Dr Bazhenova on Perioperative Treatment Selection in EGFR– or ALK-Mutated NSCLC

Lyudmila A. Bazhenova, MD, medical oncologist, professor, medicine, the University of California San Diego (UCSD) Moores Cancer Center, discusses factors to consider when navigating the use of neoadjuvant vs adjuvant EGFR– and ALK-directed treatment strategies for patients with non–small cell lung cancer (NSCLC) who express oncogenic drivers.

Patients harboring EGFR mutations and ALKrearrangements exhibit limited responses with immunotherapy-based regimens, Bazhenova begins. In such cases, neoadjuvant chemoimmunotherapy or adjuvant immunotherapy is not generally recommended. Instead, patients typically proceed to surgery, Bazhenova explains. Neoadjuvant chemotherapy may instead be appropriate for patients with stage III cancers, she adds. Adjuvant osimertinib (Tagrisso) should be offered to patients following the completion of neoadjuvant therapy, Bazhenova emphasizes.

Osimertinib is currently approved by the FDA as adjuvant therapy following resection for patients with NSCLC whose tumors express EGFR exon 19 deletions or exon 21 L858R mutations, Bazhenova states. This approval was supported by the overall survival benefit seen with adjuvant osimertinib in the phase 3 ADAURA trial (NCT02511106).

Additionally, the TKI alectinib (Alecensa) may provide patients with early-stage ALK-positive NSCLC with a viable adjuvant therapy, Bazhenova continues. Promising data from the phase 3 ALINA trial (NCT03456076) demonstrated that adjuvant alectinib significantly improved disease-free survival vs platinum-based chemotherapy in this population. These findings could support the agent's FDA approval in the adjuvant setting, she says.

Ultimately, clinicians should aim to conduct thorough testing for EGFR mutations and ALK rearrangements in patients with NSCLC prior to the selection of a neoadjuvant strategy, as treatment decisions hinge on the presence or absence of these specific abnormalities, Bazhenova concludes.