Howard L. “Jack” West, MD
The use of EGFR tyrosine kinase inhibitors (TKIs)—such as erlotinib (Tarceva), afatinib (Gilotrif), and gefitinib (Iressa)—has become a go-to first-line approach for patients with EGFR
-mutated non–small cell lung cancer (NSCLC).
, West, who is the medical director of the Thoracic Oncology Program at the Swedish Cancer Institute, discusses the benefits of EGFR TKIs in NSCLC, challenges with determining optimal sequencing, and potential combinations on the horizon.
OncLive: Please discuss some of the available EGFR TKI’s for patients with NSCLC.
: Looking at the issue of what is the best EGFR TKI in the first-line setting, there have been more than 6 clinical trials that have looked at a different EGFR TKI versus conventional chemotherapy. They have all found the same result: that there's a markedly higher and significantly better response rate and progression-free survival (PFS) with any of these EGFR TKI's, whether it's a first-generation inhibitor like gefitinib or erlotinib, or a second-generation irreversible inhibitor like afatinib.
In the end, I would say it's a range of choices without a clear best answer. The toxicity profile of gefitinib is the most benign and erlotinib is somewhere between gefitinib and afatinib. Afatinib has the highest rate of toxicities, such as diarrhea, stomatitis, paramecia, and rash. Therefore, it depends on a patient's and physician’s discussion of whether they want to pursue efficacy that is likely a little bit better with afatinib, but with a greater toxicity challenge.
Do you have a preferred regimen you use in frontline?
I would say that, in the United States, erlotinib is the most commonly pursued option. I use that on a lot of my patients. I have many patients with activating EGFR
mutations who have been on a combination of erlotinib and bevacizumab (Avastin) for 18 months or 2 years. Some people object that it's medicalizing things, since you need to come in every 3 weeks and go to the infusion center.
... to read the full story