In resectable NSCLC, the consequence of
Even when treated with adjuvant chemotherapy, the majority of resectable stage IB-III NSCLC patients will have a recurrence or will have died within 5 years1*
5-YEAR RECURRENCE OR DEATHIn a separate study, the 2016 IASLC database shows that 5-year survival rates in NSCLC are as follows: stage I, 68-92%; stage II, 53-60%; stage III, 13-36%; stage IV, 0-10%.2
A lung cancer diagnosis is associated with factors that may increase psychological distress, and clinical studies have shown that metastatic disease has physical consequences for patients.3,4‡§
~40% of patients treated with adjuvant chemotherapy recur with metastatic NSCLC5||
It’s critical to help prevent metastatic recurrence*Postoperative adjuvant cisplatin-based chemotherapy is recommended in patients with completely resected stage II-IIIA and, subject to postoperative evaluation to assess benefits and risks, selected patients with stage IB disease.6 Pooled clinical analysis demonstrated that postoperative adjuvant cisplatin-based chemotherapy was associated with a 16% disease-free survival risk reduction and 5% overall survival benefit at 5 years.1 †Resectable patients. ‡Linden et al (2012) included 10,153 patients across cancer types, including lung cancer, who were screened with the Psychosocial Screen for Cancer questionnaire at diagnosis.3 §In Trippoli et al (2001), SF-36 and EuroQoL questionnaires were utilized in 95 patients in 15 Italian hospitals. Patients with metastasis had significantly lower scores for physical functioning, P=0.009; bodily pain, P=0.016.4 IIThe study included a total of 1867 stage I-III patients with 932 randomly assigned to the chemotherapy group and 935 to the control (no chemotherapy) group. Of the total population, 36% presented with stage I, 24% with stage II, and 40% with stage III disease. Of the 284 patients in the chemotherapy group and 288 patients in the control group assigned to receive adjuvant radiotherapy, only 70.4% and 84.2%, respectively, received the treatment.5,7
NSCLC is not a single disease—know the driver
In resectable NSCLC, disease may recur as metastases throughout the body even after resection8,9*
EGFR mutations lead to unregulated proliferation and survival of tumor cells, making EGFR a key driver of disease regardless of stage10-13*Chouaid et al (2018) conducted a retrospective observational study in 831 patients with complete resection of stage IB-IIIA NSCLC with no information on EGFRm status. Of the 831 patients, 200 experienced metastatic recurrence during the observed study follow-up period.9 †Prevalence of EGFR mutations in adenocarcinoma were based on data from 4 references; Sholl et al (2015) performed mutation analysis on 1007 specimens with confirmed diagnosis of stage I-IV lung adenocarcinoma; Jones et al (2019) analyzed genomic differences across pathologic stages I-III in an unspecified number of patients with lung adenocarcinoma; D’Angelo et al (2012) analyzed tumor specimens from a cohort of 1118 patients with stage I-III surgically resected lung adenocarcinomas; and Jordan et al (2017) analyzed tumors from 860 patients with stage IV lung adenocarcinoma.11,12,14,15
Refer all resectable patients, test every surgical specimen. Test and confirm EGFR mutation status early on
DISCUSS Adjuvant treatment and testing with patients
INVOLVE A MEDICAL ONCOLOGIST Refer patients to a medical oncologist as early as possible
TEST FOR EGFR MUTATIONS AT RESECTION Ensure every surgical specimen is tested for EGFR mutations
A strong partnership between surgeons and medical oncologists helps establish optimal care for patients.
In metastatic NSCLC
Smoking history, race, and gender are irrelevant—any patient may have an EGFR mutation16*
CLINICOPATHOLOGIC FEATURES IN EGFRm PATIENTS TREATED WITH EGFR TKIs (N=1151)*EGFR TKI prescription data from Flatiron Health EHR-derived database. Included 1151 patients who started treatment between October 1, 2017, and April 30, 2020.16
In metastatic NSCLC
In metastatic NSCLC
In metastatic NSCLC, EGFRm is one of a number of actionable mutations that can be treated with targeted therapy.15,17,18
PD-L1 positive does not mean EGFR mutation negative
Up to 70% of EGFRm patients also express at least 1% PD-L119-23
Treatment-naïve metastatic EGFRm NSCLC patients were excluded in 11 pivotal first-line immunotherapy trials25-36
Don’t settle for unknown molecular status. Test and confirm mutational status in every eligible metastatic patient
In metastatic NSCLC
Liquid biopsy plus tissue testing are critical to help find as many metastatic EGFRm NSCLC patients as possibleIf liquid biopsy comes back negative, reflex to tissue biopsy.42 *TAT is for next-generation sequencing.
Use liquid biopsy + tissue testing to help give more of your metastatic NSCLC patients the chance to benefit from targeted therapy
*Study description: Eight (8) healthy male volunteers (age 52±8 years) were examined for ~90 minutes with PET imaging after single intravenous microdose (1.3 mcg; range 1.1-1.4 mcg) of 11C-labeled TAGRISSO. Concentrations of 11C-labeled TAGRISSO were also measured in arterial and venous blood and plasma. Brain MRI was acquired and used for co-registration of PET data and automatic delineation of regions of interest in the brain. PK parameters Cmax (brain), Tmax (brain), and AUC0–90 min brain/blood ratio were calculated. Safety and tolerability monitoring included recording of AEs, vital signs, and ECG.49AEs, adverse events; ALK, anaplastic lymphoma kinase; AUC, area under the curve; BRAF, B-Raf proto-oncogene; ECG, electrocardiogram; EGFR, epidermal growth factor receptor; EGFRm, epidermal growth factor receptor mutation positive; EHR, electronic health records; exon 19 del, exon 19 deletion; FDA, US Food and Drug Administration; IASLC, International Association for the Study of Lung Cancer; L858R, exon 21 leucine 858 arginine substitution; MET, mesenchymal-epithelial transition; mNSCLC, metastatic non-small cell lung cancer; MRI, magnetic resonance imaging; NSCLC, non-small cell lung cancer; NTRK, neurotrophic tyrosine receptor kinase; PD-L1, programmed death-ligand 1; PET, positron emission tomography; PK, pharmacokinetics; QNS, quantity not sufficient; QoL, quality of life; ROS1, ROS proto-oncogene 1; SF-36, 36-Item Short-Form Health Survey; T790M, exon 20 threonine 790 methionine substitution; TAT, turnaround time; TKIs, tyrosine kinase inhibitors; WT, wild-type.
References: 1. Pignon JP, Tribodet H, Scagliotti GV, et al; LACE Collaborative Group. Lung Adjuvant Cisplatin Evaluation: a pooled analysis by the LACE Collaborative Group. J Clin Oncol. 2008;26(21):3552-3559. 2. Goldstraw P, Chansky K, Crowley J, et al; IASLC. The IASLC Lung Cancer Staging Project: proposals for revision of the TNM stage groupings in the forthcoming (eighth) edition of the TNM classification for lung cancer. J Thorac Oncol. 2016;11(1):39-51. 3. Linden W, Vodermaier A, MacKenzie R, Greig D. Anxiety and depression after cancer diagnosis: prevalence rates by cancer type, gender, and age. J Affect Disord. 2012;141:343-351. 4. Trippoli S, Vaiani M, Lucioni C, Messori A. Quality of life and utility in patients with non-small cell lung cancer. Quality-of-life Study Group of the Master 2 Project in Pharmacoeconomics. Pharmacoeconomics. 2001;19(8):855-863. 5. Arriagada R, Dunant A, Pignon JP, et al. Long-term results of the international adjuvant lung cancer trial evaluating adjuvant cisplatin-based chemotherapy in resected lung cancer. J Clin Oncol. 2010;28(1):35-42. 6. Kris MG, Gaspar LE, Chaft JE, et al. Adjuvant systemic therapy and adjuvant radiation therapy for stage I to IIIA completely resected non-small-cell lung cancers: American Society of Clinical Oncology/Cancer Care Ontario Clinical Practice guideline update. J Clin Oncol. 2017;35(25):2960-2974. 7. Arriagada R, Bergman B, Dunant A, Le Chevalier T, Pignon JP, Vansteenkiste J. Cisplatin-based adjuvant chemotherapy in patients with completely resected non-small-cell lung cancer. N Engl J Med. 2004;350(4):351-360. 8. Uramoto H, Tanaka F. Recurrence after surgery in patients with NSCLC. Trans Lung Cancer Res. 2014;3(4):242-249. 9. Chouaid C, Danson S, Andreas S, et al. Adjuvant treatment patterns and outcomes in patients with stage IB-IIIA non-small cell lung cancer in France, Germany, and the United Kingdom based on the LuCaBIS burden of illness study. Lung Cancer. 2018;124:310-316. 10. Sholl LM, Aisner DL, Varella-Garcia M, et al; LCMC Investigators. Multi-institutional oncogenic driver mutation analysis in lung adenocarcinoma: The Lung Cancer Mutation Consortium experience. J Thorac Oncol. 2015;10(5):768-777 [supplementary appendix]. 11. Jones DR. Introducing tumor genomics to predict recurrence following complete resection of lung adenocarcinoma. Presented at: 2019 Annual Meeting of the American Association for Thoracic Surgery; May 4-7, 2019; Toronto, Canada. 12. D'Angelo SP, Janjigian YY, Ahye N, et al. Distinct clinical course of EGFR-mutant resected lung cancers: results of testing of 1118 surgical specimens and effects of adjuvant gefitinib and erlotinib. J Thorac Oncol. 2012;7(12):1815-1822. 13. Black RC, Khurshid H. NSCLC: an update of driver mutations, their role in pathogenesis and clinical significance. R I Med J. 2015;98(10):25-28. 14. Jordan EJ, Kim HR, Arcila ME, et al. Prospective comprehensive molecular characterization of lung adenocarcinomas for efficient patient matching to approved and emerging therapies. Cancer Discov. 2017;7(6):596-609. 15. Sholl LM, Aisner DL, Varella-Garcia M, et al; LCMC Investigators. Multi-institutional oncogenic driver mutation analysis in lung adenocarcinoma: The Lung Cancer Mutation Consortium experience. J Thorac Oncol. 2015;10(5):768-777. 16. Data on File. US-42770. EGFR TKI prescription data from Flatiron Health EHR-derived database (included patients who started treatment between October 2017 to April 2020, all data collected online). Ipsos data © Ipsos 2020, all rights reserved. AstraZeneca Pharmaceuticals LP. 17. Stransky N, Cerami E, Schalm S, Kim JL, Lengauer C. The landscape of kinase fusions in cancer. Nat Commun. 2014;5:4846. doi:10.1038/ncomms5846. 18. Bergethon K, Shaw AT, Ou SH, et al. ROS1 rearrangements define a unique molecular class of lung cancers. J Clin Oncol. 2012;30(8):863-870. 19. Akamine T, Takada K, Toyokawa G, et al. Association of preoperative serum CRP with PD-L1 expression in 508 patients with non-small cell lung cancer: a comprehensive analysis of systemic inflammatory markers. Surg Oncol. 2018;27(1):88-94. 20. D'lncecco A, Andreozzi M, Ludovini V, et al. PD-1 and PD-L1 expression in molecularly selected non-small-cell lung cancer patients. Br J Cancer. 2015;112(1):95-102. 21. Liu SY, Dong ZY, Wu SP, et al. Clinical relevance of PD-L1 expression and CD8+ T cells infiltration in patients with EGFR-mutated and ALK-rearranged lung cancer. Lung Cancer. 2018;125:86-92. 22. Yoneshima Y, ljichi K, Anai S, et al. PD-L1 expression in lung adenocarcinoma harboring EGFR mutations or ALK rearrangements. Lung Cancer. 2018;118:36-40. 23. Brown H, Vansteenkiste J, Nakagawa K, et al. Programmed cell death ligand 1 expression in untreated EGFR mutated advanced NSCLC and response to osimertinib versus comparator in FLAURA. J Thorac Oncol. 2020;15(1):138-143. 24. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for NSCLC V.4.2021. ©National Comprehensive Cancer Network, Inc. 2021. All rights reserved. Accessed March 3, 2021. To view the most recent and complete version of the guideline, go online to NCCN.org. NCCN makes no warranties of any kind whatsoever regarding their content, use or application and disclaims any responsibility for their application or use in any way. 25. Reck M, Rodríguez-Abreu D, Robinson AG, et al; KEYNOTE-024 Investigators. Pembrolizumab versus chemotherapy for PD-L1–positive non-small-cell lung cancer. N Engl J Med. 2016;375(19):1823-1833. 26. Clinicaltrials.gov. Study of MK-3475 (pembrolizumab) versus platinum-based chemotherapy for participants with PD-L1-positive advanced or metastatic non-small cell lung cancer (MK-3475-042/KEYNOTE-042). https://clinicaltrials.gov/ct2/show/NCT02220894. Accessed July 1, 2020. 27. Langer CJ, Gadgeel SM, Borghaei H, et al; KEYNOTE-021 Investigators. Carboplatin and pemetrexed with or without pembrolizumab for advanced, non-squamous non-small-cell lung cancer: a randomised, phase 2 cohort of the open-label KEYNOTE-021 study. Lancet Oncol. 2016;17(11):1497-1508. 28. Broderick JM. Frontline pembrolizumab combo improves survival in phase Ill NSCLC trial. https://www.onclive.com/web-excIusives/frontline-pembroIizumab-combo-improves-survival-in-phase-iii-nsclc-trial. Published January 16, 2018. Accessed July 1, 2020. 29. Carbone DP, Reck M, Paz-Ares L, et al; CheckMate 026 Investigators. First-line nivolumab in stage IV or recurrent non-small-cell lung cancer. N Engl J Med. 2017;376(25):2415-2426. 30. Hellmann MD, Ciuleanu TE, Pluzanski A, et al. Nivolumab plus ipilimumab in lung cancer with a high tumor mutational burden. N Engl J Med. 2018;378(22):2093-2104. 31. EU Clinical Trials Register. A phase III multicenter, randomized, open-label study evaluating the efficacy and safety of atezolizumab (MPDL3280A, anti-PD-L1 antibody) in combination with carboplatin+nab-paclitaxel for chemotherapy-naive patients with stage IV non-squamous non-small cell lung cancer. EudraCT number 2014-003206-32. 32. Kowanetz M, Socinski MA, Zou W, et al. IMpower150: efficacy of atezolizumab plus bevacizumab and chemotherapy across PD-L1 expression subgroups defined by the SP142 and SP263 IHC assays confirm all-comer benefit in 1L metastatic NSCLC. Presented at: AACR; April 14-18, 2018; Chicago, IL. 33. Papadimitrakopoulou VA, Cobo M, Bordoni R, et al. IMpower132: PFS and safety results with 1L atezolizumab + carboplatin/cisplatin + pemetrexed in stage IV non-squamous NSCLC [oral presentation]. Presented at: IASLC WCLC; September 23-26, 2018; Toronto, Canada. 34. Clinicaltrials.gov. A study of nivolumab and ipilimumab combined with chemotherapy compared to chemotherapy alone in first line NSCLC (CheckMate 9LA). https://clinicaltrials.gov/ct2/show/NCT03215706. Accessed July 1, 2020. 35. Spigel D, de Marinis F, Giaccone G, et al. lMpower110: interim overall survival (OS) analysis of a phase III study of atezolizumab (atezo) vs platinum-based chemotherapy (chemo) as first-line (1L) treatment (tx) in PD-L1–selected NSCLC. Presented at: European Society for Medical Oncology; September 27-October 1, 2019; Barcelona, Spain. Abstract LBA78. 36. Clinicaltrials.gov. A study of atezolizumab (MPDL3280A) compared with a platinum agent (cisplatin or carboplatin) + (pemetrexed or gemcitabine) in participants with stage IV non-squamous or squamous non-small cell lung cancer (NSCLC) [IMpower110]. https://clinicaltrials.gov/ct2/show/NCT02409342. Accessed July 1, 2020. 37. Keytruda [package insert]. Whitehouse Station, NJ: Merck & Co., Inc; 2020. 38. Tecentriq [package insert]. South San Francisco, CA: Genentech Inc.; 2021. 39. Opdivo [package insert]. Princeton, NJ: Bristol-Meyers Squibb Company; 2021. 40. Leighl NB, Page RD, Raymond VM, et al. Clinical utility of comprehensive cell-free DNA analysis to identify genomic biomarkers in patients with newly diagnosed metastatic non-small cell lung cancer. Clin Cancer Res. 2019;25(15):4691-4700. 41. Aggarwal C, Thompson JC, Black TA, et al. Clinical implications of plasma-based genotyping with the delivery of personalized therapy in metastatic non-small cell lung cancer. JAMA Oncol. 2019;5(2):173-180. 42. Merker JD, Oxnard GR, Compton C, et al. Circulating tumor DNA analysis in patients with cancer: American Society of Clinical Oncology and College of American Pathologists joint review. J Clin Oncol. 2018;36(16):1631-1641. 43. TAGRISSO [package insert]. Wilmington, DE: AstraZeneca Pharmaceuticals LP; 2020. 44. Soria JC, Ohe Y, Vansteenkiste J, et al; FLAURA Investigators. Osimertinib in untreated EGFR-mutated advanced non-small-cell lung cancer. N Engl J Med. 2018;378(2):113-125. 45. Cross DA, Ashton SE, Ghiorghiu S, et al. AZD9291, an irreversible EGFR TKI, overcomes T790M-mediated resistance to EGFR inhibitors in lung cancer. Cancer Discov. 2014;4(9):1046-1061. 46. Finlay MR, Anderton M, Ashton S, et al. Discovery of a potent and selective EGFR inhibitor (AZD9291) of both sensitizing and T790M resistance mutations that spares the wild type form of the receptor. J Med Chem. 2014;57(20):8249-8267. 47. Ballard P, Yates JW, Yang Z, et al. Preclinical comparison of osimertinib with other EGFR-TKls in EGFR-mutant NSCLC brain metastases models, and early evidence of clinical brain metastases activity. Clin Cancer Res. 2016;22(20):5130-5140. 48. Colclough N, Ballard PG, Barton P, et al. 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There are no contraindications for TAGRISSO
Interstitial lung disease (ILD)/pneumonitis occurred in 3.7% of the 1479 TAGRISSO-treated patients; 0.3% of cases were fatal. Withhold TAGRISSO and promptly investigate for ILD in patients who present with worsening of respiratory symptoms which may be indicative of ILD (eg, dyspnea, cough and fever). Permanently discontinue TAGRISSO if ILD is confirmed
Heart rate-corrected QT (QTc) interval prolongation occurred in TAGRISSO-treated patients. Of the 1479 TAGRISSO-treated patients in clinical trials, 0.8% were found to have a QTc >500 msec, and 3.1% of patients had an increase from baseline QTc >60 msec. No QTc-related arrhythmias were reported. Conduct periodic monitoring with ECGs and electrolytes in patients with congenital long QTc syndrome, congestive heart failure, electrolyte abnormalities, or those who are taking medications known to prolong the QTc interval. Permanently discontinue TAGRISSO in patients who develop QTc interval prolongation with signs/symptoms of life-threatening arrhythmia
Cardiomyopathy occurred in 3% of the 1479 TAGRISSO-treated patients; 0.1% of cardiomyopathy cases were fatal. A decline in left ventricular ejection fraction (LVEF) ≥10% from baseline and to <50% LVEF occurred in 3.2% of 1233 patients who had baseline and at least one follow-up LVEF assessment. In the ADAURA study, 1.5% (5/325) of TAGRISSO-treated patients experienced LVEF decreases ≥10% from baseline and a drop to <50%. Conduct cardiac monitoring, including assessment of LVEF at baseline and during treatment, in patients with cardiac risk factors. Assess LVEF in patients who develop relevant cardiac signs or symptoms during treatment. For symptomatic congestive heart failure, permanently discontinue TAGRISSO
Keratitis was reported in 0.7% of 1479 patients treated with TAGRISSO in clinical trials. Promptly refer patients with signs and symptoms suggestive of keratitis (such as eye inflammation, lacrimation, light sensitivity, blurred vision, eye pain and/or red eye) to an ophthalmologist
Postmarketing cases consistent with Stevens-Johnson syndrome (SJS) and erythema multiforme major (EMM) have been reported in patients receiving TAGRISSO. Withhold TAGRISSO if SJS or EMM is suspected and permanently discontinue if confirmed
Postmarketing cases of cutaneous vasculitis including leukocytoclastic vasculitis, urticarial vasculitis, and IgA vasculitis have been reported in patients receiving TAGRISSO. Withhold TAGRISSO if cutaneous vasculitis is suspected, evaluate for systemic involvement, and consider dermatology consultation. If no other etiology can be identified, consider permanent discontinuation of TAGRISSO based on severity
Verify pregnancy status of females of reproductive potential prior to initiating TAGRISSO. Advise pregnant women of the potential risk to a fetus. Advise females of reproductive potential to use effective contraception during treatment with TAGRISSO and for 6 weeks after the final dose. Advise males with female partners of reproductive potential to use effective contraception for 4 months after the final dose
Most common (≥20%) adverse reactions, including laboratory abnormalities, were leukopenia, lymphopenia, thrombocytopenia, diarrhea, anemia, rash, musculoskeletal pain, nail toxicity, neutropenia, dry skin, stomatitis, fatigue, and cough
TAGRISSO is indicated as adjuvant therapy after tumor resection in adult patients with non-small cell lung cancer (NSCLC) whose tumors have epidermal growth factor receptor (EGFR) exon 19 deletions or exon 21 L858R mutations, as detected by an FDA-approved test
TAGRISSO is indicated for the first-line treatment of adult patients with metastatic non-small cell lung cancer (NSCLC) whose tumors have epidermal growth factor receptor (EGFR) exon 19 deletions or exon 21 L858R mutations, as detected by an FDA-approved test
TAGRISSO is indicated for the treatment of adult patients with metastatic EGFR T790M mutation-positive NSCLC, as detected by an FDA-approved test, whose disease has progressed on or after EGFR tyrosine kinase inhibitor (TKI) therapy
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