nsclc: terapia medica nella fase avanzata€¦ · adeno lcc/nos scc sclc egfr mutants balk ros/re t...
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Paolo Bidoli
S.C. Oncologia Medica H S. Gerardo
Monza
NSCLC: Terapia medica nella fase avanzata
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Food and Drug Administration. At http://www.fda.gov/cder/cancer/druglistframe.htm. Accessed August 28, 2006.; National Comprehensive
Cancer Network (NCCN). Practice Guidelines in Oncology. Non-small cell lung cancer v2.2006. Accessed August 28, 2006. Schrump et al.
Non-small cell lung cancer. In: Cancer: Principles and Practice of Oncology. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005.
*Label does not include NSCLC-specific indication
First-line
Second-line
Third-line
Not approved
1970 1980 1990 2000
Median
overall
survival,
months
12+
~8–
10 ~6 ~2–
4
Best supportive care Single-agent platinum Doublets Bevacizumab + PC
Cisplatin*
1978
Carboplatin*
1989
Erlotinib
Pemetrexed
2004
Docetaxel
1999
Paclitaxel
Gemcitabine
1998
Vinorelbine
1994
Docetaxel
2002
Bevacizumab
2006
Gefitinib
2003
Standard Therapies
CT AND SILENT APPROVAL
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Adeno LCC/NOS SCC SCLC
EGFR mutants ALK ROS/RET
HER2
b-raf
K-ras
K-ras
Courtesy G Scagliotti
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THE FIRST HIT ON HISTOLOGY
Sandler NEJM 2006
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THE SECOND HIT ON HISTOLOGY
Scagliotti JCO 2008
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MAINTENANCE TREATMENT
Paz Ares JCO 2013
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PS 0
PS 1
pemetrexed PS 0: 17.2 months versus placebo PS 0: 12.9, p =
0.059; pemetrexed PS 1: 12.9 months versus placebo PS 1: 10.7,
p = 0.121
Reck JTO JCO 2014
THE DRIVERS OF CHOICE
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Benefit of first-line EGFR TKIs: 9 randomized phase III studies
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Crizotinib in first line
Solomon BJ 2014
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Second-line options for metastatic NSCLC in 2015
EGFR Mut+
pretreated
front-line
with EGFR-
TKIs
EGFR
WT/ALK-
non-
squamous
EGFR
WT/ALK-
squamous
Platinum
doublet +
bevacizumab
OR
platinum
+ pemetrexed
+/- bevacizumab
Erlotinib
or
Pemetrexed
or
Docetaxel
Erlotinib
or
Docetaxel
ALK+
pretreated
front-line
with
crizotinib
Ceritinib
or
Platinum
+ pemetrexed
+/- bevacizumab
Consider clinical trials with
new irreversible inhibitors
Consider platinum re-challenge or clinical trials
Consider clinical trials with
new inhibitors
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CheckMate 017 (NCT01642004) - Study Design
• One pre-planned interim analysis for OS
• At time of DBL (December 15, 2014), 199 deaths were reported (86% of deaths required for final analysis)
• The boundary for declaring superiority for OS at the pre-planned interim analysis was P <0.03
Patients stratified by region and prior paclitaxel use
Nivolumab 3 mg/kg IV Q2W
until PD or unacceptable toxicity n = 135
Docetaxel 75 mg/m2 IV Q3W
until PD or unacceptable toxicity n = 137
Ran
do
miz
e 1
:1
• Primary Endpoint:
– OS
• Additional Endpoints:
Investigator-assessed ORR
Investigator-assessed PFS
Correlation between PD-L1 expression and efficacy
Safety
Quality of life (LCSS)
• Stage IIIb/IV SQ NSCLC
• 1 prior platinum doublet-based chemotherapy
• ECOG PS 0–1
• Pre-treatment (archival or fresh) tumor samples required for PD-L1 analysis
N = 272
LCSS = Lung cancer symptom scale
Brahmer J, et al. NEJM 2015
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CheckMate 017: Overall
Survival Nivolumab
n = 135 Docetaxel
n = 137
mOS, months (95% CI)
9.2 (7.33, 12.62)
6.0 (5.29, 7.39)
# events 103 122
HR = 0.62 (0.48, 0.81); P = 0.0004
0 6 14 25 37 51 57 69 86 113 135 0 Nivolumab
Number of Patients at Risk
0 3 7 11 15 22 33 46 69 104 137 Docetaxel 1
OS
(%
)
Time (months)
100
90
80
70
60
50
40
30
10
0
20
33 27 24 21 18 15 12 9 6 3 0 30
Nivolumab
18-month
OS rate = 28% 12-month
OS rate = 42%
Docetaxel
18-month
OS rate = 13%
12-month OS rate = 24%
Based on August 2015 DBL.
Minimum follow-up for survival: 18 months
mOS = median overall survival. Symbols refer to censored observations.
Reckamp K, et al. Presented at the 16th World Conference on Lung Cancer; September 6–9, 2015; Denver, Colorado, USA. Oral 02.01.
17
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CheckMate 057 (NCT01673867) Study Design
• PD-L1 expression measured using the Dako/BMS automated IHC assay14,15
– Fully validated with analytical performance having met all pre-determined acceptance criteria for sensitivity, specificity, precision, and robustness
a Maintenance therapy included pemetrexed, bevacizumab, or erlotinib (not considered a separate line of therapy); b Per RECIST v1.1 criteria as determined by the investigator.
Ran
do
miz
e 1
:1
• Stage IIIB/IV non-SQ NSCLC
• Pre-treatment (archival or recent) tumor samples required for PD-L1
• ECOG PS 0–1
• Failed 1 prior platinum doublet
• Prior maintenance therapy alloweda
• Prior TKI therapy allowed for known ALK translocation or EGFR mutation
N = 582
Nivolumab 3 mg/kg IV Q2W
until PD or unacceptable toxicity
n = 292
Docetaxel 75 mg/m2 IV Q3W
until PD or unacceptable toxicity
n = 290
• Primary Endpoint – OS • Additional Endpoints – ORRb
– PFSb
– Safety – Efficacy by tumor PD-L1 expression – Quality of life (LCSS)
Patients stratified by prior maintenance therapy and line of therapy (second- vs third-line)
Paz-Ares L, et al. ASCO 2015
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H. Borghaei, L. Paz-Ares, N Engl J Med. 2015 Sep 27
Nivolumab
(n = 292)
Docetaxel
(n = 290)
mOS, mo 12.2 9.4
HR = 0.73 (96% CI: 0.59, 0.89);
P = 0.0015
CheckMate 057 (NCT01673867)- OS
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Anti PD1/PD-L1 agents: open
questions
• How to select patients?
• Clinical characteristics?
• PD-L1 expression or other biomarkers?
• Treatment duration
• Best tool(s) to assess drug activity?
• Patient communication
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AURA (AZD9291):
best % change in target-lesion
size
Janne PA, NEJM 2015
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For p
erson
al use o
nly
Alectinib: Best systemic and best tumor response
ORR = 55%
Gadgeel SM et al; Lancet Oncology 2014; 15: 1119-28
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Second-line options for metastatic NSCLC in 2016
EGFR Mut+
pretreated
front-line
with EGFR-
TKIs
EGFR
WT/ALK-
/ROS1-
non-
squamous
Squamous
Osimertinib
(T790M+)
NIVOLUMAB
DOCETAXEL
+ANTIANGIO
GENIC
AGENTS
ALK+
pretreated
front-line
with
crizotinib
Ceritinib or
alectinib
Consider clinical trials with
new irreversible inhibitors
Consider platinum re-challenge or clinical trials
Consider clinical trials with
new inhibitors
NIVOLUMAB
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“Benchè i dottori lo
curassero,
gli cavassero sangue e gli
facessero prendere molte
medicine, tuttavia guarì”.
LEV NIKOLAEVIC TOLSTOJ