New Biological Insights and Recent Therapeutic Advances in the Management of Lung Cancer: A Clinical Investigator Think Tank
An 82-year-old man with advanced NSCLC has a VeriStrat® assay performed and experiences durable benefit from erlotinib
5:06 minutes.
TRANSCRIPTION:
DR CARBONE: Okay. So this is an 82-year-old who presented with bilateral lung cancer, EGFR-, KRAS- and ALK-negative. And he was felt not to be a candidate for doublet chemotherapy, so he was treated first line with single-agent pemetrexed and received quite a benefit from that and tolerated it for 18 cycles. He received a little radiation to a progressing lesion. And so he had progressive disease in surveillance after the radiation, and we were looking for what to treat him with next. And again, he’s in his mideighties by now. And we sent a VeriStrat test, which was good. And he was started on erlotinib and has had at least arrest of his progression. He had clear progressive disease before starting, and then he’s now been stable on it for another 6 months. DR LOVE: Corey, any thoughts about this case and about the use of erlotinib in wild-type disease and whether or not, in your practice, the VeriStrat assay is something you ever use? DR LANGER: So we have to remember back that erlotinib’s original approval was in the broad population, essentially mostly unselected patients, most of whom, in retrospect, were wild type. Granted, it was a strongman control. It was a placebo control in a second- and third-line setting, something we’d never do in actual clinical practice. But it did show a survival advantage. It showed a PFS advantage. It showed a response advantage. It showed those advantages in squamous cell, smokers, males. So I do use it, not commonly, but on occasion. And I have, in the last 6 to 12 months, probably in about 8 to 10 patients, used the VeriStrat test to determine whom I will not use it on, because I think it basically tells us where chemo might be better. It doesn’t tell us where erlotinib is superior. DR LOVE: And I’m just kind of curious. If it had been VeriStrat poor, what would you have done in this man? DR CARBONE: I think decided between palliative care and another single agent, single-agent paclitaxel or something at that point. DR LOVE: So Jeff, what about this question of EGFR TKI in wild-type disease and the issue of the VeriStrat test? DR OXNARD: I’m more likely to use an IV weekly chemo in a patient like that, where I actually have the chance of a real response, and I don’t think — there are lot of toxicities that are real in an elderly patient. And this trial does not tell me that there’s a population where erlotinib’s better. It merely says it’s a toss-up. And I don’t find that I have a lot of patients who are saying, “No. Please. I want a pill that will give me rash and diarrhea.” They want a drug that’s going to give them the best chance of a benefit or they want to not get treatment and just be on supportive care. DR LOVE: Mark, what are your thoughts about this? And what about the younger patient? Again, do you use erlotinib in wild-type disease, and do you use the VeriStrat? DR KRIS: I don’t and I don’t. However, I think the test should be used, actually. For those physicians like Corey, who feels that it’s helpful, I think it’s helpful in getting the drug to the right person. Or at least helps you along that way. So I think the test should be used for those situations. I agree with Jeff. I tend to go with chemotherapy, personally, but I think the test should be around for those people like Corey who choose to treat wild-type patients with erlotinib. DR TSAO: So I actually do still treat wild type with erlotinib. I actually will, on occasion, give erlotinib maintenance in squamous cell after 4 cycles of cisplatin/docetaxel, if they’ve had a nice response. I think sometimes you can stabilize their disease for longer periods of time. Do I use VeriStrat? No, mostly because I’m at MD Anderson. We usually have a lot of other competing research studies. But do I think it should be used by people? Absolutely. I think there are quite a few people who find it helpful. DR LOVE: What about afatinib, Anne, in wild-type disease? DR TSAO: I haven’t done that. DR LOVE: Do we know anything about it? Are there any data, Jeff, out there? DR OXNARD: There is a randomized trial in squams, afatinib versus erlotinib, which showed slightly more favorable data. The question is, is erlotinib the standard regimen for squams or would you rather use a mild weekly chemo? If we think of erlotinib as a slightly dirty drug, afatinib is an even dirtier drug, can hit a number more targets and maybe that makes it a little more active. But for my practice, since I don’t use erlotinib in these patients, it doesn’t really move the bar. |