Global Perspectives in the Treatment of EGFR-mutant Resectable and Advanced NSCLC - Episode 5
Perspectives on optimal treatment approaches for patients with resectable non–small cell lung cancer in Asia, with a focus on stage IB disease.
Tony S.K. Mok, MD: Let’s come back to talk about module 2, which is on the adjuvant situation. There’s a lot of new stuff coming out on early stage disease, including immunotherapy, and also last year with the ADAURA study. It’s ground shaking for the whole adjuvant world for lung cancer. Why don’t we start with a bit about the standard of practice of resectable lung cancer in China, Korea, and Japan? This time, why don’t I start with China? Let’s start with Yi-Long. What’s the standard practice for resectable lung cancer in China?
Yi-Long Wu, MD, PhD: For resectable lung cancer, the guidelines indicate that for stage I and stage II patients, the standard of care is adjuvant chemotherapy. Sometimes called high-risk stage IB patients are also recommended to totally shift to adjuvant chemotherapy. Personally, in stage IB, I don’t give the patient any adjuvant chemotherapy. Since the CTONG 1104/ADJUVANT trial was published in 2017 and Chinese guidelines approved in 2018, if the patient has the EGFR mutation at N1-N2, the patient could augment adjuvant gefitinib as the adjuvant treatment. Also, osimertinib could become the adjuvant chemotherapy. In 2021, the ADAURA trial published in China also approved it as the adjuvant treatment.
Tony S.K. Mok, MD: I will get you talk a bit more about ADAURA in just a moment. Let’s hold the details for the time being, because I want you to talk about it in a moment. Shun, is there anything different in your place from what Yi-Long says?
Shun Lu, MD, PhD: Generally it’s the same, but for the stage 1B, in some high-risk…patients, we’ll recommend adjuvant chemotherapy. Besides what Yi-Long mentioned, first-generation icotinib, based on the study of evidence, was already approved by the Chinese CDE [Center for Drug Evaluation] as an adjuvant setting for stage II to stage III EGFR-mutant non–small cell lung cancer. We actually have 2 TKIs [tyrosine kinase inhibitors] approved for the adjuvant setting, for not only osimertinib but also icotinib.
Tony S.K. Mok, MD: We’ll have an interesting discussion about third vs first generation on adjuvant setting in just a moment, so stay put on that. In Korea?
Myung-Ju Ahn, MD: They’re basically the same. All the patients who resected, from stage IB to IIIA, should receive the adjuvant chemotherapy first line as long as the patient has a good performance. But in terms of stage IB…we select patients with 4 cm of the tumor. For those patients who are high risk, we give adjuvant chemotherapy. Also, in terms of EGFR-mutant patients, osimertinib is the only approved drug as adjuvant, but it’s not reimbursed unfortunately.
Tony S.K. Mok, MD: Japan, any difference?
Tetsuya Mitsudomi, MD, PhD: We have UFT, tegafur-uracil. That adjuvant therapy was approved for stage IB; now it’s IA. Without lymph node metastasis, we use UFT for 2 years. In stage II or III adjuvant with the cisplatin doublet, usually people use the cisplatin vinorelbine. We had the study comparing cisplatin vinorelbine with cisplatin pemetrexed. To our disappointment, cisplatin pemetrexed was not good. It was no better than cisplatin vinorelbine. The routine use is cisplatin vinorelbine. Osimertinib is not approved in Japan as an adjuvant therapy, so we can’t use any TKI for EGFR-mutated patients.
Tony S.K. Mok, MD: You have to elaborate on what UFT is. Most people outside Japan may not know.
Tetsuya Mitsudomi, MD, PhD: That’s the derivative of 5-FU [5-fluororacil]. The tegafur-uracil adds the uracil, which will enhance the effect of the tegafur. That’s what I know.
Tony S.K. Mok, MD: Across the board in Asia, that’s standard practice. But let me focus a little on the controversial point: stage IB. I heard from more than 1 of you that you select by size, based on a CALGB [Cancer and Leukemia Group B] study and on common sense. However, there are some data from awhile back that use a genomic prediction. There’s a company in the United States called Razor Genomics that uses a gene profile based on retrospective data from China to predict the worst outcome of their patient according to their genomic profile. Do you think we can use genomic data to decide whether patients should receive adjuvant chemotherapy?
Myung-Ju Ahn, MD: I agree, but those data should be validated prospectively. That’s my opinion. All the data is retrospective.
Tetsuya Mitsudomi, MD, PhD: I don’t know the details of that test, but recently the [INAUDIBLE] presented data of the itacitinib, which increased the user [INAUDIBLE] expression pool. So it’s a customized therapy. Unfortunately, the curve is separated, but there’s no significant difference. We don’t have a reliable genomic test to indicate that it’s a legitimate therapy.
Yi-Long Wu, MD, PhD: We have no solid evidence to start using the genome 5 to select the patient for the adjuvant chemotherapy. In clinical practice, we’re by the stage, not by the gene profile for adjuvant chemotherapy.
Tony S.K. Mok, MD: Thank you. I agree with all of you. That study is nice and intuitive, but it’s not prospective validated, so I don’t think that’s sufficient for clinical use either.
Transcript edited for clarity.