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Progress Continues in EGFR+ NSCLC Paradigm

Caroline Seymour
Published: Monday, Jul 16, 2018

Charu Aggarwal, MD, MPH
Charu Aggarwal, MD, MPH
Recent progress in the treatment paradigm for EGFR-mutant non–small cell lung cancer (NSCLC) includes the FDA’s frontline approval of osimertinib (Tagrisso) and priority review designation for dacomitinib, both of which have demonstrated longer progression-free survival (PFS) and overall survival (OS) outcomes versus standard therapy, said Charu Aggarwal, MD.

“This is such an exciting time to be a lung cancer oncologist because we are making tremendous progress in the treatment of the subset of patients with EGFR-mutant lung cancer,” said Aggarwal.

The FDA approved osimertinib in April 2018 as a frontline treatment for patients with NSCLC whose tumors harbor EGFR mutations (exon 19 deletions or exon 21 L858R substitution mutations), based on results from the phase III FLAURA trial.1

At the 2018 ASCO Annual Meeting, OS data with dacomitinib were presented from the phase III ARCHER 1050 trial. In the study, the median OS was 34.1 months in patients randomized to dacomitinib versus 26.8 months in those randomized to gefitinib (Iressa).2 Based on results from the ARCHER 1050 trial, dacomitinib was granted an FDA priority review designation in April 2018 as a first-line agent for patients with EGFR-positive NSCLC.

Moreover, regimens are being explored with antiangiogenic inhibitors for this patient population, primarily combinations with bevacizumab (Avastin).

In an interview during the 2018 OncLive® State of the Science SummitTM on Lung Cancer, Aggarwal, an assistant professor of Medicine at University of Pennsylvania, discussed the latest developments in EGFR-mutant lung cancer.

OncLive: Can you discuss recent advances in EGFR-mutant NSCLC?

Aggarwal: I spoke about the preferential use of osimertinib (Tagrisso), which is our third-generation tyrosine kinase inhibitor (TKI) in the first-line setting. That offers patients a tremendous opportunity to live longer, as well as avoid some of the other side effects with first- or second-generation TKIs.

I also discussed new data from the 2018 ASCO Annual Meeting. There were data on dacomitinib, which is an oral TKI. Patients were randomized against the use of gefitinib, which is one of our first-generation TKIs. PFS data were presented at the 2017 ASCO Annual Meeting. This year, we heard about OS data, which was simultaneously published in the Journal of Clinical Oncology. The data show an improvement in OS compared with gefitinib. However, in my opinion, it's being compared with a nonrelevant first-line therapy. I'm not sure if there is a clear role [for dacomitinib] moving forward. Still, it was an interesting and well-conducted trial.

There were a couple of trials that evaluated the use of antiangiogenic agents in the treatment of patients with EGFR-mutant NSCLC, mainly with bevacizumab. These trials looked at combinations in the upfront setting in chemotherapy-naïve and previously untreated patients with EGFR-mutant NSCLC. There were improvements in PFS. One of the trials reported consistent benefit across all subtypes. However, it's being compared with lorlatinib, which is not our current favorite and most-used agent in the United States.

I wanted to highlight the trial [from the meeting] that looked at triplet therapy. We have become so used to using triplet therapy in the upfront treatment of lung cancer, but that's a different triplet of chemotherapy plus immunotherapy. What if we were to use chemotherapy in combination with a TKI for EGFR-mutant lung cancer?

In fact, the authors of this Japanese study showed that you can delay progression by more than 20 months and make a dent in OS. The OS improvement was quite significant at 52 months. These are definitely data that should be looked at more carefully. It added more toxicity as we can imagine. There was more myelosuppression and the usual chemotherapy-related side effects, but they combined it with gefitinib which is well tolerated. These are data worth looking at.

I also highlighted some of the data with regard to emerging resistance mechanisms. We all know about T790M, but as we start using osimertinib upfront, T790M may no longer be an escape mechanism of resistance. We are finding different resistance mechanisms, such as MET amplification, small cell transformation, and HER2. We are even finding mutations such as C797S, which resensitizes patients to the use of first- and second-line EGFR TKIs. It underscores the importance of rebiopsy to best figure out the next approach. It also begs the question of what is going on with these patients at the time of resistance.

For MET amplification, MET inhibitors are being used. For small cell lung cancer, we recommend chemotherapy. There are interesting combination approaches that are being evaluated.

View Conference Coverage
Online CME Activities
TitleExpiration DateCME Credits
Online Medical Crossfire®: 5th Annual Miami Lung Cancer ConferenceMay 30, 20196.5
Community Practice Connections™: Working Group for Changing Standards in EGFR-Mutated Lung Cancers: Real-World Applications of the Evidence for NursesJun 29, 20191.5
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