Frontline Choice With Chronic Kidney Disease and Prior Thrombosis

Wade Iams, MD, MSCI, of Tennessee Oncology, works through regimen selection for a retired man with stage IVB lung adenocarcinoma, an EGFR L858R mutation, multiple bone metastases, chronic kidney disease stage 3a, and a remote provoked deep vein thrombosis (DVT). He tells Edgardo Santos, MD, FACP, FASCO, of Starling Oncology, that the patient’s wish to avoid frequent visits makes him briefly consider osimertinib monotherapy, but detectable circulating tumor DNA and symptomatic disease push him toward a combination. Comparing amivantamab plus lazertinib with platinum-based chemotherapy plus osimertinib, he notes that the former front-loads dosing and then moves to every 4 weeks, while chemotherapy means roughly 8 to 9 months of every-3-week visits. Chronic kidney disease and cumulative fatigue argue against chemotherapy. He considers the remote DVT and aspirin manageable, and names facial and scalp rash as the main trade-off. Dr Santos raises diabetes and steroid exposure.