The European Commission has approved brigatinib for the first-line treatment of patients with ALK-positive metastatic non–small cell lung cancer.
Sanjay Popat, BSc MBBS FRCP PhD
The European Commission has approved brigatinib (Alunbrig) for the first-line treatment of patients with  ALK-positive metastatic non—small cell lung cancer (NSCLC).1
The approval is based on the phase III ALTA-1L trial, in which treatment with brigatinib demonstrated a 57% reduction in the risk of disease progression or death compared with crizotinib (Xalkori) in patients with advanced  ALK-positive NSCLC who had not received a prior ALK inhibitor.2,3
Two-year investigator-assessed results, which were presented during the 2019 ESMO Asia Congress, showed that brigatinib led to a 76% (HR, 0.24; 95% CI, 0.12-0.45) reduction in the risk of disease progression or death in newly diagnosed patients who had brain metastases at time of enrollment.
With the 2-year follow-up data, the trial’s results were evaluated and reported by study investigators as well as a blinded independent review committee (BIRC). At the data cutoff for the second interim analysis, which was June 28, 2019, results showed that by BIRC assessment, there was a 51% reduction in the risk of disease progression or death with brigatinib over crizotinib (HR, 0.49; 95% CI, 0.35-0.68; log-rank  P <.0001).
“Patients with ALK-positive NSCLC, particularly those who have developed brain metastases, have been in need of additional treatment options that are proven effective in the first-line setting,” Sanjay Popat, BSc, MBBS, FRCP, PhD, consultant medical oncologist at The Royal Marsden NHS Foundation Trust, stated in a press release. “As brigatinib has shown superiority compared to crizotinib in this setting, including in patients whose disease has spread to the brain, this approval is an important advancement for these patients and gives physicians in the European Union another choice when addressing the needs of ALK-positive NSCLC patients.”
In the international, open-label, comparative, multicenter, phase III ALTA-1L trial, investigators compared the efficacy and safety of brigatinib with crizotinib in 275 patients with stage IIIB/IV  ALK-positive NSCLC who have not received prior treatment with an ALK inhibitor, but may have received ≤1 prior regimen of chemotherapy in the advanced setting.
The investigators randomized patients 1:1 to receive either 180 mg of brigatinib once daily (n = 137), with a 7-day lead-in period at 90 mg, or 250 mg of crizotinib twice daily (n = 138). Crossover from the crizotinib arm to receive brigatinib was permitted at BICR-assessed progression-free survival (PFS).
The median age was 59 years, and 55% of patients were female. Twenty-nine percent had brain metastases at baseline with comparable pre-enrollment central nervous system (CNS) radiotherapy rates among both cohorts. Overall, 27% of patients had prior chemotherapy in the locally advanced or metastatic setting.
The primary endpoint was BICR-assessed PFS, and secondary endpoints included objective response rate (ORR) per RECIST v1.1 criteria, intracranial ORR, intracranial PFS, overall survival (OS), safety, and tolerability.
At the first interim analysis, results showed that brigatinib reduced the risk of disease progression or death by 51% compared with crizotinib (HR, 0.49; 95% CI, 0.33-74; P  = .0007).3,4 At a follow-up of 25 months in the intent-to-treat population, the investigator-assessed median PFS was 29.4 months (95% CI, 21.2—not estimated [NE]) and 9.2 months (95% CI, 7.4-12.9) with brigatinib and crizotinib, respectively. The BIRC-assessed median PFS was 24.0 months (95% CI, 18.5–NE) with brigatinib and 11.0 months (95% CI, 9.2-12.9) for crizotinib.
When assessed by BICR, the confirmed ORR was 74% with brigatinib and 62% for crizotinib; the median duration of response (DOR) was not reached (95% CI, 19.4—NE) and 13.8 months (95% CI, 9.3-8) with brigatinib and crizotinib, respectively. When assessed by BICR, brigatinib reduced the risk of intracranial disease progression or death by 69% in patients with brain metastases at baseline (HR, 0.31; 95% CI, 0.17-0.56). The median intracranial PFS was 24 months compared with 5.6 months for crizotinib; the median PFS was not reached with brigatinib and was 5.9 months with crizotinib, as assessed by investigators.
Additionally, the confirmed intracranial ORR for patients with measurable brain metastases at baseline was 78% for patients treated with brigatinib and 26% for those who received crizotinib. The median intracranial DOR in confirmed responders with measurable brain metastases at baseline was not reached with brigatinib and 9.2 months with crizotinib, respectively.
Patients on the brigatinib arm also experienced significant improvements in health-related quality of life (HRQoL). Brigatinib led to a delayed median time to worsening in Global Health Score (GHS)/QoL score (≥10-point worsening in score) by 27 months versus 8 months with crizotinib.
Moreover, the duration of improvement in GHS/QoL with brigatinib was not reached versus 12 months with crizotinib. Brigatinib also delayed time to worsening and prolonged duration of improvement in multiple subscales such as fatigue, nausea and vomiting, appetite loss, and emotional and social functioning.
In the United States, the FDA previously granted a priority review designation to a supplemental New Drug Application (sNDA) for brigatinib for use in the same setting. Under the Prescription Drug User Fee Act, the action date for the sNDA is June 23, 2020.