A Case of Metastatic ALK-Rearranged Non-Small Cell Lung Cancer - Episode 5
Lyudmila A. Bazhenova, MD:We all are aware that immunotherapy has been a major breakthrough in lung cancer treatment for stage 4 lung cancer. However, what we’re also learning is that immunotherapy is not as effective for patients withALKmutations as well asEGFRmutations. So, outside of the clinical trial, I will not be using immunotherapy up front for patients withALK-fused genes. I might consider using it down the line, after I go through all my desired ALK inhibitors and probably give them a platinum-based doublet. Because, we know pemetrexed works very well forALK-mutant lung cancer patients. Maybe somewhere down the line we can use immunotherapy, but at this point the data are underwhelming for the efficacy of immunotherapy inALK-fused lung cancers. Currently, we have several studies looking at the efficacy of immunotherapy in combination with ALK inhibitors. Those studies have not been showing us any data yet, and I think eventually we will learn if adding immunotherapy to, let’s say, crizotinib at the time of the patient diagnosis will make a difference.
Lorlatinib is a third-generation ALK inhibitor that is currently being investigated for patients withALK-fused stage 4 lung cancer who have failed 1 or 2 ALK inhibitors. Preliminary data look certainly interesting, but we are noticing that efficacy of lorlatinib is better if the patient had 1 ALK inhibitor versus 2 ALK inhibitors versus 3 ALK inhibitors. Lorlatinib is an interesting drug. There is 1 very resistant mutation in theALKkinase domain called 1202R. Ceritinib doesn’t cover that mutation. Alectinib doesn’t cover that mutation. There are some case reports of patients with that mutation responding to brigatinib. But one benefit of lorlatinib is that it covers that resistant mutation. This resistance mutation is not really that frequent, but there is certainly some preclinical rationale that lorlatinib will be able to salvage some of those patients who develop resistance to crizotinib or to other second-generation drugs based on1202R.
We also see improvement in the management of the patients withROS1-mutant lung cancer. Currently, we have crizotinib, which is approved forROS1-mutant patients, but other drugs such as entrectinib are being investigated for that population. I haven’t seen any data yet, so, at this point, I can’t really say if entrectinib is going to become the next standard of care option for those patients. But, preclinically, entrectinib has very good activity againstROS-mutant cancers.
Today, we covered a lot of very important questions, and for a lot of those questions we do not have an answer. I think the question that we’re all eager to find an answer to is, “What’s the right way of sequencing ALK inhibitors?” It will take some additional trials, and I hope that in the future we will learn what the right thing to do is for our patients. I hope that in the future, we will be able to have more third-generation ALK inhibitors effective against resistant mutations that we’ve discussed today. I strongly support everybody who is listening to me to treat yourALK-mutant patients on trials, because that’s the only way we can get better. That’s the only way we can find answers to questions that we covered today.
Transcript edited for clarity.
ALK-Rearranged NSCLC Progressing on Crizotinib