New Biological Insights and Recent Therapeutic Advances in the Management of Lung Cancer: A Clinical Investigator Think Tank
Targeted agents versus whole brain radiation therapy for patients with asymptomatic EGFR- or ALK-mutant CNS metastases
2:26 minutes.
TRANSCRIPTION:
DR OXNARD: Routinely, for patients with an EGFR mutation. EGFR TKIs can have great CNS penetration, if they’re small, subcentimeter, asymptomatic brain mets. Patients can actually have a durable CNS response. You can delay whole brain radiation for years sometimes in these patients, especially elderly patients, where whole brain has serious side effects. And I’m increasingly doing that for ALK as well now, trying to delay radiation with its associated toxicities. DR LOVE: Anne, agree or disagree? DR TSAO: I think with the ALK patients, I would use ceritinib, since there’s better CNS penetration. I wouldn’t use crizotinib in that setting. For the EGFR mutants, I have not done that, while usually if it’s multiple brain mets, I will give whole brain ahead of time and then start with erlotinib. DR LANGER: Asymptomatic small lesions with minimal vasogenic edema, I’d certainly approach these folks with a TKI up front. Our patients are living longer, so the consequences, the sequelae of whole brain radiation becomes more and more important over time. DR SPIGEL: Yes. I agree with Corey. Asymptomatic, especially with drugs like ceritinib, I mean, we see these benefits all the time. DR LOVE: So you think there’s a difference clinically, ceritinib versus crizotinib, in terms of brain? DR SPIGEL: Yes. I’m not sure that’s been borne out in the data, but at least clinically, that seems to be the case. We all have patients who’ve been now 1, 2 years out, never got radiation therapy and, at diagnosis, had lesions. DR LOVE: Mark? What about this issue of a targeted therapy with brain mets? DR KRIS: There is no blood-brain barrier when you have a lesion. Blood-brain barrier is gone, so if something’s going to work, it’s going to work. I happen to be taught by Jerome Posner, probably the father of neuro-oncology, and he always encouraged us to give whatever systemic therapy we had first in an asymptomatic patient, be it chemo or be it a targeted therapy. And I’ve embraced that. And if it works in the chest, it’ll work in the head. DR CARBONE: I totally agree with the discussion, though it may, in the community, be difficult to give ceritinib first line in the brain met setting, just because it’s not approved in that setting. DR LOVE: I was going to ask about that. Have you been able to access ceritinib first line, Anne? DR TSAO: I haven’t had a situation where I’ve had an outpatient present like this. DR OXNARD: Crizotinib can cause CNS response. I mean, you have to be vigilant. You have to be careful, but it is possible. DR CARBONE: So personally, I would start with crizotinib, follow closely and then switch if I see progression. |