Those are factors that we are considering, but a lot of times it comes down to the patient. Some of these drugs have different side effects than others, which needs to be considered in terms of their comorbidities.
What is the status of osimertinib?
Osimertinib is approved if you have an acquired T790M mutation, which is resistance acquired following first-line TKIs with the EGFR
-mutated population. The FLAURA study that was just presented at the 2017 ESMO Congress showed that using frontline osimertinib may have some prolonged PFS benefit. We may see that move up, but it is not currently approved in the first-line setting. It is not even approved in the second-line setting if you do not have the T790M demonstrated.
What additional information would you like to add about this evolving paradigm?
In addition to the treatments that I have mentioned and advanced disease, I presented some data on oligometastatic disease, which is a population of patients who we encounter frequently in advanced lung cancer. These are patients who usually have fewer than 5 metastatic lesions. We have data from a study published in The Lancet Oncology
in December 2016 by our group that looked at chemotherapy followed by localized treatment for the oligometastatic sites. Those patients have a better survival than those who were kept on maintenance therapy alone.
We are now looking at incorporating immunotherapy into that in a trial. The point to keep in mind is that there are patients with oligometastatic disease for which surgery or radiation, as part of their treatment after systemic therapy, might still be worth considering. It is not for everyone, but it is something that the right patient might benefit from.
The newer movement with the targeted agents, such as alectinib versus crizotinib and the osimertinib advances, are exciting areas. There are some changes on the horizon coming soon. There are new drugs being tested, as well. We have changed NSCLC into a more chronic illness and, although it is not curable, we have a lot more treatment options compared with 10 or 15 years ago.
Ramalingam S, Reungwetwattana T, Chewaskulyong B, et al. Osimertinib vs standard of care (SoC) EGFR-TKI as first-line therapy in patients (pts) with EGFRm advanced NSCLC: FLAURA. In: Proceedings from the 2017 ESMO Congress; September 9-12, 2017; Madrid, Spain. Abstract LBA2_PR.