Sai-Hong Ignatius Ou, MD, PhD
Novel targeted therapies against ALK, BRAF, and RET have demonstrated promising outcomes in molecularly-defined patients with non-small cell lung cancer (NSCLC), according to a collection of phase II studies presented at the 2015 ASCO Annual Meeting.
In the first study, the second-generation ALK inhibitor alectinib demonstrated robust activity in patients with ALK-positive NSCLC following progression on crizotinib (Xalkori), including those with central nervous system metastases.1
In data presented from the phase II trial, alectinib showed an overall response rate (ORR) of 50%, with a duration of response of 11.2 months.
In another study presented during the oral abstract session, the combination of the BRAF inhibitor dabrafenib (Tafinlar) and the MEK inhibitor trametinib (Mekinist) showed promising efficacy and a tolerable safety profile, in a single-arm phase II study. The ORR with the combination was 68% by independent review in patients with BRAFV600E
In a third analysis, the multikinase inhibitor cabozantinib demonstrated responses in a relatively rare population of patients with RET
-rearranged lung adenocarcinoma.3
In this phase II study, responses were seen in 38% of patients with this rare alteration, which is present in approximately 1% to 2% of individuals with lung cancer.
Alectinib Shows CNS Activity
The highly selective oral ALK inhibitor alectinib has potent clinical activity against many of the clinically relevant acquired resistance mutations that render crizotinib ineffective, according to the study presented by Sai-Hong Ignatius Ou, MD, PhD.
This activity allows alectinib to be highly effective following crizotinib resistance. Additionally, alectinib has demonstrated activity in the central nervous system (CNS), which is a common site of progression for patients treated with crizotinib.
In the phase II study, 122 crizotinib-pretreated patients were evaluable for response. The median age of patients was 51.6 years and 60% had baseline central nervous system (CNS) metastases. Most patients (80%) had received prior chemotherapy.
The median progression-free survival (PFS) with alectinib was 8.9 months (95% CI, 5.6-11.3). The ORR in the full population of patients was 50%, which consisted of all partial responses (PR). The stable disease rate was 35%, for a total disease control rate of 96% (95% CI, 70.6-85.6).
"Alectinib achieved a robust response rate in crizotinib-resistant patient populations, a majority of whom received a platinum-based chemotherapy," Ou, a health science associate clinical professor at the University of California, Irvine, said during his presentation.
In all patients enrolled in the study with CNS metastases, the CNS-specific ORR was 57.1%, with a complete response (CR) rate of 27.4%. In those with untreated CNS metastases, the CR rate was 43.5%.
"The disease control rate in the CNS was excellent, with a sustained median duration of 10.3 months," Ou commented. "These data taken together may signal a new standard of care for CNS metastases in ALK-positive non-small cell lung cancer."
Grade 3/4 adverse events were relatively infrequent. Dose reductions due to adverse events were required in 8.7% of patients. Dose delays or interruptions were needed in 19.6% of patients.
"More than 90% of patients were able to tolerate alectinib without dose reductions," Ou said.
In a second study being presented at the ASCO meeting, treatment with alectinib demonstrated an ORR of 47.8%.4
In patients with CNS metastases, the ORR was 68.8% in this study, with a median duration of response of 7.5 months.
Genentech, the company developing alectinib in the United States, plans to submit results from the two clinical trials presented at ASCO to the FDA for a potential approval for patients with ALK-positive NSCLC. Alectinib was approved in Japan for this indication last year, under the name Alecensa.
The phase III ALEX study is comparing alectinib with crizotinib in chemotherapy-naive patients with ALK-positive NSCLC. In this study, alectinib will be administered at 600 mg twice daily with food. The study hopes to enroll 286 patients, with early results expected in 2018.
BRAF Plus MEK in BRAF-mutant NSCLC
Findings from the first 33 patients enrolled in a phase II study investigating the combination of dabrafenib and trametinib were presented by Bruce E. Johnson, MD, during the oral abstract session. In this study, dabrafenib was administered at 150 mg twice daily and trametinib was given at 2 mg once daily for patients with previously treated BRAFV600E
Bruce E. Johnson, MD
By investigator assessment, ORR was 63% (comprised of all PRs). The stable disease rate was 25% leading to a disease control rate of 88% (95% CI, 67.6-97.3). In those reviewed independently, the ORR was 68% (all PRs) and the disease control rate was 86% (95% CI, 65.1-97.1).