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Zhao M, Shao T, Shao H, Zhou C, Tang W. Identifying optimal ALK inhibitors in first- and second-line treatment of patients with advanced ALK-positive non-small-cell lung cancer: a systematic review and network meta-analysis. BMC Cancer 2024; 24:186. [PMID: 38331773 PMCID: PMC10851546 DOI: 10.1186/s12885-024-11916-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 01/23/2024] [Indexed: 02/10/2024] Open
Abstract
OBJECTIVES To compare the efficacy, safety and effects on quality of life of different ALK-inhibitors for global and Asian patients with advanced ALK-positive non-small-cell lung cancer (NSCLC). METHODS The included RCTs were identified through a systematic search of PubMed, EMBASE, Cochrane Library, Clinical Trials.gov, and major cancer conferences. The assessment of progression-free survival (PFS), intracranial PFS, overall survival (OS), and patient-reported outcomes (PROs) was carried out using restricted mean survival time (RMST) model, fractional polynomial model and Royston-Parmar model. Time-invariant hazard ratio (HR) models were also used to validate and supplement the primary analysis. Objective response rate (ORR) and adverse events with any grade, grade 3-5 were assessed through a Bayesian network meta-analysis. The primary measures for OS, PFS, and PROs were HR and RMST. The odds ratio was the metric for evaluating safety, ORR, 12-month PFS rate, 24-month OS rate, and the 12-month non-deterioration rate of PROs. Subgroup analyses based on patient characteristics were performed. RESULTS A total of fourteen studies (ten for first-line, four for second-line) consisting of nine treatments (chemotherapy, crizotinib, alectinib [600mg BID], low-dose alectinib [300mg BID], brigatinib, ceritinib, ensartinib, envonalkib, and lorlatinib) were included. In the first-line setting, alectinib showed a significant advantage over crizotinib and had the longest OS among all ALK-inhibitors. Compared to crizotinib, lorlatinib had the best efficacy regarding PFS for global patients, followed closely by alectinib and brigatinib. For Asian patients, alectinib significantly improved PFS compared to other treatments. In second-line, alectinib had the highest PFS for patients pretreated with crizotinib, followed by brigatinib, ceritinib and chemotherapy. Alectinib, irrespective of the dose, was the safest first-line option, whereas lorlatinib, brigatinib, and ceritinib showed poorer safety profiles. Alectinib was also the safest ALK-inhibitor for crizotinib-resistant patients. Brigatinib had the best performance in terms of PROs. CONCLUSIONS Considering both efficacy and safety, alectinib appears to be the preferable treatment in first-line and second-line, particularly for Asian patients.
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Affiliation(s)
- Mingye Zhao
- Department of Pharmacoeconomics, School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, Jiangsu, China
- Center for Pharmacoeconomics and Outcomes Research, China Pharmaceutical University, Nanjing, Jiangsu, China
| | - Taihang Shao
- Department of Pharmacoeconomics, School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, Jiangsu, China
- Center for Pharmacoeconomics and Outcomes Research, China Pharmaceutical University, Nanjing, Jiangsu, China
| | - Hanqiao Shao
- Department of Pharmacoeconomics, School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, Jiangsu, China
- Center for Pharmacoeconomics and Outcomes Research, China Pharmaceutical University, Nanjing, Jiangsu, China
| | - Caicun Zhou
- Shanghai Pulmonary Hospital, Tongji University, Shanghai, China.
| | - Wenxi Tang
- Department of Pharmacoeconomics, School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, Jiangsu, China.
- Center for Pharmacoeconomics and Outcomes Research, China Pharmaceutical University, Nanjing, Jiangsu, China.
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Yang M, Vioix H, Hook ES, Hatswell AJ, Batteson RL, Gaumond BR, O'Brate A, Popat S, Paik PK. Health Utility Analysis of Tepotinib in Patients With Non-Small Cell Lung Cancer Harboring MET Exon 14 Skipping. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2023; 26:1155-1163. [PMID: 36805576 PMCID: PMC11145519 DOI: 10.1016/j.jval.2023.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 02/06/2023] [Accepted: 02/10/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVES The VISION trial showed durable activity of tepotinib in MET exon 14 (METex14) skipping non-small cell lung cancer. We analyzed health state utilities using patient-reported outcomes from VISION. METHODS 5-level version of EQ-5D (EQ-5D-5L) and European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 responses were collected at baseline, every 6 to 12 weeks during treatment, and at the end of treatment and safety follow-up. EQ-5D-5L and European Organisation for Research and Treatment of Cancer Quality of Life Utility Measure-Core 10 Dimensions (QLU-C10D) utilities were derived using United States, Canada, United Kingdom, and Taiwan value sets, where available. Utilities were analyzed with linear mixed models including covariates for progression or time-to-death (TTD). RESULTS Utilities were derived for 273/291 patients (EQ-5D-5L, 1545 observations; QLU-C10D, 1546 observations). Mean (± SD) US EQ-5D-5L utilities increased after tepotinib initiation, from 0.687 ± 0.287 at baseline to 0.754 ± 0.250 before independently assessed progression, and decreased post progression (0.704 ± 0.288). US QLU-C10D utilities showed similar trends (0.705 ± 0.215, 0.753 ± 0.195, and 0.708 ± 0.209, respectively). Progression-based models demonstrated a statistically significant impact of progression on utilities and predicted higher utilities pre versus post progression. TTD-based models showed statistically significant associations of TTD with utilities and predicted declining utilities as TTD decreased. Prior treatment (yes/no) did not significantly predict utilities in progression- or TTD-based models. Utilities for Canada, United Kingdom, and Taiwan showed comparable trends. CONCLUSIONS In this first analysis of health state utilities in patients with METex14 skipping non-small cell lung cancer, who received tepotinib, utilities were significantly associated with progression and TTD, but not prior treatment.
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Affiliation(s)
- Mo Yang
- EMD Serono, Rockland, MA, USA.
| | - Helene Vioix
- The Healthcare Business of Merck KGaA, Darmstadt, Germany
| | | | | | | | | | - Aurora O'Brate
- The Healthcare Business of Merck KGaA, Darmstadt, Germany
| | | | - Paul K Paik
- Thoracic Oncology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Weill Cornell Medical College, New York, NY, USA
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3
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Yu Y, Wang Z, Wang L, Wang Q, Tang R, Xiang S, Deng Q, Hou T, Sun H. Deciphering the Shared and Specific Drug Resistance Mechanisms of Anaplastic Lymphoma Kinase via Binding Free Energy Computation. RESEARCH (WASHINGTON, D.C.) 2023; 6:0170. [PMID: 37342628 PMCID: PMC10278961 DOI: 10.34133/research.0170] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 05/25/2023] [Indexed: 06/23/2023]
Abstract
Anaplastic lymphoma kinase (ALK), a tyrosine receptor kinase, has been proven to be associated with the occurrence of numerous malignancies. Although there have been already at least 3 generations of ALK inhibitors approved by FDA or in clinical trials, the occurrence of various mutations seriously attenuates the effectiveness of the drugs. Unfortunately, most of the drug resistance mechanisms still remain obscure. Therefore, it is necessary to reveal the bottom reasons of the drug resistance mechanisms caused by the mutations. In this work, on the basis of verifying the accuracy of 2 main kinds of binding free energy calculation methodologies [end-point method of Molecular Mechanics with Poisson-Boltzmann/Generalized Born and Surface Area (MM/PB(GB)SA) and alchemical method of Thermodynamic Integration (TI)], we performed a systematic analysis on the ALK systems to explore the underlying shared and specific drug resistance mechanisms, covering the one-drug-multiple-mutation and multiple-drug-one-mutation cases. Through conventional molecular dynamics (cMD) simulation in conjunction with MM/PB(GB)SA and umbrella sampling (US) in conjunction with contact network analysis (CNA), the resistance mechanisms of the in-pocket, out-pocket, and multiple-site mutations were revealed. Especially for the out-pocket mutation, a possible transfer chain of the mutation effect was revealed, and the reason why different drugs exhibited various sensitivities to the same mutation was also uncovered. The proposed mechanisms may be prevalent in various drug resistance cases.
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Affiliation(s)
- Yang Yu
- Department of Medicinal Chemistry,
China Pharmaceutical University, Nanjing 210009, Jiangsu, P. R. China
| | - Zhe Wang
- Innovation Institute for Artificial Intelligence in Medicine ofZhejiang University, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, Zhejiang, P. R. China
| | - Lingling Wang
- Department of Medicinal Chemistry,
China Pharmaceutical University, Nanjing 210009, Jiangsu, P. R. China
| | - Qinghua Wang
- Department of Medicinal Chemistry,
China Pharmaceutical University, Nanjing 210009, Jiangsu, P. R. China
| | - Rongfan Tang
- Department of Medicinal Chemistry,
China Pharmaceutical University, Nanjing 210009, Jiangsu, P. R. China
| | - Sutong Xiang
- Department of Medicinal Chemistry,
China Pharmaceutical University, Nanjing 210009, Jiangsu, P. R. China
| | - Qirui Deng
- Department of Medicinal Chemistry,
China Pharmaceutical University, Nanjing 210009, Jiangsu, P. R. China
| | - Tingjun Hou
- Innovation Institute for Artificial Intelligence in Medicine ofZhejiang University, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, Zhejiang, P. R. China
| | - Huiyong Sun
- Department of Medicinal Chemistry,
China Pharmaceutical University, Nanjing 210009, Jiangsu, P. R. China
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Samacá-Samacá D, Prieto-Pinto L, Peréz AY, Valderrama C, Hernández F. Alectinib for treating patients with metastatic ALK-positive NSCLC: systematic review and network metanalysis. Lung Cancer Manag 2023; 12:LMT59. [PMID: 37287941 PMCID: PMC10242442 DOI: 10.2217/lmt-2022-0018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 04/21/2023] [Indexed: 06/09/2023] Open
Abstract
Aim To compare the efficacy and safety of alectinib with other ALK inhibitors in treating patients with metastatic or locally advanced ALK-positive NSCLC. Methods A systematic literature review was conducted up to November 2021. Network meta-analyses were performed using the frequentist method (random effects). GRADE evidence profile was conducted. Results 13 RCTs were selected. For overall survival, alectinib was found to reduce the risk of death compared with crizotinib. In progression-free survival, alectinib reduced the risk of death or progression compared with crizotinib and ceritinib. Subgroup analysis by brain metastasis at baseline showed the superiority of alectinib over crizotinib and a similar effect compared with second-and third-generation inhibitors. Alectinib showed a good safety profile compared with the other ALK inhibitors.
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Affiliation(s)
| | | | - Andrés Yepes Peréz
- Oncology Unit, Centro Oncológico de Antioquia & Clínica de Oncología Astorga, Medellín, Colombia
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Wang Z, Xing Y, Li B, Li X, Liu B, Wang Y. Molecular pathways, resistance mechanisms and targeted interventions in non-small-cell lung cancer. MOLECULAR BIOMEDICINE 2022; 3:42. [PMID: 36508072 PMCID: PMC9743956 DOI: 10.1186/s43556-022-00107-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 11/03/2022] [Indexed: 12/14/2022] Open
Abstract
Lung cancer is the leading cause of cancer-related mortality worldwide. The discovery of tyrosine kinase inhibitors effectively targeting EGFR mutations in lung cancer patients in 2004 represented the beginning of the precision medicine era for this refractory disease. This great progress benefits from the identification of driver gene mutations, and after that, conventional and new technologies such as NGS further illustrated part of the complex molecular pathways of NSCLC. More targetable driver gene mutation identification in NSCLC patients greatly promoted the development of targeted therapy and provided great help for patient outcomes including significantly improved survival time and quality of life. Herein, we review the literature and ongoing clinical trials of NSCLC targeted therapy to address the molecular pathways and targeted intervention progress in NSCLC. In addition, the mutations in EGFR gene, ALK rearrangements, and KRAS mutations in the main sections, and the less common molecular alterations in MET, HER2, BRAF, ROS1, RET, and NTRK are discussed. The main resistance mechanisms of each targeted oncogene are highlighted to demonstrate the current dilemma of targeted therapy in NSCLC. Moreover, we discuss potential therapies to overcome the challenges of drug resistance. In this review, we manage to display the current landscape of targetable therapeutic patterns in NSCLC in this era of precision medicine.
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Affiliation(s)
- Zixi Wang
- grid.412901.f0000 0004 1770 1022Thoracic Oncology Ward, Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan China
| | - Yurou Xing
- grid.412901.f0000 0004 1770 1022Thoracic Oncology Ward, Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan China
| | - Bingjie Li
- grid.412901.f0000 0004 1770 1022Thoracic Oncology Ward, Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan China
| | - Xiaoyu Li
- grid.412901.f0000 0004 1770 1022Clinical Trial Center, National Medical Products Administration Key Laboratory for Clinical Research and Evaluation of Innovative Drugs, West China Hospital, Sichuan University, Chengdu, Sichuan China ,grid.412901.f0000 0004 1770 1022State Key Laboratory Biotherapy, Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan China
| | - Bin Liu
- grid.54549.390000 0004 0369 4060Department of Medical Oncology, School of Medicine, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, University of Electronic Science and Technology of China, Chengdu, Sichuan China
| | - Yongsheng Wang
- grid.412901.f0000 0004 1770 1022Thoracic Oncology Ward, Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan China ,grid.412901.f0000 0004 1770 1022State Key Laboratory Biotherapy, Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan China
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Identification of ALK-positive patients with advanced NSCLC and real-world clinical experience with crizotinib in Spain (IDEALK study). Lung Cancer 2022; 173:83-93. [PMID: 36162227 DOI: 10.1016/j.lungcan.2022.09.010] [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: 07/07/2022] [Revised: 09/07/2022] [Accepted: 09/13/2022] [Indexed: 11/20/2022]
Abstract
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.
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TABBÒ F, DE FILIPPIS M, JACOBS F, NOVELLO S. Strengths and pitfalls of brigatinib in non-small cell lung cancer patients' management. Minerva Med 2022; 113:315-332. [DOI: 10.23736/s0026-4806.21.07693-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Temel JS, Petrillo LA, Greer JA. Patient-Centered Palliative Care for Patients With Advanced Lung Cancer. J Clin Oncol 2022; 40:626-634. [PMID: 34985932 DOI: 10.1200/jco.21.01710] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
The evidence base demonstrating the benefits of an early focus on palliative care for patients with serious cancers, including advanced lung cancer, is substantial. Early involvement of specialty-trained palliative care clinicians in the care of patients with advanced lung cancer improves patient-reported outcomes, such as quality of life, and health care delivery, including hospice utilization. Since the time that many of these palliative care trials were conducted, the paradigm of cancer care for many cancers, including lung cancer, has changed dramatically. The majority of patients with advanced lung cancer are now treated with immune checkpoint inhibitors or targeted therapies, both of which have had a significant impact on patient's experience and outcomes. With this changing landscape of lung cancer therapeutics, patients are facing new and different challenges, including dealing with novel side effect profiles and coping with greater uncertainty regarding their prognosis. Patients who are living longer with their advanced cancer also struggle with how to address survivorship issues, such as sexual health and exercise, and decision making about end-of-life care. Although palliative care clinicians remain well-suited to address these care needs, they may need to learn new skills to support patients treated with novel therapies. Additionally, as the experience of patients with advanced lung cancer is becoming more varied and individualized, palliative care research interventions and clinical programs should also be delivered in a patient-centered manner to best meet patient's needs and improve their outcomes. Tailored and technology-based palliative care interventions are promising strategies for delivering patient-centered palliative care.
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Affiliation(s)
- Jennifer S Temel
- Harvard Medical School, Boston, MA.,Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Laura A Petrillo
- Harvard Medical School, Boston, MA.,Division of Palliative Care, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Joseph A Greer
- Harvard Medical School, Boston, MA.,Department of Psychiatry, Massachusetts General Hospital, Boston, MA
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Cameron LB, Hitchen N, Chandran E, Morris T, Manser R, Solomon BJ, Jordan V. Targeted therapy for advanced anaplastic lymphoma kinase (<I>ALK</I>)-rearranged non-small cell lung cancer. Cochrane Database Syst Rev 2022; 1:CD013453. [PMID: 34994987 PMCID: PMC8740884 DOI: 10.1002/14651858.cd013453.pub2] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Targeted therapies directed at specific driver oncogenes have improved outcomes for individuals with advanced non-small cell lung cancer (NSCLC). Approximately 5% of lung adenocarcinomas, the most common histologic subtype of NSCLC, harbour rearrangements in the anaplastic lymphoma kinase (ALK) gene leading to constitutive activity of the ALK kinase. Crizotinib was the first tyrosine kinase inhibitor (TKI) demonstrated to be effective in advanced NSCLC. Next-generation ALK TKIs have since been developed including ceritinib, alectinib, brigatinib, ensartinib, and lorlatinib, and have been compared with crizotinib or chemotherapy in randomised controlled trials (RCTs). These ALK-targeted therapies are currently used in clinical practice and are endorsed in multiple clinical oncology guidelines. OBJECTIVES To evaluate the safety and efficacy of ALK inhibitors given as monotherapy to treat advanced ALK-rearranged NSCLC. SEARCH METHODS We conducted electronic searches in the Cochrane Lung Cancer Group Specialised Register, Cochrane Central Register of Controlled Trials, MEDLINE, and Embase. We also searched conference proceedings from the American Society for Clinical Oncology (ASCO), European Society of Medical Oncology (ESMO), and International Association for the Study of Lung Cancer (IASLC) World Conference on Lung Cancer, as well as the reference lists of retrieved articles. All searches were conducted from 2007 until 7 January 2021. SELECTION CRITERIA We included RCTs comparing ALK inhibitors with cytotoxic chemotherapy or another ALK inhibitor in individuals with incurable locally advanced or metastatic pathologically confirmed ALK-rearranged NSCLC. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for eligibility, extracted study characteristics and outcome data, and assessed risk of bias using the Cochrane risk of bias tool for each included study. We assessed the certainty of evidence using GRADE. Primary outcomes were progression-free survival (PFS) and adverse events (AE); secondary outcomes were overall survival (OS), OS at one year, overall response rate (ORR) by RECIST (Response Evaluation Criteria in Solid Tumours) criteria, and health-related quality of life (HRQoL). We performed a meta-analysis for all outcomes, where appropriate, using the fixed-effect model. We reported hazard ratios (HR) for PFS, OS, and a composite HRQoL of life outcome (time to deterioration), and risk ratios (RR) for AE, ORR, and one-year OS. We presented 95% confidence intervals (95% CIs) and used the I² statistic to investigate heterogeneity. We planned comparisons of 'ALK inhibitor versus chemotherapy' and 'next-generation ALK inhibitor versus crizotinib' with subgroup analysis by type of ALK inhibitor, line of treatment, and baseline central nervous system involvement. MAIN RESULTS Eleven studies (2874 participants) met our inclusion criteria: six studies compared an ALK inhibitor (crizotinib, ceritinib, and alectinib) to chemotherapy, and five studies compared a next-generation ALK inhibitor (alectinib, brigatinib, and lorlatinib) to crizotinib. We assessed the evidence for most outcomes as of moderate to high certainty. Most studies were at low risk for selection, attrition, and reporting bias; however, no RCTs were blinded, resulting in a high risk of performance and detection bias for outcomes reliant on subjective measurement. ALK inhibitor versus chemotherapy Treatment with ALK inhibitors resulted in a large increase in PFS compared to chemotherapy (HR 0.45, 95% CI 0.40 to 0.52, 6 RCTs, 1611 participants, high-certainty evidence). This was found regardless of line of treatment. ALK inhibitors may result in no difference in overall AE rate when compared to chemotherapy (RR 1.01, 95% CI 1.00 to 1.03, 5 RCTs, 1404 participants, low-certainty evidence). ALK inhibitors slightly improved OS (HR 0.84, 95% CI 0.72 to 0.97, 6 RCTs, 1611 participants, high-certainty evidence), despite most included studies having a significant number of participants crossing over from chemotherapy to receive an ALK inhibitor after the study period. ALK inhibitors likely increase ORR (RR 2.43, 95% CI 2.16 to 2.75, 6 RCTs, 1611 participants, moderate-certainty evidence) including in measurable baseline brain metastases (RR 4.88, 95% CI 2.18 to 10.95, 3 RCTs, 108 participants) when compared to chemotherapy. ALK inhibitors result in a large increase in the HRQoL measure, time to deterioration (HR 0.52, 95% CI 0.44 to 0.60, 5 RCTs, 1504 participants, high-certainty evidence) when compared to chemotherapy. Next-generation ALK inhibitor versus crizotinib Next-generation ALK inhibitors resulted in a large increase in PFS (HR 0.39, 95% CI 0.33 to 0.46, 5 RCTs, 1263 participants, high-certainty evidence), particularly in participants with baseline brain metastases. Next-generation ALK inhibitors likely result in no difference in overall AE (RR 1.00, 95% CI 0.98 to 1.01, 5 RCTs, 1263 participants, moderate-certainty evidence) when compared to crizotinib. Next-generation ALK inhibitors likely increase OS (HR 0.71, 95% CI 0.56 to 0.90, 5 RCTs, 1263 participants, moderate-certainty evidence) and slightly increase ORR (RR 1.18, 95% CI 1.10 to 1.25, 5 RCTs, 1229 participants, moderate-certainty evidence) including a response in measurable brain metastases (RR 2.45, 95% CI 1.7 to 3.54, 4 RCTs, 138 participants) when compared to crizotinib. Studies comparing ALK inhibitors were conducted exclusively or partly in the first-line setting. AUTHORS' CONCLUSIONS Next-generation ALK inhibitors including alectinib, brigatinib, and lorlatinib are the preferred first systemic treatment for individuals with advanced ALK-rearranged NSCLC. Further trials are ongoing including investigation of first-line ensartinib. Next-generation inhibitors have not been compared to each other, and it is unknown which should be used first and what subsequent treatment sequence is optimal.
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Affiliation(s)
- Laird B Cameron
- Department of Medical Oncology "Te Puriri o Te Ora", Auckland District Health Board, Auckland, New Zealand
| | - Nadia Hitchen
- Department of Medical Oncology "Te Puriri o Te Ora", Auckland District Health Board, Auckland, New Zealand
| | - Elias Chandran
- Department of Medical Oncology "Te Puriri o Te Ora", Auckland District Health Board, Auckland, New Zealand
| | - Tessa Morris
- Southern Blood and Cancer Service, Southern District Healthboard, Dunedin, New Zealand
- Department of Medicine, University of Otago, Dunedin, New Zealand
| | - Renée Manser
- Department of Haematology and Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
- Department of Respiratory and Sleep Medicine, Royal Melbourne Hospital, Parkville, Australia
- Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Parkville, Australia
| | - Benjamin J Solomon
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Vanessa Jordan
- Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
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Zhou C, Ramalingam SS, Kim TM, Kim SW, Yang JCH, Riely GJ, Mekhail T, Nguyen D, Garcia Campelo MR, Felip E, Vincent S, Jin S, Griffin C, Bunn V, Lin J, Lin HM, Mehta M, Jänne PA. Treatment Outcomes and Safety of Mobocertinib in Platinum-Pretreated Patients With EGFR Exon 20 Insertion-Positive Metastatic Non-Small Cell Lung Cancer: A Phase 1/2 Open-label Nonrandomized Clinical Trial. JAMA Oncol 2021; 7:e214761. [PMID: 34647988 PMCID: PMC8517885 DOI: 10.1001/jamaoncol.2021.4761] [Citation(s) in RCA: 164] [Impact Index Per Article: 54.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 07/09/2021] [Indexed: 12/15/2022]
Abstract
IMPORTANCE Metastatic non-small cell lung cancer (mNSCLC) with EGFR exon 20 insertion (EGFRex20ins) mutations is associated with a poor prognosis. Mobocertinib is an oral tyrosine kinase inhibitor designed to selectively target EGFRex20ins mutations. OBJECTIVE To evaluate treatment outcomes and safety of mobocertinib in patients with previously treated EGFRex20ins-positive mNSCLC. DESIGN, SETTING, AND PARTICIPANTS This 3-part, open-label, phase 1/2 nonrandomized clinical trial with dose-escalation/dose-expansion cohorts (28 sites in the US) and a single-arm extension cohort (EXCLAIM; 40 sites in Asia, Europe, and North America) was conducted between June 2016 and November 2020 (data cutoff date). The primary analysis populations were the platinum-pretreated patients (PPP) cohort and the EXCLAIM cohort. The PPP cohort included 114 patients with platinum-pretreated EGFRex20ins-positive mNSCLC who received mobocertinib 160 mg once daily from the dose-escalation (n = 6), dose-expansion (n = 22), and EXCLAIM (n = 86) cohorts. The EXCLAIM cohort included 96 patients with previously treated EGFRex20ins-positive mNSCLC (10 were not platinum pretreated and thus were excluded from the PPP cohort). INTERVENTIONS Mobocertinib 160 mg once daily. MAIN OUTCOMES AND MEASURES The primary end point of the PPP and EXCLAIM cohorts was confirmed objective response rate (ORR) assessed by independent review committee (IRC). Secondary end points included confirmed ORR by investigator, duration of response, progression-free survival, overall survival, and safety. RESULTS Among the PPP (n = 114) and EXCLAIM (n = 96) cohorts, the median (range) age was 60 (27-84) and 59 (27-80) years, respectively; most patients were women (75 [66%] and 62 [65%], respectively) and of Asian race (68 [60%] and 66 [69%], respectively). At data cutoff, median follow-up was 14.2 months in the PPP cohort (median 2 prior anticancer regimens; 40 [35%] had baseline brain metastases), with confirmed ORR of 28% (95% CI, 20%-37%) by IRC assessment and 35% (95% CI, 26%-45%) by investigator assessment; median duration of response by IRC assessment was 17.5 months (95% CI, 7.4-20.3). Median progression-free survival by IRC assessment was 7.3 months (95% CI, 5.5-9.2). Median overall survival was 24.0 months (95% CI, 14.6-28.8). In the EXCLAIM cohort, median follow-up was 13.0 months, with confirmed ORR by IRC assessment of 25% (95% CI, 17%-35%) and by investigator assessment of 32% (95% CI, 23%-43%). The most common treatment-related adverse events were diarrhea and rash. CONCLUSIONS AND RELEVANCE In this open-label, phase 1/2 nonrandomized clinical trial, mobocertinib was associated with clinically meaningful benefit in patients with previously treated EGFRex20ins-positive mNSCLC, with a manageable safety profile. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02716116.
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Affiliation(s)
- Caicun Zhou
- Department of Oncology, Shanghai Pulmonary Hospital, Shanghai, China
| | | | - Tae Min Kim
- Seoul National University Hospital, Seoul, South Korea
| | - Sang-We Kim
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | | | | | | | - Danny Nguyen
- Pacific Shores Medical Group, Long Beach, California
| | - Maria R. Garcia Campelo
- Complejo Hospitalario Universitario A Coruña Hospital Teresa Herrera-Materno Infantil, A Coruña, Spain
| | | | - Sylvie Vincent
- Millennium Pharmaceuticals, Inc, a wholly owned subsidiary of Takeda Pharmaceutical Company Limited, Cambridge, Massachusetts
| | - Shu Jin
- Millennium Pharmaceuticals, Inc, a wholly owned subsidiary of Takeda Pharmaceutical Company Limited, Cambridge, Massachusetts
| | - Celina Griffin
- Millennium Pharmaceuticals, Inc, a wholly owned subsidiary of Takeda Pharmaceutical Company Limited, Cambridge, Massachusetts
| | - Veronica Bunn
- Millennium Pharmaceuticals, Inc, a wholly owned subsidiary of Takeda Pharmaceutical Company Limited, Cambridge, Massachusetts
| | - Jianchang Lin
- Millennium Pharmaceuticals, Inc, a wholly owned subsidiary of Takeda Pharmaceutical Company Limited, Cambridge, Massachusetts
| | - Huamao M. Lin
- Millennium Pharmaceuticals, Inc, a wholly owned subsidiary of Takeda Pharmaceutical Company Limited, Cambridge, Massachusetts
| | - Minal Mehta
- Millennium Pharmaceuticals, Inc, a wholly owned subsidiary of Takeda Pharmaceutical Company Limited, Cambridge, Massachusetts
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11
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Minchom A, Tan AC, Massarelli E, Subbiah V, Boni V, Robinson B, Wirth LJ, Hess LM, Jen MH, Kherani J, Olek E, McCoach CE. Patient-Reported Outcomes with Selpercatinib Among Patients with RET Fusion-Positive Non-Small Cell Lung Cancer in the Phase I/II LIBRETTO-001 Trial. Oncologist 2021; 27:22-29. [PMID: 34523767 DOI: 10.1002/onco.13976] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 12/21/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND LIBRETTO-001 is an ongoing, global, open-label, phase I/II study of selpercatinib in patients with advanced or metastatic solid tumors. We report interim patient-reported outcomes in patients with RET fusion-positive non-small cell lung cancer (NSCLC). PATIENTS AND METHODS Patients completed the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (QLQ-C30) version 3.0 at baseline (cycle 1, day 1), approximately every other 28-day cycle until cycle 13, and every 12 weeks thereafter. Data were evaluated through cycle 13 as few patients had reached later time points. A change of ≥10 points from baseline in domain scores was considered clinically meaningful. RESULTS Among 253 selpercatinib-treated patients, 239 were categorized into subgroups by prior therapy: treatment-naïve (n = 39), one prior line of therapy (n = 64), or two or more prior lines of therapy (n = 136). The QLQ-C30 was completed by >85% of patients at each time point. Most patients overall and in each subgroup maintained or improved in all health-related quality of life (HRQoL) domains during treatment. The percentage of patients who experienced clinically meaningful improvements ranged from 61.1% to 66.7% for global health status, 33.3% to 61.1% for dyspnea, and 46.2% to 63.0% for pain. The 61.1% of patients with improved dyspnea had two or more prior lines of therapy; median time to first improvement was 3.4 months. At the first postbaseline evaluation (cycle 3), 45.9% of all patients reported a ≥ 10-point reduction in pain. CONCLUSION In this interim analysis, the majority of patients with RET fusion-positive NSCLC remained stable or improved on all QLQ-C30 subscales at each study visit, demonstrating favorable HRQoL as measured by the QLQ-C30 during treatment with selpercatinib. IMPLICATIONS FOR PRACTICE Patients with non-small cell lung cancer (NSCLC) generally experience greater symptom burden and lower health-related quality of life (HRQoL) as the disease progresses. In a phase I/II trial, improvements in HRQoL were observed in over 60% of patients with advanced RET fusion-positive NSCLC who received selpercatinib, a highly selective RET inhibitor. More than one third of patients reported a reduction in dyspnea during study participation, and nearly half reported a reduction in pain by the first follow-up assessment.
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Affiliation(s)
- Anna Minchom
- Royal Marsden Hospital and Institute of Cancer Research, Sutton, United Kingdom
| | | | | | - Vivek Subbiah
- The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Valentina Boni
- START Madrid-Centro Integral Oncológico Clara Campal (CIOCC), Hm Hospitales Sanchinarro, Madrid, Spain
| | | | - Lori J Wirth
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | | | - Jennifer Kherani
- Loxo Oncology, a wholly owned subsidiary of Eli Lilly & Co, Stamford, Connecticut, USA
| | - Elizabeth Olek
- Loxo Oncology, a wholly owned subsidiary of Eli Lilly & Co, Stamford, Connecticut, USA
| | - Caroline E McCoach
- University of California at San Francisco, San Francisco, California, USA
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12
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Paz-Ares L, Barlesi F, Siena S, Ahn MJ, Drilon A, Conley A, Rolfo C, Wolf J, Seto T, Doebele R, Kapre A, Chen D, McCallum S, Osborne S, Demetri G. Patient-reported outcomes from STARTRK-2: a global phase II basket study of entrectinib for ROS1 fusion-positive non-small-cell lung cancer and NTRK fusion-positive solid tumours. ESMO Open 2021; 6:100113. [PMID: 33930659 PMCID: PMC8100628 DOI: 10.1016/j.esmoop.2021.100113] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 03/19/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Patient-reported outcomes (PROs) are increasingly relevant endpoints in clinical trials, contributing to our understanding of risk-benefit profiles, in addition to efficacy and safety data. We investigated the impact of entrectinib on patient-reported symptoms, functioning, and health-related quality of life. PATIENTS AND METHODS STARTRK-2 is a phase II basket study in patients with locally advanced/metastatic neurotrophic receptor tyrosine kinase 1/2/3 (NTRK1/2/3) and ROS proto-oncogene 1 (ROS1) fusion-positive solid tumours. PROs (prespecified secondary endpoint) were evaluated using the European Organization for Research and Treatment of Cancer quality-of-life questionnaire (QLQ-C30), lung cancer module (QLQ-LC13), and colorectal cancer module (QLQ-CR29), and the EuroQoL 5-Dimension 3-Level instruments, completed before cycle 1 day 1 and each subsequent 4-week cycle of entrectinib dosing, and the end of treatment. Adverse events and treatment-related symptoms were assessed in the safety analysis (SA)-PRO population. Tumour-related symptoms, functioning, and global health status were assessed in the efficacy analysis (EA)-PRO population. Data cut-offs: 31 October 2018 NTRK cohort; 01 May 2019 ROS1 cohort. RESULTS SA-PRO populations comprised patients with NTRK fusion-positive solid tumours (N = 88) or ROS1 fusion-positive non-small-cell lung cancer (N = 180) who received one or more doses of entrectinib, completed PRO questionnaires on cycle 1 day 1 and answered one or more questions on-study. EA-PRO populations (N = 71) and (N = 145), respectively, comprised SA-PRO patients with measurable baseline disease. Moderate-to-high baseline global health status scores were maintained in EA-PRO populations during treatment. Role and physical functioning scores were moderate-to-high at baseline, with trends towards clinical improvement during treatment. Both cohorts reported low-to-moderate symptom burden at baseline, which was maintained or trended towards clinically meaningful improvement. Symptoms commonly associated with cancer treatment (e.g. nausea, fatigue) remained stable or improved during treatment. All SA-PRO patients experienced one or more adverse events, most frequently constipation or diarrhoea. CONCLUSIONS PRO findings were consistent with the favourable safety profile of entrectinib, and further reinforce the positive benefit-risk profile of this treatment, indicating minimal overall treatment burden.
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Affiliation(s)
- L Paz-Ares
- Medical Oncology Department, Hospital Universitario 12 de Octubre, CNIO-H12o Lung Cancer Clinical Research Unit, Universidad Complutense & Ciberonc, Madrid, Spain.
| | - F Barlesi
- Medical Oncology Department, Gustave Roussy Cancer Campus, Villejuif, France
| | - S Siena
- Medical Oncology Department, Niguarda Cancer Center, Grande Ospedale Metropolitano Niguarda, Milan, Italy; Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milan, Italy
| | - M-J Ahn
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - A Drilon
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, USA; Weill Cornell Medical College, New York, USA
| | - A Conley
- Department of Sarcoma Medical Oncology, MD Anderson Cancer Center, University of Texas, Houston, USA
| | - C Rolfo
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, USA
| | - J Wolf
- Department I of Internal Medicine, Center for Integrated Oncology, University Hospital of Cologne, Cologne, Germany
| | - T Seto
- Department of Thoracic Oncology, National Hospital Organization Kyushu Cancer Center, Fukuoka, Japan
| | - R Doebele
- Division of Medical Oncology, University of Colorado, Aurora, USA
| | - A Kapre
- Department of Patient-Centered Outcomes Research, Genentech, Inc., South San Francisco, USA
| | - D Chen
- Product Development Oncology, Genentech, Inc., South San Francisco, USA
| | - S McCallum
- Medication Safety and Risk Management, Genentech, Inc., South San Francisco, USA
| | - S Osborne
- PDMA Operations (Biometrics), F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - G Demetri
- Department of Oncologic Pathology, Dana-Farber Cancer Institute and Ludwig Center at Harvard Medical School, Boston, USA
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13
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Tacar SY, Yilmaz M, Oz B, Tural D. Crizotinib for c-MET-amplified advanced NSCLC: a single-center experience. TUMORI JOURNAL 2021; 108:258-262. [PMID: 33849345 DOI: 10.1177/03008916211009303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Lung cancer is the most common cause of cancer-related death in the world. Changes in the treatment of metastatic lung cancer in recent years have made targetable mutations gain importance. MET alteration is one of these driver mutations and crizotinib is a tyrosine kinase inhibitor used in therapy. METHODS In our study, data of patients with c-MET amplification who received crizotinib treatment between July 2017 and November 2020 in the Medical Oncology Clinic of Bakırköy Dr. Sadi Konuk Training and Research Hospital were retrospectively analyzed. c-MET scanning was performed by the fluorescent in situ hybridization method by using Cytotest MET/CCP7 probe kit by evaluating 100 tumor cells and the threshold value for positivity was accepted as above 20%. RESULTS Eight of 28 patients who received crizotinib treatment had c-MET amplification. Seven of these patients were male and one was female. Progression-free survival and overall survival in these eight patients were 9.4 and 10.9 months, respectively, and objective response rate was 50%. Grade 4 nausea was observed in only one patient; there was no grade 4-5 toxicity and no patient discontinued the drug due to toxicity. CONCLUSION Crizotinib is an effective treatment option other than cytotoxic chemotherapy in the limited number of patients with MET amplification in the stage 4 lung adenocarcinoma subgroup. It is important to investigate this amplification, which can be detected especially in smoking patients in the appropriate patient group, and to use appropriate tyrosine kinase inhibitors in treatment.
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Affiliation(s)
- Seher Yildiz Tacar
- Medical Oncology Department, Bakırköy Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Mesut Yilmaz
- Medical Oncology Department, Bakırköy Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Buge Oz
- Pathology Department, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Deniz Tural
- Medical Oncology Department, Bakırköy Sadi Konuk Training and Research Hospital, Istanbul, Turkey
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Tabbò F, Passiglia F, Novello S. Upfront Management of ALK-Rearranged Metastatic Non-small Cell Lung Cancer: One Inhibitor Fits All? Curr Oncol Rep 2021; 23:10. [PMID: 33387080 DOI: 10.1007/s11912-020-00989-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2020] [Indexed: 12/29/2022]
Abstract
PURPOSE OF REVIEW Anaplastic lymphoma kinase (ALK) rearrangements represent a seldom event in non-small cell lung cancer (NSCLC). Given the oncogene alteration, ALK targeting represents the main therapeutic strategy. Here, we review evidence regarding ALK inhibitors (ALKi): clinical activity, safety profiles, financial costs, and biomarkers of efficacy. RECENT FINDINGS During the past 10 years, multiple ALKi have been developed, and four different compounds are currently available as upfront options for ALK+ NSCLC patients: crizotinib, ceritinib, alectinib, and brigatinib. Second-generation (2G) ALKi demonstrated superior clinical activity in terms of median progression-free survival (mPFS), objective response rate (ORR), intracranial disease control, and duration of response (DOR) when compared with crizotinib. 2G ALKi represent the current gold-standard first-line treatment for ALK-rearranged metastatic NSCLC. Among all available options, in our opinion, alectinib has likely the best profile of clinical activity and safety, thus emerging as the best upfront therapy. More insights will come from ongoing trials and analysis of biomarkers.
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Affiliation(s)
- Fabrizio Tabbò
- Department of Oncology, University of Turin, San Luigi Hospital, Orbassano, TO, Italy
| | - Francesco Passiglia
- Department of Oncology, University of Turin, San Luigi Hospital, Orbassano, TO, Italy
| | - Silvia Novello
- Department of Oncology, University of Turin, San Luigi Hospital, Orbassano, TO, Italy.
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Tse BC, Said BI, Fan ZJ, Hueniken K, Patel D, Gill G, Liang M, Razooqi M, Brown MC, Sacher AG, Bradbury PA, Shepherd FA, Leighl NB, Xu W, Howell D, Liu G, O'Kane G. Longitudinal health utilities, symptoms and toxicities in patients with ALK-rearranged lung cancer treated with tyrosine kinase inhibitors: a prospective real-world assessment. Curr Oncol 2020; 27:e552-e559. [PMID: 33380870 PMCID: PMC7755437 DOI: 10.3747/co.27.6563] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Tyrosine kinase inhibitors (tkis) have dramatically improved the survival of patients with ALK-rearranged (ALK+) non-small-cell lung cancer (nsclc). Clinical trial data can generally compare drugs in a pair-wise fashion. Real-world collection of health utility data, symptoms, and toxicities allows for the direct comparison between multiple tki therapies in the population with ALK+ nsclc. Methods In a prospective cohort study, outpatients with ALK+ recruited between 2014 and 2018, treated with a variety of tkis, were assessed every 3 months for clinico-demographic, patient-reported symptom and toxicity data and EQ-5D-derived health utility scores (hus). Results In 499 longitudinal encounters of 76 patients with ALK+ nsclc, each tki had stable longitudinal hus when disease was controlled, even after months to years: the mean overall hus for each tki ranged from 0.805 to 0.858, and longitudinally from 0.774 to 0.912, with higher values associated with second- or third-generation tkis of alectinib, brigatinib, and lorlatinib. Disease progression was associated with a mean hus decrease of 0.065 (95% confidence interval: 0.02 to 0.11). Health utility scores were inversely correlated to multiple symptoms or toxicities: rho values ranged from -0.094 to -0.557. Fewer symptoms and toxicities were associated with the second- and third-generation tkis compared with crizotinib. In multivariable analysis, only stable disease state and baseline Eastern Cooperative Oncology Group performance status were associated with improved hus. Conclusions There was no significant decrease in hus when patients with ALK+ disease were treated longitudinally with each tki, as long as patients were clinically stable. Alectinib, brigatinib, and lorlatinib had the best toxicity profiles and exhibited high mean hus longitudinally in the real-world setting.
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Affiliation(s)
- B C Tse
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON
| | - B I Said
- Radiation Medicine Program, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON
| | - Z J Fan
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON
| | - K Hueniken
- Department of Biostatistics, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON
| | - D Patel
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON
| | - G Gill
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON
| | - M Liang
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON
| | - M Razooqi
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON
| | - M C Brown
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON
| | - A G Sacher
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON
| | - P A Bradbury
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON
| | - F A Shepherd
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON
| | - N B Leighl
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON
| | - W Xu
- Department of Biostatistics, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON
| | - D Howell
- Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON
| | - G Liu
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON
- Department of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, ON
- Department of Medical Biophysics, University of Toronto, Toronto, ON
| | - G O'Kane
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON
- Radiation Medicine Program, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON
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16
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Lin HM, Pan X, Biller A, J Covey K, Huang H, Sugarman R, Scipione F, West H. Humanistic burden of living with anaplastic lymphoma kinase-positive non-small-cell lung cancer: findings from the ALKConnect patient insight network and research platform. Lung Cancer Manag 2020; 10:LMT42. [PMID: 33318754 PMCID: PMC7724653 DOI: 10.2217/lmt-2020-0018] [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] [Indexed: 12/24/2022] Open
Abstract
Aim: Evaluate real-world patient preferences, experiences and outcomes (health-related quality of life [HRQoL]) from patients with anaplastic lymphoma kinase-positive (ALK+) non-small-cell lung cancer (NSCLC) utilizing the ALKConnect Patient Insight Network. Patients & methods: Demographics, disease history/status/treatment, patient preferences and HRQoL (MD Anderson Symptom Inventory lung cancer module, reported as symptom severity and interference) were evaluated for US adults with ALK+ NSCLC. Results: Among 104 patients (median age: 53.0 years, 67.3% female, 40.0% employed), HRQoL and 3-month delay in disease progression were important treatment attributes. Burdensome symptoms included fatigue and disturbed sleep. Symptoms interfered most with work and day-to-day activity. Higher HRQoL was associated with ALK tyrosine kinase inhibitor (TKI) treatment and employment. Conclusion: ALKConnect demonstrated that disease progression, HRQoL, fatigue/sleep, ALK TKIs and employment matter in ALK+ NSCLC.
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Affiliation(s)
- Huamao M Lin
- Millennium Pharmaceuticals, Inc., Cambridge, MA 02139, USA, a wholly owned subsidiary of Takeda Pharmaceutical Company Limited
| | - Xiaoyun Pan
- Millennium Pharmaceuticals, Inc., Cambridge, MA 02139, USA, a wholly owned subsidiary of Takeda Pharmaceutical Company Limited
| | - Alyssa Biller
- Millennium Pharmaceuticals, Inc., Cambridge, MA 02139, USA, a wholly owned subsidiary of Takeda Pharmaceutical Company Limited
| | - Kyla J Covey
- Invitae Corporation, San Francisco, CA 94103, USA
| | - Hui Huang
- Millennium Pharmaceuticals, Inc., Cambridge, MA 02139, USA, a wholly owned subsidiary of Takeda Pharmaceutical Company Limited
| | | | - Fatima Scipione
- Millennium Pharmaceuticals, Inc., Cambridge, MA 02139, USA, a wholly owned subsidiary of Takeda Pharmaceutical Company Limited
| | - Howard West
- City of Hope Comprehensive Cancer Center, Duarte, CA 91010, USA
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Blom EF, Haaf KT, de Koning HJ. Systematic Review and Meta-Analysis of Community- and Choice-Based Health State Utility Values for Lung Cancer. PHARMACOECONOMICS 2020; 38:1187-1200. [PMID: 32754857 PMCID: PMC7547043 DOI: 10.1007/s40273-020-00947-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
BACKGROUND Using appropriate health state utility values (HSUVs) is critical for economic evaluation of new lung cancer interventions, such as low-dose computed tomography screening and immunotherapy. Therefore, we provide a systematic review and meta-analysis of community- and choice-based HSUVs for lung cancer. METHODS On 6 March 2017, we conducted a systematic search of the following databases: Embase, Ovid MEDLINE, Web of Science, Cochrane CENTRAL, Google Scholar, and the School of Health and Related Research Health Utility Database. The search was updated on 17 April 2019. Studies reporting mean or median lung cancer-specific HSUVs including a measure of variance were included and assessed for relevance and validity. Studies with high relevance (i.e. community- and choice-based) were further analysed. Mean HSUVs were pooled using random-effects models for all stages, stages I-II, and stages III-IV. For studies with a control group, we calculated the disutility due to lung cancer. A sensitivity analysis included only the methodologically most comparable studies (i.e. using the EQ-5D instrument and matching tariff). Subgroup analyses were conducted by time to death, histology, sex, age, treatment modality, treatment line, and progression status. RESULTS We identified and analysed 27 studies of high relevance. The pooled HSUV was 0.68 (95% confidence interval [CI] 0.61-0.75) for all stages, 0.78 (95% CI 0.70-0.86) for stages I-II, and 0.69 (95% CI 0.65-0.73) for stages III-IV (p = 0.02 vs. stage I-II). Heterogeneity was present in each pooled analysis (p < 0.01; I2 = 92-99%). Disutility due to lung cancer ranged from 0.11 (95% CI 0.05-0.17) to 0.27 (95% CI 0.18-0.36). In the sensitivity analysis with the methodologically most comparable studies, stage-specific HSUVs varied by country. Such studies were only identified for Canada, China, Spain, the UK, the USA, Denmark, Germany, and Thailand. In the subgroup analysis by time to death, HSUVs for metastatic non-small-cell lung cancer ranged from 0.83 (95% CI 0.82-0.85) at ≥ 360 days from death to 0.56 (95% CI 0.46-0.66) at < 30 days from death. Among patients with metastatic non-small-cell lung cancer, HSUVs were lower for those receiving third- or fourth-line treatment and for those with progressed disease. Results of subgroup analyses by histology, sex, age, and treatment modality were ambiguous. CONCLUSIONS The presented evidence supports the use of stage- and country-specific HSUVs. However, such HSUVs are unavailable for most countries. Therefore, our pooled HSUVs may provide the best available stage-specific HSUVs for most countries. For metastatic non-small-cell lung cancer, adjusting for the decreased HSUVs in the last year of life may be considered, as may further stratification of HSUVs by treatment line or progression status. If required, HSUVs for other health states may be identified using our comprehensive breakdown of study characteristics.
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Affiliation(s)
- Erik F Blom
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Internal Postal Address Na-2401, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands.
| | - Kevin Ten Haaf
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Internal Postal Address Na-2401, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands
| | - Harry J de Koning
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Internal Postal Address Na-2401, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands
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18
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Camidge DR, Kim HR, Ahn MJ, Yang JCH, Han JY, Hochmair MJ, Lee KH, Delmonte A, García Campelo MR, Kim DW, Griesinger F, Felip E, Califano R, Spira A, Gettinger SN, Tiseo M, Lin HM, Gupta N, Hanley MJ, Ni Q, Zhang P, Popat S. Brigatinib Versus Crizotinib in Advanced ALK Inhibitor-Naive ALK-Positive Non-Small Cell Lung Cancer: Second Interim Analysis of the Phase III ALTA-1L Trial. J Clin Oncol 2020; 38:3592-3603. [PMID: 32780660 PMCID: PMC7605398 DOI: 10.1200/jco.20.00505] [Citation(s) in RCA: 206] [Impact Index Per Article: 51.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Brigatinib, a next-generation anaplastic lymphoma kinase (ALK) inhibitor, demonstrated superior progression-free survival (PFS) and improved health-related quality of life (QoL) versus crizotinib in advanced ALK inhibitor–naive ALK-positive non–small cell lung cancer (NSCLC) at first interim analysis (99 events; median brigatinib follow-up, 11.0 months) in the open-label, phase III ALTA-1L trial (ClinicalTrials.gov identifier: NCT02737501). We report results of the second prespecified interim analysis (150 events).
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Affiliation(s)
| | - Hye Ryun Kim
- Division of Medical Oncology, Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | | | | | | | - Maximilian J Hochmair
- Department of Respiratory and Critical Care Medicine, Krankenhaus Nord-Klinik Floridsdorf, Vienna, Austria
| | - Ki Hyeong Lee
- Chungbuk National University Hospital, Cheongju, South Korea
| | - Angelo Delmonte
- Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST), IRCCS, Meldola, Italy
| | | | - Dong-Wan Kim
- Seoul National University Hospital, Seoul, South Korea
| | - Frank Griesinger
- Pius-Hospital Oldenburg, University of Oldenburg, Oldenburg, Germany
| | | | - Raffaele Califano
- The Christie NHS Foundation Trust and Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
| | - Alexander Spira
- Virginia Cancer Specialists and US Oncology Research, The Woodlands, TX
| | | | | | | | | | | | | | | | - Sanjay Popat
- Royal Marsden Hospital, London, United Kingdom.,The Institute of Cancer Research, London, United Kingdom
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Breadner D, Blanchette P, Shanmuganathan S, Boldt RG, Raphael J. Efficacy and safety of ALK inhibitors in ALK-rearranged non-small cell lung cancer: A systematic review and meta-analysis. Lung Cancer 2020; 144:57-63. [PMID: 32371261 DOI: 10.1016/j.lungcan.2020.04.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 03/30/2020] [Accepted: 04/13/2020] [Indexed: 12/22/2022]
Abstract
OBJECTIVES No overall survival (OS) benefit has been reported from a mature randomized trial with the use of ALK inhibitors. We conducted a systematic review and meta-analysis to assess the efficacy of ALK inhibitors compared to chemotherapy (ALK vs. chemo) and 2nd generation ALK inhibitors compared to 1 st generation ALK inhibitors (ALK-2 G vs. ALK-1 G). METHODS The electronic databases Medline (PubMed), EMBASE, and the Cochrane Database of Systematic Reviews were searched for relevant randomized trials. Pooled hazard ratios (HR) for OS and progression free survival (PFS), and pooled risk ratios for objective response rates (ORR) and toxicity were meta-analyzed using the generic inverse variance and the Mantel-Haenszel methods. To account for between-studies heterogeneity, random-effect models were used. Subgroup analyses compared PFS by gender, smoking status, brain metastases, race and age. RESULTS Six trials were included in the analysis of ALK vs. chemo and four in the analysis of ALK-2 G vs. ALK-1 G. Treatment with ALK inhibitors improved OS compared to chemotherapy (HR: 0.84, 95 %CI 0.72-0.97) while a trend toward a better OS was seen with ALK-2 G vs. ALK-1 G (HR: 0.66, 95 %CI 0.43-1.02). PFS was improved with ALK vs. chemo and ALK-2 G vs. ALK-1 G (HR: 0.44, 95 %CI 0.35-0.54 and HR: 0.38, 95 %CI-0.29-0.51, respectively). ORR was improved with ALK vs. chemo and ALK-2 G vs. ALK-1 G. No difference in toxicity was observed. CONCLUSIONS This meta-analysis is the first, to our knowledge, to report an OS and PFS benefit with the use of ALK inhibitors compared to chemotherapy from randomized trial data. A trend toward a better OS was also seen with ALK-2 G vs. ALK-1 G and this is likely because of crossover effects and limited OS follow-up. Longer follow up and further research are warranted to directly compare ALK inhibitor sequences and to understand the outcomes of second generation ALK inhibitors as initial therapy.
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Affiliation(s)
- Daniel Breadner
- Department of Oncology, London Regional Cancer Program, Schulich School of Medicine and Dentistry, 800 Commissioners Road East, London, Ontario, N6A5W9, Canada.
| | - Phillip Blanchette
- Department of Oncology, London Regional Cancer Program, Schulich School of Medicine and Dentistry, 800 Commissioners Road East, London, Ontario, N6A5W9, Canada.
| | - Sumugan Shanmuganathan
- Department of Medicine, Schulich School of Medicine and Dentistry, E6-117 Victoria Hospital, London, Ontario, N6A5A5, Canada.
| | - Ronald Gabriel Boldt
- Department of Oncology, London Regional Cancer Program, Schulich School of Medicine and Dentistry, 800 Commissioners Road East, London, Ontario, N6A5W9, Canada.
| | - Jacques Raphael
- Department of Oncology, London Regional Cancer Program, Schulich School of Medicine and Dentistry, 800 Commissioners Road East, London, Ontario, N6A5W9, Canada.
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20
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Peters S, Shaw AT, Besse B, Felip E, Solomon BJ, Soo RA, Bearz A, Gadgeel SM, Lin CC, Kao S, Seto T, Masters ET, Abbattista A, Clancy JS, Thurm H, Reisman A, Peltz G, Ross Camidge D. Impact of lorlatinib on patient-reported outcomes in patients with advanced ALK-positive or ROS1-positive non-small cell lung cancer. Lung Cancer 2020; 144:10-19. [PMID: 32344248 DOI: 10.1016/j.lungcan.2020.02.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 02/12/2020] [Accepted: 02/18/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To evaluate patient-reported outcomes (PROs) from a phase 1/2 study (NCT01970865) in patients with anaplastic lymphoma kinase (ALK)- or ROS1-positive advanced non-small cell lung cancer (NSCLC) treated with lorlatinib 100 mg once daily. MATERIALS AND METHODS PRO measures, including global quality of life (QoL), functioning domains and symptoms, were assessed by the European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire Core 30 (QLQ-C30) and the 13-item Lung Cancer (QLQ-LC13) module. Mean changes of absolute scores from baseline were assessed. Percentages of patients showing improvement, stability or worsening on each scale were reported, with a change of ≥10 points considered clinically meaningful (CM). RESULTS 255 patients completed baseline and ≥1 post-baseline PRO assessment. Most patients had CM improvement (42.4 %) or stable (38.0 %) scores for global QoL. Functioning domains with the greatest proportion of patients with improved scores were role (37.6 %) and emotional (36.9 %); only one domain had more patients showing worsening than improving function (cognitive [24.3 % vs 22.4 %]). Most patients showed improved or stable scores for disease-related symptoms. No QLQ-C30 symptom domains had more patients worsening than improving. Symptoms on the QLQ-C30 scale with the greatest proportion of patients with improved scores were fatigue (49.4 %) and insomnia (46.3 %). Four QLQ-LC13 domains had more patients worsening than improving (two most affected were peripheral neuropathy [37.3 % vs 13.7 %] and alopecia [19.2 % vs 13.3 %]). Symptoms on the QLQ-LC13 scale with the greatest proportion of patients with improved scores were cough (42.7 %) and pain in other parts (32.9 %). CONCLUSIONS Lorlatinib treatment showed CM improvement from baseline in global QOL that was maintained over time. Additionally, there were improvements in physical, emotional, social, and role functioning. Improvements were shown in appetite loss and key symptoms such as pain, dyspnea, cough and fatigue; a worsening in peripheral neuropathy was noted.
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Affiliation(s)
- Solange Peters
- Centre Hospitalier Universitaire Vaudois, Lausanne University, Lausanne, Switzerland.
| | - Alice T Shaw
- Massachusetts General Hospital, Boston, MA, USA.
| | - Benjamin Besse
- Gustave Roussy Cancer Campus, Villejuif, France; Paris-Sud University, Orsay, France.
| | - Enriqueta Felip
- Vall d'Hebron University Hospital and Vall d'Hebron Institute of Oncology, Barcelona, Spain.
| | | | - Ross A Soo
- National University Cancer Institute, Singapore.
| | | | | | - Chia-Chi Lin
- National Taiwan University Hospital, Taipei, Taiwan.
| | - Steven Kao
- Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia.
| | - Takashi Seto
- National Hospital Organization Kyushu Cancer Center, Fukuoka, Japan.
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21
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Elliott J, Bai Z, Hsieh SC, Kelly SE, Chen L, Skidmore B, Yousef S, Zheng C, Stewart DJ, Wells GA. ALK inhibitors for non-small cell lung cancer: A systematic review and network meta-analysis. PLoS One 2020; 15:e0229179. [PMID: 32074131 PMCID: PMC7029857 DOI: 10.1371/journal.pone.0229179] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 02/01/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND We sought to assess the relative effects of individual anaplastic lymphoma kinase (ALK) inhibitors for the treatment of non-small cell lung cancer (NSCLC). METHODS We searched MEDLINE, Embase, Cochrane CENTRAL, and grey literature (July 23, 2019) for randomized controlled trials (RCTs) that included participants with ALK- or ROS1-positive NSCLC who received any ALK inhibitor compared with placebo, another ALK inhibitor, or the same ALK inhibitor at a different dose. The primary outcome was treatment-related death. Secondary outcomes were overall survival (OS), progression-free survival (PFS), and serious adverse events. Data were pooled via meta-analysis and network meta-analysis, and risk of bias was assessed. PROSPERO: CRD42017077046. RESULTS Thirteen RCTs reporting outcomes of interest among participants with ALK-positive NSCLC were identified. Treatment-related deaths were rare, with 10 deaths attributed to crizotinib (risk difference v. chemotherapy: 0.49, 95% credible interval [CrI] -0.16 to 1.46; odds ratio 2.58 (0.76-11.37). All ALK inhibitors improved PSF relative to chemotherapy (hazard ratio [95% CrI]: crizotinib 0.46 [0.39-0.54]; ceritinib 0.52 [0.42-0.64]; alectinib 300 BID 0.16 [0.08-0.33]; alectinib 600 BID 0.23 [0.17-0.30]; brigatinib 0.23 [0.15-0.35]), while alectinib and brigatinib improved PFS over crizotinib and ceritinib (alectinib v. crizotinib 0.34 [0.17-0.70]; alectinib v. ceritinib 0.30 [0.14-0.64]; brigatinib v. crizotinib 0.49 [0.33-0.73]; brigatinib v. ceritinib 0.43 [0.27-0.70]). OS was improved with alectinib compared with chemotherapy (HR 0.57 [95% CrI 0.39-0.83]) and crizotinib (0.68 [0.48-0.96]). Use of crizotinib (odds ratio 2.08 [95% CrI 1.56-2.79]) and alectinib (1.60 [1.00-2.58]) but not ceritinib (1.25 [0.90-1.74), increased the risk of serious adverse events compared with chemotherapy. Results were generally consistent among treatment-experienced or naïve participants. CONCLUSION(S) Treatment-related deaths were infrequent among ALK-positive NSCLC. PFS may be improved by alectinib and brigatinib relative to other ALK inhibitors; however, the assessment of OS is likely confounded by treatment crossover and should be interpreted with caution.
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Affiliation(s)
- Jesse Elliott
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Canada
| | - Zemin Bai
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Canada
| | - Shu-Ching Hsieh
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Canada
| | - Shannon E. Kelly
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Canada
| | - Li Chen
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Canada
| | | | - Said Yousef
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Canada
| | - Carine Zheng
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Canada
| | - David J. Stewart
- Division of Medical Oncology, University of Ottawa and The Ottawa Hospital, Ottawa, Canada
| | - George A. Wells
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Canada
- * E-mail:
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22
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Cavanna L, Citterio C, Orlandi E. Feasibility and Utility of Incorporating Patient-Reported Outcomes into Surveillance Strategies for Advanced Lung Cancer. Patient Relat Outcome Meas 2020; 11:49-66. [PMID: 32104126 PMCID: PMC7025658 DOI: 10.2147/prom.s179185] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Accepted: 02/06/2020] [Indexed: 12/25/2022] Open
Abstract
PURPOSE To identify and to describe patient-reported outcomes (PROs) in lung cancer patients and to evaluate the feasibility and utility of PROs into surveillance strategies, a review was carried out. PATIENTS AND METHODS A systematic search in bibliographic databases evaluating the instruments used in PROs of non-small-Cell lung cancer (NSCLC) patients was done. RESULTS From August 2014 to August 2019, 33 studies were included in this review and 16,491 patients were evaluated. PROs were divided into 6 different categories: 1) PROs as a guide in therapeutic choice, 2) PROs as indicator of disease progression, 3) agreement between PROs and the evaluated parameters, 4) PROs to evaluate the effects of immunotherapy, 5) need to deepen the knowledge of PROs, and 6) use of new electronic PROs. CONCLUSION The most frequently used instruments are EORTC QLQ-30 (16, 50%) and EORTC LC-13 (14, 43.75%) and in some studies (37.5%) they are used together. For different reasons (disease progression, adverse event, death, incomplete participation, etc.), the completion of these instruments decreased over time from baseline to subsequent measurements. This review demonstrates that PROs can play an important role as part of health care, and that routine use implementation could improve patient management in addition to the traditionally collected outcome.
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Affiliation(s)
- Luigi Cavanna
- Oncology and Hematology Department, Oncology Unit, Piacenza General Hospital, Piacenza29121, Italy
| | - Chiara Citterio
- Oncology and Hematology Department, Oncology Unit, Piacenza General Hospital, Piacenza29121, Italy
| | - Elena Orlandi
- Oncology and Hematology Department, Oncology Unit, Piacenza General Hospital, Piacenza29121, Italy
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23
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Treatment of anaplastic lymphoma kinase-positive non-small cell lung cancer: update and perspectives. Curr Opin Oncol 2020; 31:8-12. [PMID: 30394941 DOI: 10.1097/cco.0000000000000494] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW We describe recent developments in the rapidly evolving field of anaplastic lymphoma kinase-targeting agents. RECENT FINDINGS Five targeted drugs are currently available in the clinic via regular approval or named patient programs, including crizotinib, ceritinib, alectinib, brigatinib and lorlatinib. Further drugs are tested in clinical trials. This review summarizes published data, together with drug-specific information on dosing and toxicity. Moreover, we discuss different clinical scenarios and potential treatment options in patients with tumor progression, based on current literature and our own experience. SUMMARY Patients with metastatic, anaplastic lymphoma kinase-rearranged nonsmall cell lung cancer should be managed by interdisciplinary expert teams. New drugs with enhanced brain activity are available, and some patients may benefit from local therapies.
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24
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Garassino MC, Gadgeel S, Esteban E, Felip E, Speranza G, Domine M, Hochmair MJ, Powell S, Cheng SYS, Bischoff HG, Peled N, Reck M, Hui R, Garon EB, Boyer M, Wei Z, Burke T, Pietanza MC, Rodríguez-Abreu D. Patient-reported outcomes following pembrolizumab or placebo plus pemetrexed and platinum in patients with previously untreated, metastatic, non-squamous non-small-cell lung cancer (KEYNOTE-189): a multicentre, double-blind, randomised, placebo-controlled, phase 3 trial. Lancet Oncol 2020; 21:387-397. [PMID: 32035514 DOI: 10.1016/s1470-2045(19)30801-0] [Citation(s) in RCA: 106] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 11/22/2019] [Accepted: 11/26/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Pembrolizumab plus pemetrexed-platinum led to superior overall survival and progression-free survival, and a higher proportion of patients with a confirmed complete or partial response over placebo plus pemetrexed-platinum in the KEYNOTE-189 study. We aimed to evaluate prespecified exploratory patient-reported outcomes (PROs) in patients in KEYNOTE-189. METHODS In the multicentre, double-blind, randomised, placebo-controlled, phase 3 KEYNOTE-189 study done at 126 cancer centres in 16 countries, eligible patients aged 18 years or older with histologically or cytologically confirmed metastatic non-squamous non-small-cell lung cancer without sensitising EGFR or ALK alterations, measurable disease as per Response Evaluation Criteria in Solid Tumors (version 1.1), and an Eastern Cooperative Oncology Group performance status of 0 or 1 were enrolled. Patients were randomly assigned (2:1) to receive intravenous pembrolizumab (200 mg) or saline placebo every 3 weeks for up to 2 years (35 cycles); all patients received four cycles of intravenous pemetrexed (500 mg/m2) with carboplatin (5 mg/mL per min) or cisplatin (75 mg/m2; investigator's choice) every 3 weeks for four cycles, followed by pemetrexed maintenance therapy every 3 weeks. Permuted block randomisation (block size six) was done with an interactive voice-response system and stratified by PD-L1 expression, choice of platinum, and smoking status. Patients, investigators, and other study personnel were unaware of treatment assignment. The European Organisation for Research and Treatment of Cancer Quality-of-Life Questionnaire-Core 30 (QLQ-C30) and Lung Cancer 13 (QLQ-LC13) were administered at cycles 1-5, every three cycles thereafter during year 1, and every four cycles during years 2-3. The primary endpoints (overall survival and progression-free survival) have been published previously. Key PRO endpoints were change from baseline to week 12 (during chemotherapy) and week 21 (following chemotherapy) in QLQ-C30 global health status/quality of life (GHS/QOL) score, and time to deterioration in cough, chest pain, or dyspnoea. PROs were analysed in all randomly assigned patients who received at least one dose of study medication and who completed at least one PRO assessment, and the results are provided with two-sided, nominal p values. This ongoing study is registered with ClinicalTrials.gov, number NCT02578680. FINDINGS Between Feb 26, 2016, and March 6, 2017, 616 patients were enrolled; median follow-up was 10·5 months (range 0·2-20·4) as of data cutoff on Nov 8, 2017. 402 (99%) of 405 patients in the pembrolizumab plus pemetrexed-platinum group and 200 (99%) of 202 patients in the placebo plus pemetrexed-platinum-treated group completed at least one PRO assessment. At baseline, 359 (89%) of 402 patients in the pembrolizumab plus pemetrexed-platinum group and 180 (90%) of 200 in the placebo plus pemetrexed-platinum group were compliant with QLQ-C30; at week 12, 319 (90%) of 354 and 149 (89%) of 167 patients were compliant, respectively; and at week 21, 249 (76%) of 326 and 91 (64%) of 143 patients were compliant, respectively. From baseline to week 12, GHS/QOL scores were maintained with both pembrolizumab plus pemetrexed-platinum (least-squares mean change: 1·0 point [95% CI -1·3 to 3·2] increase) and placebo plus pemetrexed-platinum (-2·6 points [-5·8 to 0·5] decrease; between-group difference: 3·6 points [-0·1 to 7·2]; p=0·053). From baseline to week 21, GHS/QOL scores were better maintained with pembrolizumab plus pemetrexed-platinum (least-squares mean change: 1·3 points [95% CI -1·2 to 3·6] increase) than with placebo plus pemetrexed-platinum (-4·0 points [-7·7 to -0·3] decrease; between-group difference: 5·3 points [1·1 to 9·5]; p=0·014). Median time to deterioration in cough, chest pain, or dyspnoea was not reached (95% CI 10·2 months to not reached) with pembrolizumab plus pemetrexed-platinum, and was 7·0 months (4·8 months to not reached) with placebo plus pemetrexed-platinum (hazard ratio 0·81 [95% CI 0·60-1·09], p=0·16). INTERPRETATION The addition of pembrolizumab to standard chemotherapy maintained GHS/QOL, with improved GHS/QOL scores at week 21 in the pembrolizumab plus chemotherapy group compared with the placebo plus chemotherapy group. These data further support use of pembrolizumab plus pemetrexed-platinum as first-line therapy for patients with metastatic non-squamous non-small-cell lung cancer. FUNDING Merck Sharp & Dohme.
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Affiliation(s)
| | - Shirish Gadgeel
- Department of Medical Oncology 1, University of Michigan, Ann Arbor, MI, USA
| | - Emilio Esteban
- Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Enriqueta Felip
- Vall d'Hebron University, Vall d'Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | - Giovanna Speranza
- Centre Intégré de Cancérologie de la Montérégie, Hôpital Charles-Le Moyne, Greenfield Park, QC, Canada
| | - Manuel Domine
- Hospital Universitario Fundación Jiménez Díaz (IIS-FJD), Madrid, Spain
| | - Maximilian J Hochmair
- Department of Respiratory and Critical Care Medicine and Ludwig Boltzmann Institute for COPD and Respiratory Epidemiology, Vienna, Austria
| | | | | | | | - Nir Peled
- Clalit Health Services, Soroka Medical Center, Beer-Sheeva, Israel
| | - Martin Reck
- LungenClinic, Airway Research Center North, German Center for Lung Research, Grosshansdorf, Germany
| | - Rina Hui
- Westmead Hospital and University of Sydney, Sydney, NSW, Australia
| | - Edward B Garon
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | | | | | | | | | - Delvys Rodríguez-Abreu
- Complejo Hospitalario Universitario Insular Materno-Infantil de Gran Canaria, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
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Huang M, Tian Y, He M, Liu J, Ren L, Gong Y, Peng F, Wang Y, Ding Z, Wang J, Zhu J, Xu Y, Liu Y, Li L, Lu Y. Crizotinib versus chemotherapy: a real-world cost-effectiveness study in China. J Comp Eff Res 2020; 9:93-102. [PMID: 31958984 DOI: 10.2217/cer-2019-0075] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Aim: To assess the cost-effectiveness of crizotinib verses platinum-based doublet chemotherapy as the first-line treatment for anaplastic lymphoma kinase (ALK)-positive non-small-cell lung cancer (NSCLC) in the real-world setting. Methods: Data from 163 advanced ALK positive NSCLC patients were collected from West China Hospital, Sichuan University (Chengdu, China). They were categorized into two groups as treated with crizotinib (n = 83) or chemotherapy (n = 80) as a first-line therapy. The progression-free survival (PFS) as the primary clinical outcome, and the direct medical costs were collected from hospital information systems. Incremental cost-effectiveness ratio (ICER) was calculated with costs, quality-adjusted life-years, as well as the costs discounted at 3% annually. Additionally, two different kinds of medical insurance (MI) for pharma-economic assessment were considered. Results: Crizotinib improved PFS versus chemotherapy in ALK positive patients (median PFS 19.67 m vs 5.47 m; p < 0.001). Moreover, crizotinib obtained an ICER of US$36,285.39 before the end of 2016, when crizotinib, pemetrexed and anti-angiogenesis drugs were not MI covered. This is more than the willingness to pay threshold (three-times of gross domestic product per capita in mainland China or Sichuan Province). However, ICER was US$7321.16, which is less than willingness to pay, when crizotinib and all chemotherapy drugs were covered by MI from the end of 2016. Sensitivity analysis demonstrated a 99.7% probability for crizotinib to be more cost-effective than chemotherapy, when crizotinib and all anticancer drugs were MI covered. One-way sensitivity analysis for the reimbursement ratio of crizotinib indicated that cost-effective tendency for crizotinib increased as reimbursement ratio increased. Conclusion: Crizotinib could be an effective, and cost-effective first-line treatment for ALK positive advanced NSCLC with the MI coverage currently available in Chengdu, Sichuan Province, China.
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Affiliation(s)
- Meijuan Huang
- Department of Thoracic Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Yuke Tian
- Department of Thoracic Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Mingmin He
- Fengling Clinic, Wuhou, Chengdu 610041, China
| | - Juan Liu
- Fengling Clinic, Wuhou, Chengdu 610041, China
| | - Li Ren
- Department of Thoracic Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Youling Gong
- Department of Thoracic Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Feng Peng
- Department of Thoracic Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Yongsheng Wang
- Department of Thoracic Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Zhenyu Ding
- Department of Thoracic Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Jin Wang
- Department of Thoracic Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Jiang Zhu
- Department of Thoracic Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Yong Xu
- Department of Thoracic Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Yongmei Liu
- Department of Thoracic Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Lanting Li
- Shanghai Palan DataRx Co. Ltd, Shanghai 200051, China
| | - You Lu
- Department of Thoracic Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu 610041, China
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26
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Liu J, Zhao YQ, Han X, Hu XF, Wu HB, Chen LJ, Song YP. Correlation between pre-treatment serum carcinoembryonic antigen levels and genotypes in a large population of Chinese people with advanced lung adenocarcinoma. Intern Med J 2020; 49:634-643. [PMID: 30379408 DOI: 10.1111/imj.14152] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Revised: 10/18/2018] [Accepted: 10/20/2018] [Indexed: 01/22/2023]
Abstract
BACKGROUND A positive correlation between serum carcinoembryonic antigen (CEA) levels and epidermal growth factor receptor (EGFR) mutations has been reported in lung adenocarcinoma patients. AIM To investigate retrospectively whether serum CEA levels are also associated with genotypes in a large population of advanced lung adenocarcinoma. METHODS A large cohort of 701 patients with advanced lung adenocarcinoma was studied retrospectively. RESULTS EGFR mutations were found in 47.5% (333/701) of advanced lung adenocarcinoma patients, being identified at high frequencies in never-smokers, females, and in patients with abnormal pre-treatment serum CEA levels (53.1% vs 37.5%, P < 0.001). In contrast, anaplastic lymphoma kinase gene rearrangements were found in 7.8% (55/701) of patients, being identified at high frequencies in younger patients, and in patients with normal CEA levels (11.5% vs 5.8%, P = 0.012). Serum CEA levels were divided into four groups: <5, 5-19, 20-99 and ≥100 ng/mL. The rate of EGFR mutations significantly increased as the serum CEA levels increased (37.5%, 49.5%, 53.9% and 57.7%, respectively, P < 0.001). Anaplastic lymphoma kinase gene rearrangements showed the opposite result (11.5%, 7.1%, 5.7% and 4.1%, respectively, P = 0.044). A multivariate analysis revealed that higher pre-treatment serum CEA levels were independently associated with EGFR mutations (95% CI: 1.291-2.487, P < 0.001), but normal serum CEA levels were independently associated with anaplastic lymphoma kinase gene rearrangements (95% CI: 0.275-0.842, P = 0.010). CONCLUSION Our study demonstrated that a significant association exists between the serum CEA levels and genotypes in patients with advanced lung adenocarcinoma.
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Affiliation(s)
- Jie Liu
- Department of Internal Medicine, The Affiliated Tumor Hospital of Zhengzhou University, Zhengzhou, China
| | - Yan-Qiu Zhao
- Department of Internal Medicine, The Affiliated Tumor Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiao Han
- Department of Obstetrics and Gynaecology, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiu-Feng Hu
- Department of Internal Medicine, The Affiliated Tumor Hospital of Zhengzhou University, Zhengzhou, China
| | - Hong-Bo Wu
- Department of Internal Medicine, The Affiliated Tumor Hospital of Zhengzhou University, Zhengzhou, China
| | - Li-Juan Chen
- Department of Internal Medicine, The Affiliated Tumor Hospital of Zhengzhou University, Zhengzhou, China
| | - Yong-Ping Song
- Department of Hematology, The Affiliated Tumor Hospital of Zhengzhou University, Zhengzhou, China
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Mattar MS, Chang J, Benayed R, Halpenny D, Powers A, Kleiner DE, Drilon A, Kris MG. Complete Pathological Response to Crizotinib in a Patient with ALK-rearranged Lung Adenocarcinoma. Clin Lung Cancer 2020; 21:e25-e29. [PMID: 31690489 PMCID: PMC6996866 DOI: 10.1016/j.cllc.2019.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 09/09/2019] [Accepted: 10/01/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Marissa S Mattar
- Antitumor Assessment Core Facility, Molecular Pharmacology Program, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jason Chang
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Ryma Benayed
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Darragh Halpenny
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Astin Powers
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - David E Kleiner
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Alexander Drilon
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY.
| | - Mark G Kris
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
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Leighl NB, Karaseva N, Nakagawa K, Cho BC, Gray JE, Hovey T, Walding A, Rydén A, Novello S. Patient-reported outcomes from FLAURA: Osimertinib versus erlotinib or gefitinib in patients with EGFR-mutated advanced non-small-cell lung cancer. Eur J Cancer 2019; 125:49-57. [PMID: 31838405 DOI: 10.1016/j.ejca.2019.11.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 11/06/2019] [Indexed: 01/23/2023]
Abstract
BACKGROUND In the FLAURA trial, osimertinib demonstrated superior progression-free survival and a favorable toxicity profile to erlotinib or gefitinib as initial therapy in patients with EGFR-mutated advanced non-small-cell lung cancer. Patient-reported outcomes from FLAURA are discussed here. METHODS Patients (N = 556) completed the EORTC QLQ-LC13 weekly for 6 weeks, then every 3 weeks, and the QLQ-C30 every 6 weeks. Prespecified key symptoms were cough, dyspnea, chest pain, appetite loss, and fatigue. Score changes from baseline to randomized treatment discontinuation were assessed using a mixed-effects model. A ≥10-point change was considered clinically relevant. Odds of improvement and time to deterioration were investigated. QLQ-C30 functioning scores were assessed post hoc. RESULTS Questionnaire completion rates were >70% at most time points. Baseline mean scores were similar in the osimertinib and erlotinib/gefitinib arms. Scores improved in both arms, but none reached clinical relevance at 5% significance level. A statistically significant difference favoring osimertinib for chest pain was not clinically relevant (-6.84 vs -3.88; p = 0.021). Odds of improvement and time to deterioration were similar between treatments. In post hoc analyses, improvements favored osimertinib for emotional functioning (8.79 vs 4.91; p = 0.004) and social functioning (7.66 vs 1.74; p < 0.001). Cognitive functioning remained stable with osimertinib but deteriorated with erlotinib/gefitinib (0.03 vs -3.91; p = 0.005). CONCLUSIONS Key symptoms improved from baseline in both treatment arms in FLAURA. Key symptom improvements that were both statistically significant and clinically relevant were not observed in favor of either treatment arm. CLINICAL TRIAL REGISTRATION NCT02296125.
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Affiliation(s)
| | - Nina Karaseva
- City Clinical Oncology Dispensary, St. Petersburg, Russia
| | - Kazuhiko Nakagawa
- Department of Medical Oncology, Kindai University Faculty of Medicine, Osakasayama, Japan
| | - Byoung-Chul Cho
- Division of Medical Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jhanelle E Gray
- Department of Thoracic Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | | | | | | | - Silvia Novello
- Department of Oncology, University of Turin, Azienda Ospedaliero-Universitaria San Luigi Gonzaga, Turin, Italy.
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Pérol M, Pavlakis N, Levchenko E, Platania M, Oliveira J, Novello S, Chiari R, Moran T, Mitry E, Nüesch E, Liu T, Balas B, Konopa K, Peters S. Patient-reported outcomes from the randomized phase III ALEX study of alectinib versus crizotinib in patients with ALK-positive non-small-cell lung cancer. Lung Cancer 2019; 138:79-87. [DOI: 10.1016/j.lungcan.2019.10.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 10/01/2019] [Accepted: 10/05/2019] [Indexed: 12/25/2022]
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Li W, Bai R, Cui J. [Targeted Therapies for Driver Gene Mutation-positive Lung Cancer Patients with Brain Metastasis]. ZHONGGUO FEI AI ZA ZHI = CHINESE JOURNAL OF LUNG CANCER 2019; 22:719-726. [PMID: 31771742 PMCID: PMC6885421 DOI: 10.3779/j.issn.1009-3419.2019.11.06] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
脑是晚期肺癌转移最常见的部位,驱动基因阳性者脑转移发病率更高,肺癌脑转移患者预后较差,且不同治疗方式的选择影响肺癌脑转移患者的病程转归及预后。近年来,随着精准医学的发展,针对肺癌脑转移,尤其是具有特殊靶点的驱动基因阳性患者治疗方式的选择越来越成为人们的研究热点,并逐步取得进展。本文主要阐述了肺癌脑转移治疗存在的挑战,系统综述了驱动基因阳性肺癌脑转移的靶向治疗进展,以期在精准医学时代下,指导此类患者临床实践中个体化精准治疗方案的抉择。
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Affiliation(s)
- Wenqian Li
- Cancer Center, The First Hospital of Jilin University, Changchun 130021, China
| | - Rilan Bai
- Cancer Center, The First Hospital of Jilin University, Changchun 130021, China
| | - Jiuwei Cui
- Cancer Center, The First Hospital of Jilin University, Changchun 130021, China
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Van Der Weijst L, Lievens Y, Schrauwen W, Surmont V. Health-Related Quality of Life in Advanced Non-small Cell Lung Cancer: A Methodological Appraisal Based on a Systematic Literature Review. Front Oncol 2019; 9:715. [PMID: 31456938 PMCID: PMC6699450 DOI: 10.3389/fonc.2019.00715] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 07/18/2019] [Indexed: 12/24/2022] Open
Abstract
Background: The majority of lung cancer patients are diagnosed with advanced non-small cell lung cancer (NSCLC), the bulk of which receive palliative systemic treatment with the goal to provide effective symptom palliation and safeguard health-related quality of life (HRQoL). Advanced NSCLC trials with HRQoL endpoints face methodological constraints limiting interpretability. Objectives: We provide a comprehensive overview of recent clinical trials evaluating the impact of systemic therapies on HRQoL in advanced NSCLC, focusing on the methodological quality, with the ultimate goal to improve interpretation, comparison and reporting of HRQoL data. Methods: A systematic literature review was performed. Prospective studies published over the last decade evaluating the impact of systemic treatments on HRQoL in advanced NSCLC were included. Methodological quality of HRQoL reporting was assessed with the CONSORT-PRO extension. Results: Hundred-twelve manuscripts describing 85 trials met all criteria. No formal conclusion can be drawn regarding the impact on HRQoL of different treatments. We report an important variety in methodological quality in terms of definitions of HRQoL, missing data points, lack of standardization of analyzing and presenting HRQoL and no standard follow-up time. The quality of HRQoL data reporting varies substantially between studies but improves over time. Conclusion: This review shows that in the heterogeneous landscape of trials addressing HRQoL in advanced stage NSCLC. Methodology reporting remains generally poor. Adequate reporting of HRQoL outcome data is equally important to support clinical decision-making as to correctly inform health policy regarding direct approval and reimbursement of the new drugs and combinations that will come online.
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Affiliation(s)
| | - Yolande Lievens
- Department of Radiotherapy-Oncology, Ghent University Hospital, Ghent, Belgium
| | - Wim Schrauwen
- Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Veerle Surmont
- Department of Thoracic Oncology, Ghent University Hospital, Ghent, Belgium
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Hamilton G, Hochmair MJ. An evaluation of brigatinib as a promising treatment option for non-small cell lung cancer. Expert Opin Pharmacother 2019; 20:1551-1561. [PMID: 31328968 DOI: 10.1080/14656566.2019.1643839] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Introduction: Brigatinib is a second-line inhibitor for the treatment of rearranged anaplastic lymphoma kinase (ALK) in lung cancer patients which has significant activity against brain metastases. This tyrosine kinase inhibitor (TKI) overcomes a wide range of ALK mutations which confer therapeutic resistance and is increasingly applied in first-line therapy due to improved benefit for patients compared to crizotinib, the current standard of care. Areas covered: The authors review the development and characteristics of brigatinib and discuss the optimal clinical use and sequence of the application of ALK inhibitors in patients progressing under therapy. Expert opinion: ALK-rearranged NSCLC can be treated with a broad range of approved and novel inhibitors at various stages of therapy, including the second-line therapeutic brigatinib. Besides this TKI, the second-line ALK inhibitors alectinib and ceritinib, as well as the third-line lorlatinib are approved for the treatment of ALK-positive NSCLC patients. The main challenge is to find sequences and combinations of ALK inhibitors which provide the best benefit for the patients.
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Affiliation(s)
- G Hamilton
- Department of Surgery, Medical University of Vienna , Vienna , Austria
| | - M J Hochmair
- Respiratory Oncology Unit, Otto Wagner Hospital , Vienna , Austria
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Rouviere D, Veillon R, Chaltiel L, Simonneau Y, Filleron T, Milia J, Guibert N, Melloni B, Raherison C, Didier A, Mazieres J. [Management of non-small cell lung cancer patients harboring activating mutations and CNS progression]. Rev Mal Respir 2019; 36:583-590. [PMID: 31202602 DOI: 10.1016/j.rmr.2019.04.003] [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: 12/12/2016] [Accepted: 03/16/2019] [Indexed: 10/26/2022]
Abstract
The central nervous system (CNS), through carcinomatous meningitis or solid brain metastases, is the most common site of recurrence in non-small cell lung cancers (NSCLC) with activating mutations. Our retrospective study describes the population of patients with CNS metastases of NSCLC harboring activating mutation with targeted therapy (EGFR, ALK, BRAF, HER2) in 4 French regional reference hospitals. 60 patients were analyzed. The proposed treatments were heterogeneous and included combinations of chemotherapy, targeted therapy and radiotherapy±associated with topical treatments. Median overall survival following CNS metastasis in these patients was 15.8 months for meningitis carcinoma and 26 months for brain metastases. In patients with brain metastases, the addition of targeted therapy treatment allows a significant improvement in median progression free survival from 5.9 months to 10.6 months (HR 0.48 CI95 [0.24 to 0.97] P=0.035). These patients seem therefore benefit from systemic therapy and particularly targeted therapy with better survival than usual.
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Affiliation(s)
- D Rouviere
- Service de pneumologie, hôpital Larrey, université Paul Sabatier, CHU Toulouse, 31059 Toulouse, France
| | - R Veillon
- Service de pneumologie, CHU Bordeaux, 33604 Bordeaux, France
| | - L Chaltiel
- Institut universitaire du cancer, 31100 Toulouse, France
| | - Y Simonneau
- Service de pneumologie, CHU Limoges, 97042 Limoges, France
| | - T Filleron
- Institut universitaire du cancer, 31100 Toulouse, France
| | - J Milia
- Service de pneumologie, hôpital Larrey, université Paul Sabatier, CHU Toulouse, 31059 Toulouse, France
| | - N Guibert
- Service de pneumologie, hôpital Larrey, université Paul Sabatier, CHU Toulouse, 31059 Toulouse, France
| | - B Melloni
- Service de pneumologie, CHU Limoges, 97042 Limoges, France
| | - C Raherison
- Service de pneumologie, CHU Bordeaux, 33604 Bordeaux, France
| | - A Didier
- Service de pneumologie, hôpital Larrey, université Paul Sabatier, CHU Toulouse, 31059 Toulouse, France
| | - J Mazieres
- Service de pneumologie, hôpital Larrey, université Paul Sabatier, CHU Toulouse, 31059 Toulouse, France.
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Claxton L, O'Connor J, Woolacott N, Wright K, Hodgson R. Ceritinib for Untreated Anaplastic Lymphoma Kinase-Positive Advanced Non-Small-Cell Lung Cancer: An Evidence Review Group Evaluation of a NICE Single Technology Appraisal. PHARMACOECONOMICS 2019; 37:645-654. [PMID: 30298279 DOI: 10.1007/s40273-018-0720-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
The National Institute for Health and Care Excellence (NICE) invited the company that manufactures ceritinib (Zykadia®, Novartis) to submit evidence on the clinical and cost effectiveness of the drug, as a first-line treatment for adults with anaplastic lymphoma kinase (ALK)-positive (+) advanced non-small-cell lung cancer (NSCLC), as part of the Institute's single technology appraisal (STA) process. The CRD (Centre for Reviews and Dissemination) and CHE (Centre for Health Economics) Technology Assessment Group at the University of York was commissioned to act as the Evidence Review Group (ERG). This paper describes the Company's submission (CS), the ERG review and NICE's subsequent decisions. The evidence submitted in support of ceritinib, as the first-line treatment in ALK+ advanced NSCLC, was a phase III, international, multicentre, open-label randomised controlled trial (RCT) comparing ceritinib with pemetrexed/cisplatin plus pemetrexed maintenance therapy (chemotherapy [CT] group). The results indicated that ceritinib prolonged progression-free survival (PFS) compared with CT. The only comparator considered in the CS was crizotinib. The evidence selected in support of crizotinib was PROFILE 1014, an open-label RCT of crizotinib, compared with pemetrexed/cisplatin CT (without maintenance therapy), in previously untreated advanced or metastatic ALK+ NSCLC. The design and population of PROFILE 1014 was similar to that of ASCEND-4, though there were some differences between the trials. The Company considered it not possible to perform an 'anchor-based' analysis of first-line ceritinib and crizotinib, and presented a Matching-Adjusted Indirect Comparison (MAIC) of ceritinib and crizotinib using only the ALK inhibitor arm of ASCEND-4 and PROFILE 1014. The indirect comparison suggests that ceritinib may be more effective in prolonging PFS than crizotinib. The ERG agreed that an indirect comparison using only the ALK inhibitor arm of the trials was the only option available in the present assessment; however, a number of limitations and potential bias were identified in this analysis. The Company's model estimated that ceritinib was cost effective when compared with crizotinib. However, the ERG highlighted several concerns with the Company's analysis; the ERG's preferred base case estimated an incremental cost-effectiveness ratio of £69,255 per quality-adjusted life-year (no patient access scheme [PAS] included). The ERG considered the economic analysis to be sensitive to changes in assumption used, partly due to the due to the immaturity of the overall survival data from trials, which leads to uncertainty around the extrapolation used. The NICE Appraisal Committee concluded that ceritinib is recommended, within its marketing authorisation, as an option for untreated ALK+ advanced NSCLC in adults, if the Company provides it with the discount agreed in the PAS.
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Affiliation(s)
- Lindsay Claxton
- Centre for Reviews and Dissemination, University of York, York, YO10 5DD, UK.
| | - Joanne O'Connor
- Centre for Reviews and Dissemination, University of York, York, YO10 5DD, UK
| | - Nerys Woolacott
- Centre for Reviews and Dissemination, University of York, York, YO10 5DD, UK
| | - Kath Wright
- Centre for Reviews and Dissemination, University of York, York, YO10 5DD, UK
| | - Robert Hodgson
- Centre for Reviews and Dissemination, University of York, York, YO10 5DD, UK
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Ueno N, Banno S, Endo Y, Tamura M, Sugaya K, Hashigaki S, Ohki E, Yoshimura A, Gemma A. Treatment status and safety of crizotinib in 2028 Japanese patients with ALK-positive NSCLC in clinical settings. Jpn J Clin Oncol 2019; 49:676-686. [DOI: 10.1093/jjco/hyz049] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 04/09/2019] [Indexed: 12/12/2022] Open
Abstract
AbstractObjectivePost-marketing surveillance (PMS) was performed in Japan to obtain information on the safety and efficacy of crizotinib.MethodsTarget patients included almost all patients with anaplastic lymphoma kinase-positive non-small cell lung cancer who were administered crizotinib. The observation period was 52 weeks. In the present study, we focused on the treatment status and safety of crizotinib therapy and analyzed the real-world data obtained by this PMS (ClinicalTrials.gov: NCT01597258).ResultsThe safety analysis set included 2028 Japanese patients, and more than half of the patients (56.4%) were nonsmokers. The incidence of adverse drug reactions (ADRs) was 91.6%, and common ADRs (incidence ≥15%) were nausea (32.2%), diarrhea (24.3%), photopsia (18.9%), vomiting (17.5%) and dysgeusia (16.8%). Many patients (623 patients) discontinued treatment of crizotinib because of adverse events within 12 weeks after therapy initiation, which tended to frequently occur in the following cases: (1) elderly, (2) body weight <40 kg, (3) body surface area <1.2 m2 (4) ECOG PS 2–4, (5) higher Brinkman index and (6) history of occupational/environmental exposure such as asbestos/pneumoconiosis. The proportions of patients remaining on crizotinib therapy were 68.2% for 3 months, 55.2% for 6 months and 36.1% for 12 months, with a median duration of 7.9 months. Multivariate analysis with a Cox proportional hazard model identified 10 statistically significant patient background factors influencing the duration of crizotinib therapy.ConclusionsNo new safety concerns were observed in this PMS study. Our results provide useful information regarding the status of crizotinib therapy in the clinical setting.
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Affiliation(s)
- Naomi Ueno
- Pfizer Japan Inc, 3-22-7 Yoyogi, Shibuya-ku
| | | | | | | | | | | | - Emiko Ohki
- Pfizer Japan Inc, 3-22-7 Yoyogi, Shibuya-ku
| | | | - Akihiko Gemma
- Graduate School of Medicine, Nippon Medical School, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, Japan
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O'Kane GM, Su J, Tse BC, Tam V, Tse T, Lu L, Borean M, Tam E, Labbé C, Naik H, Mittmann N, Doherty MK, Bradbury PA, Leighl NB, Shepherd FA, Richard NM, Edelstein K, Shultz D, Brown MC, Xu W, Howell D, Liu G. The Impact of Brain Metastases and Associated Neurocognitive Aspects on Health Utility Scores in EGFR Mutated and ALK Rearranged NSCLC: A Real World Evidence Analysis. Oncologist 2019; 24:e501-e509. [PMID: 30952820 DOI: 10.1634/theoncologist.2018-0544] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Accepted: 03/07/2019] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND In lung cancer, brain metastases (BM) and their treatment are associated with high economic burden and inferior health-related quality of life. In the era of targeted therapy, real world evidence through health utility scores (HUS) is critical for economic analyses. MATERIALS AND METHODS In a prospective observational cohort study (2014-2016), outpatients with stage IV lung cancer completed demographic and EQ-5D-3L surveys (to derive HUS). Health states and clinicopathologic variables were obtained from chart abstraction. Patients were categorized by the presence or absence of BM; regression analyses identified factors that were associated with HUS. A subset of patients prospectively completed neurocognitive function (NCF) tests and/or the FACT-brain (FACT-Br) questionnaire, which were then correlated with HUS (Spearman coefficients; regression analyses). RESULTS Of 519 patients with 1,686 EQ-5D-3L-derived HUS, 94 (18%) completed NCF tests and 107 (21%) completed FACT-Br; 301 (58%) never developed BM, 24 (5%) developed first BM during study period, and 194 (37%) had BM at study entry. The sample was enriched (46%) for EGFR mutations (EGFRm) and ALK-rearrangements (ALKr). There were no HUS differences by BM status overall and in subsets by demographics. In multivariable analyses, superior HUS was associated with having EGFRm/ALKr (p < .0001), no prior radiation for extracranial disease (p < .001), and both intracranial (p = .002) and extracranial disease control (p < .01). HUS correlated with multiple elements of the FACT-Br and tests of NCF. CONCLUSION Having BM in lung cancer is not associated with inferior HUS in a population enriched for EGFRm and ALKr. Patients exhibiting disease control and those with oncogene-addicted tumors have superior HUS. IMPLICATIONS FOR PRACTICE In the setting of EGFR mutations or ALK rearrangement non-small cell lung cancer (NSCLC), a diagnosis of brain metastases no longer consigns the patient to an inferior health state suggesting that new economic analyses in NSCLC are needed in the era of targeted therapies. Additionally, the EQ-5D questionnaire is associated with measures of health-related quality of life and neurocognitive scores suggesting this tool should be further explored in prospective clinical studies.
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Affiliation(s)
- Grainne M O'Kane
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Jie Su
- Ontario Cancer Institute Biostatistics, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Brandon C Tse
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Vivian Tam
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Tiffany Tse
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Lin Lu
- Ontario Cancer Institute Biostatistics, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Michael Borean
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Emily Tam
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Catherine Labbé
- Centre de recherce de l'Institute universitarie de cardiologie et de pneumonologie de Quebec, University of Laval, Sherbrooke, Quebec, Canada
| | - Hiten Naik
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nicole Mittmann
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Mark K Doherty
- Medical Oncology and Hematology Division, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Penelope A Bradbury
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Natasha B Leighl
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Frances A Shepherd
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Nadine M Richard
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Kim Edelstein
- Gerry and Nancy Pencer Brain Tumor Centre, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - David Shultz
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - M Catherine Brown
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Wei Xu
- Ontario Cancer Institute Biostatistics, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Doris Howell
- Princess Margaret Cancer Centre Research Institute, Toronto, Ontario, Canada
| | - Geoffrey Liu
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
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Signorovitch J, Zhou Z, Ryan J, Anhorn R, Chawla A. Budget impact analysis of comprehensive genomic profiling in patients with advanced non-small cell lung cancer. J Med Econ 2019; 22:140-150. [PMID: 30430885 DOI: 10.1080/13696998.2018.1549056] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
AIMS Broad molecular profiling of patients with advanced non-small cell lung cancer (NSCLC) is strongly advised to optimize genomic matching with available targeted treatment options or investigational agents. Unlike conventional molecular diagnostic testing, or smaller hotspot panels, comprehensive genomic profiling (CGP) identifies genomic alterations across hundreds of clinically relevant cancer genes from a single tissue specimen. The present study sought to estimate the budget impact of increased use of CGP using a 324-gene panel (FoundationOne) vs non-CGP (represented by a mix of conventional molecular diagnostic testing and smaller NGS hotspot panels) and the number needed to test with CGP to gain 1 life year. MATERIALS AND METHODS A decision analytic model was developed to assess the budget impact of increased CGP in advanced NSCLC from a US private payer perspective. Model inputs were based on published literature (epidemiology and treatment outcomes), real-world data (testing and rates, medical service costs), list prices for CGP and anti-cancer drugs, and assumptions for clinical trial participation. RESULTS Among 2 million covered lives, 532 had advanced NSCLC; 266 underwent molecular diagnostic testing. An increase in CGP among those tested, from 2% to 10%, was associated with $0.02 per member per month budget impact, of which $0.013 was attributable to costs of prolonged drug treatment and survival and $0.005 to testing cost. Approximately 12 patients would need to be tested with CGP to add 1 life year. LIMITATIONS The model incorporated certain assumptions to account for inputs with a limited evidence profile and simplify the possible post-CGP treatments. CONCLUSIONS An increase in CGP utilization from 2% to 10% among patients with advanced NSCLC undergoing molecular diagnostic testing was associated with a modest budget impact, most of which was attributable to increased use of more effective treatments and prolonged survival.
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Affiliation(s)
| | - Zhou Zhou
- a Analysis Group, Inc. , Boston , MA , USA
| | - Jason Ryan
- b Foundation Medicine, Inc. , Cambridge , MA , USA
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Barlesi F, Garon EB, Kim DW, Felip E, Han JY, Kim JH, Ahn MJ, Fidler MJ, Gubens MA, de Castro G, Surmont V, Li Q, Deitz AC, Lubiniecki GM, Herbst RS. Health-Related Quality of Life in KEYNOTE-010: a Phase II/III Study of Pembrolizumab Versus Docetaxel in Patients With Previously Treated Advanced, Programmed Death Ligand 1-Expressing NSCLC. J Thorac Oncol 2019; 14:793-801. [PMID: 30711649 DOI: 10.1016/j.jtho.2019.01.016] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 12/19/2018] [Accepted: 01/25/2019] [Indexed: 12/12/2022]
Abstract
INTRODUCTION In the phase II/III KEYNOTE-010 study (ClinicalTrials.gov, NCT01905657), pembrolizumab significantly prolonged overall survival over docetaxel in patients with previously treated, programmed death ligand 1-expressing (tumor proportion score ≥ 1%), advanced NSCLC. Health-related quality of life (HRQoL) results are reported here. METHODS Patients were randomized 1:1:1 to pembrolizumab 2 or 10 mg/kg every 3 weeks or docetaxel 75 mg/m2 every 3 weeks. HRQoL was assessed using European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLC) Core 30 (C30), EORTC QLQ-Lung Cancer 13 (LC13), and EuroQoL-5D. Key analyses included mean baseline-to-week-12 change in global health status (GHS)/quality of life (QoL) score, functioning and symptom domains, and time to deterioration in a QLQ-LC13 composite endpoint of cough, dyspnea, and chest pain. RESULTS Patient reported outcomes compliance was high across all three instruments. Pembrolizumab was associated with better QLQ-C30 GHS/QoL scores from baseline to 12 weeks than docetaxel, regardless of pembrolizumab dose or tumor proportion score status (not significant). Compared with docetaxel, fewer pembrolizumab-treated patients had "deteriorated" status and more had "improved" status in GHS/QoL. Nominally significant improvement was reported in many EORTC symptom domains with pembrolizumab, and nominally significant worsening was reported with docetaxel. Significant prolongation in true time to deterioration for the QLQ-LC13 composite endpoint emerged for pembrolizumab 10 mg/kg compared to docetaxel (nominal two-sided p = 0.03), but not for the 2-mg/kg dose. CONCLUSIONS These findings suggest that HRQoL and symptoms are maintained or improved to a greater degree with pembrolizumab than with docetaxel in this NSCLC patient population.
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Affiliation(s)
- Fabrice Barlesi
- Multidisciplinary Oncology and Therapeutic Innovations Department, Aix Marseille University, Assistance Publique Hôpitaux de Marseille, Marseille, France.
| | - Edward B Garon
- David Geffen School of Medicine at University of California, Los Angeles, Santa Monica, California
| | - Dong-Wan Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Enriqueta Felip
- Vall d'Hebron University Hospital and Vall d'Hebron Institute of Oncology, Barcelona, Spain
| | - Ji-Youn Han
- Division of Translational & Clinical Research, National Cancer Center (Korea), Goyang-si, Republic of Korea
| | - Joo-Hang Kim
- Department of Medical Oncology, CHA Bundang Medical Center, CHA University, Gyeonggi-do, Republic of Korea
| | - Myung-Ju Ahn
- Division of Hematology and Oncology, Department of Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Mary Jo Fidler
- Division of Hematology Oncology, Rush University Medical Center, Chicago, Ilinois
| | - Matthew A Gubens
- University of California, San Francisco, Helen Diller Family Comprehensive Cancer Center, San Francisco, California
| | - Gilberto de Castro
- Clinical Oncology, Instituto do Cancer do Estado de Sao Paulo, Sao Paulo, Brazil
| | - Veerle Surmont
- Department of Respiratory Medicine/Thoracic Oncology, Universitar Ziekenhuis Ghent, Ghent, Belgium
| | - Qiao Li
- Biostatistics, Merck & Co., Inc., Kenilworth, New Jersey
| | - Anne C Deitz
- Center for Observational and Real-World Evidence, Merck & Co., Inc., Kenilworth, New Jersey
| | | | - Roy S Herbst
- Department of Medical Oncology, Yale School of Medicine, New Haven, Connecticut
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Abstract
The goal of the treatment of a disease has moved from treating organs and diseases through symptoms, biological parameters and imaging towards treating a human being as a whole. The treatments should deliver benefits that patients can personally perceive. However, the patient's perspective does not always match the one of those surrounding them. Illustratively, patients' symptom assessments are more predictable for daily health status, whereas clinicians' symptom measurements are more related to clinical outcomes. The term, patient-reported outcomes (PROs), includes any data that are reported directly by the patient without an intermediary, such as a family member or a healthcare professional. The use of PROs in oncology trials is increasing and the U.S. Food and Drug Administration has published guidelines on the review and evaluation of PROs. However, while PROs are increasingly used in clinical trials, they are rarely used in daily clinical practice. Further, healthcare payers are concerned with issues related to relevance, quality, and interpretability of these outcomes.
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Gemma A, Kusumoto M, Kurihara Y, Masuda N, Banno S, Endo Y, Houzawa H, Ueno N, Ohki E, Yoshimura A. Interstitial Lung Disease Onset and Its Risk Factors in Japanese Patients With ALK-Positive NSCLC After Treatment With Crizotinib. J Thorac Oncol 2018; 14:672-682. [PMID: 30521972 DOI: 10.1016/j.jtho.2018.11.022] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 11/21/2018] [Accepted: 11/24/2018] [Indexed: 12/19/2022]
Abstract
INTRODUCTION The study objective was to determine the incidence and characteristics of drug-induced interstitial lung disease (ILD) associated with an orally available small-molecule tyrosine kinase inhibitor, crizotinib, in a real-world clinical setting. METHODS Post-marketing surveillance was performed in Japan to obtain information on the safety and efficacy of crizotinib. Target patients included all patients with anaplastic lymphoma kinase-positive NSCLC who received crizotinib during the enrollment period between May 2012 and December 2014. The observation period was 52 weeks. Expert analysis of the ILD incidence was performed by an ILD independent review committee composed of five medical specialists. RESULTS The safety analysis set included 2028 patients, and more than half of the patients (56.4%) were nonsmokers. The incidence of ILD associated with crizotinib therapy was 5.77%; and 3.45% patients showed grade 3 or greater. Pulmonary edema-like shadows with or without diffuse alveolar damage pattern were observed in crizotinib-associated ILD (incidence: 0.39%), but a causal relationship with the prognosis could not be identified. ILD developed within 4 weeks from initiation of crizotinib administration in 41.9% and within 8 weeks in 69.2% of the patients. Age 55 years or older, Eastern Cooperative Oncology Group performance status 2-4, smoking history, previous or concomitant ILD, and comorbid pleural effusion were statistically determined as significant risk factors for crizotinib-induced ILD. CONCLUSIONS Crizotinib therapy should be applied to the NSCLC patients with any of above risk factors under a cautious monitoring for ILD occurrence, and clinicians should pay attention to the risks of severe ILD.
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Affiliation(s)
- Akihiko Gemma
- Graduate School of Medicine, Nippon Medical School, Tokyo, Japan.
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Jung D, Han JM, Yee J, Kim JY, Gwak HS. Factors affecting crizotinib-induced hepatotoxicity in non-small cell lung cancer patients. Med Oncol 2018; 35:154. [DOI: 10.1007/s12032-018-1213-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 10/24/2018] [Indexed: 11/25/2022]
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Paracha N, Abdulla A, MacGilchrist KS. Systematic review of health state utility values in metastatic non-small cell lung cancer with a focus on previously treated patients. Health Qual Life Outcomes 2018; 16:179. [PMID: 30208899 PMCID: PMC6134713 DOI: 10.1186/s12955-018-0994-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 08/08/2018] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Health state utility values (HSUVs) are an important input to economic evaluations and the choice of HSUV can affect the estimate of relative cost-effectiveness between interventions. This systematic review identified utility scores for patients with metastatic non-small cell lung cancer (mNSCLC), as well as disutilities or utility decrements relevant to the experience of patients with mNSCLC, by treatment line and health state. METHODS The MEDLINE®, Embase and Cochrane Library databases were systematically searched (September 2016) for publications describing HSUVs in mNSCLC in any treatment line. The EQ-5D website, the School of Health and Related Research Health Utilities Database (ScHARRHUD) and major pharmacoeconomic and clinical conferences in 2015-2016 were also queried. Studies in adults with previously treated mNSCLC were selected for further analysis. The information extracted included study design, description of treatment and health state, respondent details, instrument and tariff, HSUV or (dis) utility decrement estimates, quality of study, and appropriateness for use in economic evaluations. RESULTS Of 1883 references identified, 36 publications of 34 studies were included: 19 reported EQ-5D scores; eight reported HSUVs from valuations of vignettes made by members of the public using standard gamble (SG) or time trade-off (TTO); two reported SG or TTO directly elicited from patients; two reported EQ-5D visual analogue scale scores only; one reported Assessment of Quality of Life instrument scores; one reported HSUVs for caregivers to patients with mNSCLC using the 12-item Short-Form Health Survey; and one estimated HSUVs based on expert opinion. The range of HSUVs identified for comparable health states showed how differences in study type, tariff, health state and the measures used can drive variation in HSUV estimates. CONCLUSIONS This systematic review provides a set of published HSUVs that are relevant to the experience of adult patients previously treated for mNSCLC. Our review begins to address the challenge of identifying reliable estimates of utility values in mNSCLC that are suitable for use in economic evaluations, and also highlights how varying estimates result from differences in methodology.
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Affiliation(s)
| | - Ahmed Abdulla
- F. Hoffmann-La Roche AG, Basel, Switzerland
- Present address: Digipharm, Zug, Switzerland
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Ou SHI, Socinski MA, Gadgeel S, Gandhi L, West H, Chiappori AA, Cohen V, Riely GJ, Smoljanovic V, Bordogna W, Wright E, Debusk K, Zeaiter A, Shaw AT. Patient-reported outcomes in a phase II, North American study of alectinib in patients with ALK-positive, crizotinib-resistant, non-small cell lung cancer. ESMO Open 2018; 3:e000364. [PMID: 30018815 PMCID: PMC6045737 DOI: 10.1136/esmoopen-2018-000364] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 04/12/2018] [Accepted: 04/13/2018] [Indexed: 12/14/2022] Open
Abstract
Background In a phase II North American study (NP28761; NCT01871805), the anaplastic lymphoma kinase (ALK) inhibitor alectinib demonstrated both systemic and central nervous system (CNS) efficacy with good tolerability in patients with ALK-positive non-small cell lung cancer. We describe patient-reported outcomes (PROs) from the NP28761 study. Patients and methods PROs and health-related quality of life (HRQoL) benefits were assessed using two self-administered questionnaires (the European Organisation for Research and Treatment of Cancer 30-Item Quality of Life Questionnaire-Core (EORTC QLQ-C30), and the 13-item EORTC QLQ-lung cancer-specific module) at enrolment and every 6 weeks until week 66, disease progression or death. Results Clinically meaningful mean improvements (≥10 point change from baseline) were observed in 10 domains, including global health status (GHS), role and social functioning, fatigue, pain, dyspnoea, and appetite loss. A clinically meaningful improvement was observed in GHS from the first assessment (6 weeks) until week 60. Alectinib demonstrated a rapid effect, with a median time to symptom improvement, using the composite endpoint of cough, dyspnoea and pain in the chest, of 1.4 months (6.1 weeks) (95% CI 1.4 to 1.6) and a median time to symptom deterioration of 5.1 months (22.1 weeks) (95% CI 2.8 to 6.8). Patients with CNS metastases at baseline experienced comparable HRQoL over the duration of the study as patients without CNS metastases. Exploratory analysis showed that the occurrence of an objective response may be associated with a better HRQoL. Conclusions Patients treated with alectinib in this phase II study achieved clinically meaningful improvements in HRQoL and symptoms and had delayed time to symptom deterioration.
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Affiliation(s)
- Sai-Hong Ignatius Ou
- Department of Medicine Division of Hematology-Oncology, University of California Irvine School of Medicine, Chao Family Comprehensive Cancer Center, Orange, California 92868, USA.
| | | | - Shirish Gadgeel
- Department of Medicine, Division of Hematology-Oncology, University of Michigan, Ann Arbor, Michigan, USA
| | - Leena Gandhi
- Perlmutter Cancer Center, New York University School of Medicine, New York City, New York, USA
| | - Howard West
- Swedish Cancer Center, Seattle, Washington, USA
| | | | - Victor Cohen
- Peter Brojde Lung Cancer Centre, Jewish General Hospital, Montreal, Quebec, Canada
| | - Gregory J Riely
- Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | | | | | | | | | | | - Alice T Shaw
- Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, USA
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Rybarczyk-Kasiuchnicz A, Ramlau R. Current views on molecularly targeted therapy for lung cancer - a review of literature from the last five years. KARDIOCHIRURGIA I TORAKOCHIRURGIA POLSKA = POLISH JOURNAL OF CARDIO-THORACIC SURGERY 2018; 15:119-124. [PMID: 30069193 PMCID: PMC6066673 DOI: 10.5114/kitp.2018.76478] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 02/25/2018] [Indexed: 12/26/2022]
Abstract
Lung cancer is the main cause of cancer-related deaths in Poland. Epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) are a new group of agents for non-small-cell lung cancer (NSCLC) patients. Determining the predictive value of activating mutations in the EGFR and ROS-1 genes and ALK rearrangement in non-small-cell lung cancer has enabled the identification of patients likely to achieve true clinical benefits. EGFR-TKIs may produce objective response in more than 60% of patients and prolong progression-free survival to 10 months in mutation-positive patients. No improvement of overall survival was shown in randomized trials. The era of immunotherapy implementing PD-1 and PD-L1 inhibitors has changed the face of lung cancer therapy. We aimed to review the literature on the use of EGFR-TKIs and immunotherapeutic agents for NSCLC patients.
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Affiliation(s)
| | - Rodryg Ramlau
- Department of Oncology and Pulmonology, Poznan University of Medical Sciences, Poznan, Poland
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Bertranou E, Bodnar C, Dansk V, Greystoke A, Large S, Dyer M. Cost-effectiveness of osimertinib in the UK for advanced EGFR-T790M non-small cell lung cancer. J Med Econ 2018; 21:113-121. [PMID: 28880737 DOI: 10.1080/13696998.2017.1377718] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
AIM This study presents the cost-utility analysis that was developed to inform the NICE health technology assessment of osimertinib vs platinum-based doublet chemotherapy (PDC) in patients with EGFR-T790M mutation-positive non-small cell lung cancer (NSCLC) who have progressed on epidermal growth factor receptor-tyrosine kinase inhibitor (EGFR-TKI) therapy. METHODS AND MATERIALS A partitioned survival model with three health states (progression-free, progressed disease, and death) from a UK payer perspective and over lifetime (15 years) was developed. Direct costs included disease management, treatment-related (acquisition, administration, monitoring, adverse events), and T790M testing costs. Efficacy and safety data were taken from clinical trials AURA extension and AURA2 for osimertinib and IMPRESS for PDC. An adjusted indirect treatment comparison was applied to reduce the potential bias in the non-randomized comparison. Parametric functions were utilized to extrapolate survival beyond the observed period. Health state utility values were calculated from EQ-5D data collected in the trials and valued using UK tariffs. Resource use and costs were based on published sources. RESULTS Osimertinib was associated with a gain of 1.541 quality-adjusted life-years (QALYs) at an incremental cost of £64,283 vs PDC (incremental cost-effectiveness ratio [ICER]: £41,705/QALY gained). Scenario analyses showed that none of the plausible scenarios produced an ICER above £44,000 per QALY gained, and probabilistic sensitivity analyses demonstrated a 63.4% probability that osimertinib will be cost-effective at a willingness-to-pay threshold of £50,000. LIMITATIONS The analysis is subject to some level of uncertainty inherent to phase 2 single-arm data and the immaturity of the currently available survival data for osimertinib. CONCLUSIONS Osimertinib may be considered a cost-effective treatment option compared with PDC in the second-line setting in patients with EGFR-T790M mutation-positive NSCLC from a UK payer perspective. Further data from the ongoing AURA clinical trial program will reduce the inherent uncertainty in the analysis.
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Abstract
Lung cancer is the number one cause of cancer-related death in both men and women. However, over the last few years, we have witnessed improved outcomes that are largely attributable to early detection, increased efforts in tobacco control, improved surgical approaches, and the development of novel targeted therapies. Currently, there are several novel therapies in clinical practice, including those targeting actionable mutations and more recently immunotherapeutic agents. Immunotherapy represents the most significant step forward in eradicating this deadly disease. Given the ever-changing landscape of lung cancer management, here we present an overview of the most recent advances in the management of non-small cell lung cancer.
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Affiliation(s)
- Samira Shojaee
- Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University, Richmond, USA
| | - Patrick Nana-Sinkam
- Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University, Richmond, USA
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Brahmer JR, Rodríguez-Abreu D, Robinson AG, Hui R, Csőszi T, Fülöp A, Gottfried M, Peled N, Tafreshi A, Cuffe S, O'Brien M, Rao S, Hotta K, Zhang J, Lubiniecki GM, Deitz AC, Rangwala R, Reck M. Health-related quality-of-life results for pembrolizumab versus chemotherapy in advanced, PD-L1-positive NSCLC (KEYNOTE-024): a multicentre, international, randomised, open-label phase 3 trial. Lancet Oncol 2017; 18:1600-1609. [DOI: 10.1016/s1470-2045(17)30690-3] [Citation(s) in RCA: 222] [Impact Index Per Article: 31.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 08/10/2017] [Accepted: 08/14/2017] [Indexed: 12/23/2022]
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Shelikhova LN, Fominykh VV, Abramov DS, Myakova NV, Maschan MA, Maschan AA. [Use of crizotinib for refractory ALK-positive lymphomas]. TERAPEVT ARKH 2017; 89:51-56. [PMID: 28766541 DOI: 10.17116/terarkh201789751-56] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
AIM To evaluate the safety and efficacy of crizotinib used in pediatric patients with relapsed or refractory ALK-positive anaplastic large-cell lymphoma (ALCL). SUBJECTS AND METHODS The paper describes the experience with crizotinib used in 8 patients with refractory ALK-ALCL before and after allogeneic hematopoietic stem cell transplantation (HSCT). RESULTS All the 8 (100%) patients treated with crizotinib were recorded to have complete responses, including complete metabolic ones (tumor disappearance as evidenced by positron emission tomography (PET)/computed tomography. CONCLUSION Low and manageable toxicity of crizotinib and complete PET-negative responses in patients with resistant ALK lymphomas favor the need to test the drug as first-line therapy, by possibly decreasing the intensification of chemotherapy.
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Affiliation(s)
- L N Shelikhova
- Dmitry Rogachev Federal Research and Practical Center of Pediatric Hematology, Oncology, and Immunology, Ministry of Health of Russia, Moscow, Russia
| | - V V Fominykh
- Dmitry Rogachev Federal Research and Practical Center of Pediatric Hematology, Oncology, and Immunology, Ministry of Health of Russia, Moscow, Russia
| | - D S Abramov
- Dmitry Rogachev Federal Research and Practical Center of Pediatric Hematology, Oncology, and Immunology, Ministry of Health of Russia, Moscow, Russia
| | - N V Myakova
- Dmitry Rogachev Federal Research and Practical Center of Pediatric Hematology, Oncology, and Immunology, Ministry of Health of Russia, Moscow, Russia
| | - M A Maschan
- Dmitry Rogachev Federal Research and Practical Center of Pediatric Hematology, Oncology, and Immunology, Ministry of Health of Russia, Moscow, Russia
| | - A A Maschan
- Dmitry Rogachev Federal Research and Practical Center of Pediatric Hematology, Oncology, and Immunology, Ministry of Health of Russia, Moscow, Russia
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Wang Z, Yang S, Lu H. Preoperative serum carcinoembryonic antigen levels are associated with histologic subtype, EGFR mutations, and ALK fusion in patients with completely resected lung adenocarcinoma. Onco Targets Ther 2017; 10:3345-3351. [PMID: 28744138 PMCID: PMC5511014 DOI: 10.2147/ott.s134452] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Background Serum carcinoembryonic antigen (CEA) is often elevated in lung adenocarcinoma, but not in all patients. Meanwhile, epidermal growth factor receptor (EGFR) mutations and anaplastic lymphoma kinase (ALK) fusion protein are the main driving forces in lung adenocarcinoma. However, whether CEA levels are associated with histologic subtype, EGFR mutations, and ALK fusion remain largely unclear. Methods Preoperative serum CEA levels, postoperative histologic subtypes, and statuses of EGFR mutations and ALK fusion protein were retrospectively assessed in 442 patients with completely resected lung adenocarcinoma treated from January 2014 to December 2015 at Zhejiang Cancer Hospital, People’s Republic of China. Results EGFR mutations were found in 69.9% (309/442) of lung adenocarcinoma patients, and ALK fusion protein in 4.5% (20/442). EGFR mutations occurred more frequently in the lepidic subtype (P=0.001). High preoperative serum CEA levels (CEA >20 ng/mL) were independently associated with EGFR mutations (P<0.001). Moreover, in patients with CEA levels of 21–49 ng/mL, the EGFR mutation rate was 88.2%, which was higher compared to those obtained in the other subgroups. In addition, all specimens were invasive adenocarcinoma, with lepidic (18.6%), papillary (15.4%), acinar (52.7%), solid (9.7%), micropapillary (3.2%), and mucinous predominant (0.4%) subtypes; CEA levels in patients with the solid subtype were higher than those of other histologic subtypes (P=0.001). Conclusion Preoperative serum CEA levels can serve as a reference marker to identify the histologic subtype, and EGFR mutation or ALK fusion protein status, in lung adenocarcinoma patients. Moreover, histological subtypes could also predict EGFR mutations.
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Affiliation(s)
| | | | - Hongyang Lu
- Zhejiang Key Laboratory of Diagnosis and Treatment Technology on Thoracic Oncology (Lung and Esophagus), Zhejiang Cancer Hospital, Hangzhou.,Department of Oncology, Wenzhou Medical University, Wenzhou, People's Republic of China
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Brown J, Cook K, Adamski K, Lau J, Bargo D, Breen S, Chawla A. Utility values associated with advanced or metastatic non-small cell lung cancer: data needs for economic modeling. Expert Rev Pharmacoecon Outcomes Res 2017; 17:153-164. [PMID: 28335636 DOI: 10.1080/14737167.2017.1311210] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Cost-effectiveness analyses often inform healthcare reimbursement decisions. The preferred measure of effectiveness is the quality adjusted life year (QALY) gained, where the quality of life adjustment is measured in terms of utility. Areas covered: We assessed the availability and variation of utility values for health states associated with advanced or metastatic non-small cell lung cancer (NSCLC) to identify values appropriate for cost-effectiveness models assessing alternative treatments. Our systematic search of six electronic databases (January 2000 to August 2015) found the current literature to be sparse in terms of utility values associated with NSCLC, identifying 27 studies. Utility values were most frequently reported over time and by treatment type, and less frequently by disease response, stage of disease, adverse events or disease comorbidities. Expert commentary: In response to rising healthcare costs, payers increasingly consider the cost-effectiveness of novel treatments in reimbursement decisions, especially in oncology. As the number of therapies available to treat NSCLC increases, cost-effectiveness analyses will play a key role in reimbursement decisions in this area. Quantifying the relationship between health and quality of life for NSCLC patients via utility values is an important component of assessing the cost effectiveness of novel treatments.
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Affiliation(s)
- Jacqueline Brown
- a Global Patient Outcomes and Real World Evidence , Eli Lilly and Company , Windlesham , UK
| | - Keziah Cook
- b Analysis Group, Inc , Menlo Park , CA , USA
| | | | - Jocelyn Lau
- b Analysis Group, Inc , Menlo Park , CA , USA
| | - Danielle Bargo
- c UK Health Outcomes and HTA team , Eli Lilly and Company Limited , Basingstoke , Hampshire , UK
| | - Sarah Breen
- c UK Health Outcomes and HTA team , Eli Lilly and Company Limited , Basingstoke , Hampshire , UK
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