used articles searched on Google Scholar and PubMed which were assessed using the Cochrane risk-of-bias tool and Newcastle-Ottawa Scale. This yielded nine papers consisting of randomized controlled trials and cohort studies. Side effects resulting in cessation of treatment or dose reduction included liver dysfunction, nausea, neutropenia, and QT prolongation. This review showed that crizotinib has a better side effect profile than chemotherapy in ALK-positive NSCLC, even though toxicities leading to treatment withdrawal are present. Adverse effects were tackled by dose reduction, temporary withdrawal from treatment, and close monitoring.

Simultaneous quantification of thalidomide, lenalidomide and pomadomide in plasma by LC-MS/MS

OBJECTIVE

To develop a new method for quantitatively analyzing three immunomodulators (thalidomide, lenalidomide and pomadomide) by liquid chromatography tandem mass spectrometry (LC-MS/MS).

METHODS

Using thalidomide-d4 as internal standard, the three analytes were separated on Agilent Zorbax SB-C18(2.1 mm × 100 mm, 3.5 μm, Agilent, USA) column and monitored in multiple reactions monitoring mode in Agilent G6460A triple quadrupole mass spectrometer operating in positive ionization mode. The sample was pretreated by protein precipitation using methanol at 3-fold volume to sample. The mobile phase was comprised of 0.1% formic acid in water (phase A) and acetonitrile (phase B) and was delivered in gradient elution program. The flow rate was 0.3 mL/min, and the injection volume was 5 μL.

RESULTS

The accuracy and stability of the method are within ±15.0%, and the precision is not >15.0%. The recoveries were 85.04% ∼ 119.07%, and the matrix effect was 73.68% ∼ 116.75%. Specificity, linearity, LLOQ, carry-over and dilution were all in line with the requirements of pharmacopeia and guidelines. The peak concentrations of thalidomide, lenalidomide shows huge inter-individual differences.

CONCLUSIONS

This newly developed method was sensitive, simple, and robust and can be used in therapeutic drug monitoring of three immunomodulators in multiple myeloma patients.

Identification of ALK-positive patients with advanced NSCLC and real-world clinical experience with crizotinib in Spain (IDEALK study)

OBJECTIVES

To determine the incidence of ALK translocations in patients with advanced/metastatic NSCLC in Spain, to describe the clinical characteristics of these patients, and to evaluate the effectiveness and safety of treatment with crizotinib in a real-world setting.

METHODS

This is an observational prospective and retrospective cohort study to determine the incidence of ALK translocations and to analyze the effectiveness and safety of crizotinib in a real-world setting. Patient characteristics, treatment patterns, time to best overall response, duration of treatment, objective response rates (ORR), rates of adverse events (AE), progression free survival (PFS) and overall survival (OS) were evaluated in the ALK study cohort of patients treated with crizotinib (prospective and retrospective). ALK incidence and quality of life (QoL) questionnaires were measured from patients included in the prospective cohort.

RESULTS

The incidence of ALK translocations was 5.5 % (31 of 559 patients). Compared with ALK-negative patients, ALK-positive patients were significantly younger, predominantly female, and non-smokers. In the crizotinib effectiveness and safety study, 91 patients (42 prospective, 49 retrospective) with ALK-positive NSCLC (43.9 % in first-line, 56.1 % in second or more lines) were included. The ORR was 59.3 % and the median duration of response was 13.5 months (IQR, 5.3-26.2). The median PFS was 15.8 months (95 % CI, 11.8-22.3) and the median OS was 46.5 months, with 53 patients (58.2 %) still alive at data cut-off date. Frequently reported AEs included elevated transaminases, gastrointestinal disorders, and asthenia. Most patients (76.5 %) reported improved or stable scores for global QoL during treatment.

CONCLUSIONS

The observed incidence of ALK translocations in NSCLC patients is aligned with published reports. This analysis of the real-world clinical experience in Spain confirms the therapeutic benefit and safety of crizotinib in advanced/metastatic ALK-positive NSCLC.

CLINICALTRIALS

gov: NCT02679170.

Biomarker guided treatment in oncogene-driven advanced non-small cell lung cancer in older adults: A Young International Society of Geriatric Oncology Report

Lung cancer remains the leading cause of cancer-related deaths worldwide, with most patients diagnosed at an advanced age. The treatment of non-small cell lung cancer (NSCLC) has been revolutionized with the introduction of molecular guided therapy. Despites the challenges when considering treatment of older adults, they are still systematically underrepresented in registrational trials. This review aims to summarize the existing evidence on treatment of older patients with lung cancer with a targetable driver mutation or alteration (EGFR, ALK, ROS, BRAF^V600E, MET, RET, KRAS^G12C and NTRK), and consider the evidence from a geriatric oncology perspective. Early generation EGFR-tyrosine kinase inhibitors (TKIs). TKIs are fairly well-studied in older adults and have been shown to be safe and efficient. However, older adult-specific data regarding the standard-of-care first-line agent osimertinib are lacking. Erlotinib, dacomitinib, and afatinib may be more toxic than other EGFR-TKIs. Next generation ALK-TKIs are preferred over crizotinib due to increased efficacy, as demonstrated in phase III trials. Alectinib seems to be safer than crizotinib, while brigatinib is associated with increased toxicity. Lorlatinib overcomes most resistance mutations, but data regarding this agent have only recently emerged. Regarding ROS1-fusion positive NSCLC, crizotinib is an option in older adults, while entrectinib is similarly effective but shows increased neurotoxicity. In BRAF^V600E-mutant NSCLC, the combination darbafenib/tramectinib is effective, but no safety data for older adults exist. MET alterations can be targeted with capmatinib and tepotinib, and registrational trials included primarily older patients, due to the association of this alteration with advanced age. For RET-rearranged-NSCLC selpercatinib and pralsetinib are approved, and no differences in safety or efficacy between older and younger patients were shown. KRAS^G12C mutations, which are more frequent in older adults, became recently druggable with sotorasib, and advanced age does not seem to affect safety or efficacy. In NTRK-fusion positive tumors, larotrectinib and entrectinib have tumor agnostic approval, however, not enough data on older patients are available. Based on currently available data, molecularly-guided therapy for most alterations is safe and efficacious in older adults with oncogene-driven advanced NSCLC. However, for many TKIs, older adult-specific data are lacking, and should be subject of future prospective evaluations.

Effective response to crizotinib of concurrent KIF5B-MET and MET-CDR2-rearranged non-small cell lung cancer: A case report

BACKGROUND

Due to the rarity of mesenchymal-epithelial transition factor (MET) fusions, the clinical efficacy of crizotinib has only been described in a few patients with MET fusions involving various fusion partners. Herein, we report the clinical response to crizotinib of a patient with advanced poorly differentiated non-small cell carcinoma (NSCLC) having concurrent MET fusions.

CASE SUMMARY

A 46-year-old woman was diagnosed with poorly differentiated NSCLC (T4N3M1). With no classic driver mutations, she was treated with two cycles of gemcitabine and cisplatin without clinical benefit. Targeted sequencing revealed the detection of two concurrent MET fusions, KIF5B-MET and novel MET-CDR2. Crizotinib was initiated at a dose of 250 mg twice daily. Within 4 wk of crizotinib therapy, repeat computed chromatography revealed a dramatic reduction in primary and metastatic lesions, assessed as partial response. She continued to benefit from crizotinib for 3 mo until disease progression and died within 1 mo despite receiving nivolumab therapy.

CONCLUSION

Crizotinib sensitivity was observed in an advanced poorly differentiated NSCLC patient with concurrent MET fusions KIF5B-MET and MET-CDR2. Crizotinib can serve as a therapeutic option for patients with MET fusions. In addition, our case also highlights the importance of comprehensive genomic profiling particularly in patients with no classic driver mutation for guiding alternative therapeutic decisions.

Managing Severe Dysgeusia and Dysosmia in Lung Cancer Patients: A Systematic Scoping Review

Introduction

Lung cancer (LC) is highly prevalent worldwide, with elevated mortality. In this population, taste and smell alterations (TSAs) are frequent but overlooked symptoms. The absence of effective therapeutic strategies and evidence-based guidelines constrain TSAs’ early recognition, prevention and treatment (Tx), promoting cancer-related malnutrition and jeopardizing survival outcomes and quality of life.

Objectives

To systematically review the literature on TSAs in LC patients, understand the physiopathology, identify potential preventive and Tx strategies and to further encourage research in this area.

Methods

Literature search on English language articles indexed to PubMed, CINALH, SCOPUS and Web of Science using MeSH terms “Lung neoplasms”,”Dysgeusia”, “Olfaction Disorders”, “Carcinoma, Small Cell”,”Carcinoma, Non- Small-Cell Lung “Adenocarcinoma of Lung”,”Carcinoma, Large Cell”, and non-MeSH terms “Parageusia”, “Altered Taste”, “Smell Disorder”, “Paraosmia”, “Dysosmia”,”Lung Cancer” and “Oat Cell Carcinoma”.

Results

Thirty-four articles were reviewed. TSAs may follow the diagnosis of LC or develop during cancer Tx. The estimated prevalence of self-reported dysgeusia is 35-38% in treatment-naïve LC patients, and 35-69% in those undergoing Tx, based on studies involving LC patients only.

One prospective pilot trial and 1 RCT demonstrated a clinically significant benefit in combining flavor enhancement, smell and taste training and individualized nutritional counselling; a systematic review, 1 RCT and 1 retrospective study favored using intravenous or oral zinc-based solutions (150mg 2-3 times a day) for the prevention and Tx of chemotherapy (CT) and radiotherapy (RT) -induced mucositis and subsequent dysgeusia.

Conclusions

This is the first review on dysgeusia and dysosmia in LC patients to our knowledge. We propose combining taste and smell training, personalized dietary counselling and flavor enhancement with oral zinc-based solutions (150mg, 2-3 times a day) during CT and/or RT in this population, in order to prevent and help ameliorate Tx-induced dysgeusia and mucositis. However due to study heterogeneity, the results should be interpreted with caution. Developing standardized TSA measurement tools and performing prospective randomized controlled trials to evaluate their effect are warranted.

Simultaneous and Rapid Determination of Six Tyrosine Kinase Inhibitors in Patients with Non-Small Cell Lung Cancer Using HPLC-MS/MS

Objective

To develop a new method for quantitatively analyzing six tyrosine kinase inhibitors (gefitinib, erlotinib, icotinib, afatinib, osimertinib, and crizotinib) used in the treatment of non-small cell lung cancer (NSCLC) by liquid chromatography-tandem mass spectrometry (LC-MS/MS).

Methods

The analytes were detected in the selected reaction monitoring mode on a triple quadrupole mass spectrometer with the positive ionization mode. Carbamazepine was utilized as the internal standard. The pretreatment of the plasma sample was completed based on protein precipitation with acetonitrile, and the analytes were separated on an Agilent Zorbax SB-C18 reversed-phase column (2.1 mm × 100 mm, 3.5 μm, Agilent, USA) using gradient elution. The mobile phase consisted of 0.1% formic acid in water (phase A) and 0.1% formic acid in acetonitrile (phase B). The flow rate was 0.3 mL/min, and the injection volume was 5 μL. The column temperature was set and maintained at 35°C.

Results

The calibration curves were linear over the range from 5.0 to 1000.0 ng/mL for gefitinib, crizotinib, and osimertinib; from 50.0 to 4000.0 ng/mL for icotinib and erlotinib; and from 5.0 to 400.0 ng/mL for afatinib. Linear correlation coefficients were >0.990 for all regression curves. The intra- and interday accuracy and precision of the method were within ±15.0% and not more than 15.0%, respectively. The mean recovery of all the analytes ranged from 70.18% to 110.76%, the matrix effect was from 88.85% to 127.58%, and stability was within ±15.0%.

Conclusion

This newly developed method was sensitive, simple, and robust and could be used in therapeutic drug monitoring of six tyrosine kinase inhibitors in NSCLC patients.

ECOG performance status ≥2 as a prognostic factor in patients with advanced non small cell lung cancer treated with immune checkpoint inhibitors-A systematic review and meta-analysis of real world data

OBJECTIVES

ICIs have been approved and are routinely administered regardless of performance status (PS), despite randomized clinical trials of ICIs alone or combined with chemotherapy or target therapy enrolled patients with ECOG PS 0 or 1, while patients with ECOG PS 2 or more were excluded.

MATERIALS AND METHODS

We carried out a meta-analysis of available clinical studies exploring the prognostic impact of PS ≥ 2 on Overall Survival (OS), Progression Free Survival (PFS) or Overall Response Rate (ORR) in patients with non small cell lung cancer (NSCLC) treated with immunotherapy (any line).

RESULTS

We reviewed 19 studies, comprising 3600 NSCLC patients, 757 of whom with ECOG PS > 1 (average 21.0%, range 6.0-48.6%). In the overall population PS ≥ 2 resulted in worse OS, PFS and ORR (OS pooled hazard ratio of 2.72; 95% CI: 2.03-3.63; I² 72.70%, p < 0.001; PFS pooled hazard ratio of 2.39; 95% CI 1.81-3.15, p < 0.0001; I² 73.03%; ORR pooled odds ratio 0.25; 95% CI 0.11-0.56, p 0.001; I² 0.00%).

CONCLUSION

ECOG PS ≥ 2 retains an important prognostic validity in patients treated with ICI similar, in terms of effect size, to that reported for chemotherapy in NSCLC. The high level of heterogeneity for OS and PFS analysis (but not for ORR), not completely explained by the different proportion of ECOG 3-4 patients (ranging from 0% to 50% of the PS ≥ 2 population), could be the result of both patient heterogeneity within the PS 2 population and the subjectivity of ECOG PS assessment. Whether poorer PS is also a predictor of lower immunotherapy efficacy remains still to be demonstrated.