Global Perspectives in the Treatment of EGFR-mutant Resectable and Advanced NSCLC - Episode 9
In light of evolving treatment options for resectable non–small cell lung cancer, panelists discuss biomarker testing to guide adjuvant therapy in the postoperative setting.
Tony S.K. Mok, MD: Let’s ask 1 other basic question before we end. Should we routinely do molecule testing on resectable lung cancer? If so, is it just EGFR or more than EGFR? Just say in your practice now, what will you be testing in the adjuvant setting opposed resection tumor. What are the molecular testing that you do? Lu Shun?
Shun Lu, MD, PhD: At least I will test the EGFR, but besides EGFR also will test the ALK. Actually, the ALK study patient enrollment is already finished, but some patients for the ALK-positive relapse quickly in adjuvant chemotherapy. So I will test not only EGFR, but also ALK.
Tony S.K. Mok, MD: Let me put you right on the spot, you’re referring to the ALINA study. The data will not be out for a little while, but if you got [an] ALK-positive patient in your hand, stage IIB, would you give an ALK inhibitor?
Shun Lu, MD, PhD: I will select the patient. After the chemotherapy I will use it.
Tony S.K. Mok, MD: So in other words, you are implicating the ADAURA data in the ALK situation?
Shun Lu, MD, PhD: Yeah because the ALK patients [are] usually multiple N2 positive. So they usually progress quickly. So I will select a patient, not all the patients.
Tony S.K. Mok, MD: All right, let me shift to Japan. Will you be allowed to do that at all in Japan? Then I’ll ask Korea in just a moment.
Tetsuya Mitsudomi, MD, PhD: So we can’t use the ALK inhibitor or even osimertinib after the surgery. We can’t use the gefitinib, osimertinib, alectinib, any of these kind of drugs after the surgery. It’s not approved and not reimbursed. So that rule is very strict in Japan.
Tony S.K. Mok, MD: I see. So in other words, there’s no real reason for you to use molecular testing at all.
Tetsuya Mitsudomi, MD, PhD: So there’s some people that do the testing in case the patient has a recurrent disease. So the probability of the recurrence is high in some patients with advanced disease. Then people start to do the regular testing using the resected specimens. But that’s only for after the recurrence.
Tony S.K. Mok, MD: So in other words, you do not do the routine testing upfront because there is no adjuvant TKI [tyrosine kinase inhibitor] available.
Tetsuya Mitsudomi, MD, PhD: Some people do, if the patient has a relatively advanced stage, but that’s not for the advanced. That’s for the treatment for the after the recurrence. That’s a Japanese routine.
Tony S.K. Mok, MD: OK, in Korea?
Myung-Ju Ahn, MD: We used to be [the same] as Japan, but since the ADAURA data we routinely test for the EGFR, ALK, and PD-L1. So we just to prepare for when they relapse. Even though the ALK—the TKI was not, we don’t have any data, but I think the ALK adjuvant treatment will be positive just like ADAURA. So that’s my opinion.
Tony S.K. Mok, MD: All right. Next morning, you got 1 patient stage IIB ALK positive, will you give ALK inhibitor?
Myung-Ju Ahn, MD: As adjuvant? No. Not yet.
Tony S.K. Mok, MD: Have you done that in your practice so far?
Myung-Ju Ahn, MD: No, no.
Tony S.K. Mok, MD: I actually have confronted the situation a couple times. It’s sometimes a bit difficult for 2 reasons. No. 1, ALK inhibitor is not entirely risk free. There’s still some ILD [interstitial lung disease] associated with it. No. 2, we don’t really know the duration. We cannot just implicate or just say 3 years. So in a way I think Lu Shun is also correct that, yes, there’s high risk of recurrence. On the other hand, how best to give it? We just don’t have those data on hand yet. So it’s a bit risky. Let’s go back to China. Yi-Long, will you do the same as Lu Shun to consider molecular testing in the adjuvant setting? Also, would you give ALK inhibitor for ALK-positive resectable lung cancer?
Yi-Long Wu, MD, PhD: Yeah, so for all the guidelines, we don’t recommend the patient test ALK in the adjuvant setting. We only recommend the patient test the EFGR. So this is a not the guideline or the indication. In clinical practice for the ALK, I think in this part I only [INAUDIBLE] patients who receive the adjuvant chemotherapy. We want to find the results from the ALINA trial. Then they will come to a decision. So far, we only give the patient the adjuvant chemotherapy.
Transcript edited for clarity.