GRACE :: Lung Cancer


progression-free survival

Denise Brock

ASCO 2017 – Lung Cancer – Improved Progression-Free Survival with Iressa as Adjuvant Therapy for EGFR Patients

H. Jack West, MD
Medical Director
Thoracic Oncology Program Swedish Cancer Institute
President & CEO, GRACE
Matthew Gubens, MD
Thoracic Oncologist
Thoracic Surgery and Oncology Clinic
UCSF Helen Diller Family Comprehensive Cancer Center
Jyoti D. Patel, MD
Director Thoracic Oncology
University of Chicago Medicine


Drs. H. Jack West, Medical Director of the Thoracic Oncology Program at Swedish Cancer Institute in Seattle, Washington and President and CEO of GRACE, Matthew Gubens, Thoracic Oncologist at the Thoracic Surgery and Oncology Clinic of the UCSF Helen Diller Family Comprehensive Center in San Francisco, California, and Jyoti Patel, Director of Thoracic Oncology at University of Chicago Medicine gathered post meeting to discuss new information from ASCO 2017 regarding lung cancer.   In this roundtable video, the doctors discuss  Improved Progression-Free Survival with Iressa as Adjuvant Therapy for EGFR Mutation Positive Patients and Why That Doesn’t Change Anything.



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ROS-1 Rearrangements: What Are They?

GRACE Cancer Video Library - Lung



Dr. Ross Camidge, University of Colorado, describes ROS-1 rearrangements and compares them to ALK rearrangements in frequency of occurrence and response to treatment.


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ROS-1 rearrangements are like the sister to ALK gene rearrangements. They’re also a gene which is silenced in most adult tissues, which is turned on again by a gene rearrangement creating what’s called a fusion protein which can drive the cancer cell. Structurally they’re very similar to ALK rearrangements and they respond to many of the same drugs. Particularly crizotinib, the first licensed ALK inhibitor, has also clearly shown good activity in ROS-1 driven cancers.

They’re rarer, maybe one quarter as common as ALK rearrangements or less. There are subtle differences. The benefit of crizotinib in ROS-1 gene rearranged lung cancer actually seems greater than it is in ALK, so the response rate is 70% as opposed to 60%. The median progression-free survival, the time it takes for the cancer to grow, on average is about 19 months as opposed to nine or ten months with ALK.

People are wondering about why the difference is, and there are various theories. Maybe crizotinib is actually a better ROS-1 inhibitor than it is an ALK inhibitor. Maybe the frequency of progression within the brain, which we know is somewhat of an Achilles heel for crizotinib and ALK-positive lung cancer — maybe that’s not such an issue with the ROS-1 rearranged patients simply because they have a lower frequency of deposits in the brain. Increasingly on a biological level, we’ve also seen a little bit of data that ROS-1 may be a more genetically simple cancer that ALK. It occurs in a part of the genome, part of the DNA of the cell, which is more structurally stable, so its ability to mutate and evolve in the presence of the drug and then progress later may be less. Either way, it’s a good thing to have if you have it.

Dr West

PFS vs. pfs: Why Progression-Free Survival Remains Controversial in Lung Cancer


Last year, an article came out in the Journal of Clinical Oncology that noted a gradual shift away from the “hard endpoint” of overall survival (OS) for lung cancer trials toward progression-free survival (PFS), a “softer endpoint” that is much more subject to interpretation.  The analysis also noted that many of the trials that were technically negative for the primary endpoint, the prospectively defined emphasis of the trial, were written up as if they were positive, highlighting a secondary endpoint that looked favorable, or a subset of patients who demonstrated a more favorable result than was seen in the overall trial population.

The accompanying editorial implied that this shift represented a regrettable relaxing of appropriate standards, but I actually didn’t and don’t see it that way.  First, we’ve seen that some trials haven’t reported on survival because patients were responding and continuing without progression for so long that it was self-obvious that survival was improving.  For instance, the US FDA approved XALKORI (crizotinib) back in August, 2011 for ALK rearrangement-positive patients, based on the terrific results in a single-arm, phase I/II trial that showed that nearly two thirds of patients had significant tumor shrinkage and that the median PFS was in the range of 8-10 months. Both of these results were about twice what we would expect from standard chemotherapy regimens.  It wasn’t until several years later that we saw the definitive evidence that XALKORI was superior to chemotherapy in terms of OS. How many ALK-positive patients would have been denied this clearly beneficial therapy over the additional 3 years just so that we could run a randomized trial that is the equivalent of running a trial to confirm the value of parachutes for people falling out of an airplane (technical term — “gravitationally challenged”)?  Most of the lung cancer community rightly considered XALKORI the clear standard of care in the first line setting without waiting for the subsequent trial to prove a survival benefit, because the conclusion was already self-evident based on a profound PFS benefit.  The FDA has actually just put out a new document noting that they will continue to consider approving drugs for lung cancer based on secondary endpoints like PFS.

Back in 2000-2005, there was much more reason to question the value of PFS as an independent and predictive endpoint.  Before trials with targeted therapies, the magnitude of PFS differences that you’d see between two arms of a trial was usually only up to 1.5-2 months. If that isn’t accommodated by at least as much of an improvement in OS, it’s hard to get excited about that. Yes, patients can argue that a few extra weeks before being told that their scan looks worse is valuable, and while that’s justifiable for drugs that don’t cost $5000-10,000/month or more, it’s fair for society to expect much more compelling value for cancer drugs when everyone ends up sharing the cost burden by paying taxes or rising insurance premiums.  On the other hand, I have firmly believe that seeing a PFS of more than 6 months in a randomized trial of Tarceva (erlotinib) with or without Avastin (bevacizumab) in favor of the combination is very clinically meaningful and predicts for a high probability of a survival benefit with additional follow up.   Imagine having two homes for sale that are next door to each other, very comparable, but one is in a color you clearly prefer and one is a less preferred color. Does color matter? Yes, and if they cost the same, you should jump at this minor factor. But if the home in your preferred color costs 25% more, it’s absolutely not worth it. It’s a very minor factor. On the other hand, if the color of the home also correlated with something that really matters, such as if the home in the color you prefer was also bigger and much nicer, it’s clearly worth paying the 25% premium.  

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Is Progression-Free Survival Meaningful?


Progression-free survival is something that doctors measure to determine how well a patient responds to a particular treatment. But does it translate to increased overall survival?


Dr West

Maintenance Alimta in Advanced NSCLC Shows Significant Improvement in Progression-Free Survival


Last year, a provocative trial was presented at ASCO that compared early vs. later taxotere as second line therapy. I described that study here, and it showed a very significant improvement in progression-free survival (PFS) and a near significant improvement in overall survival (OS) for the recipients of taxotere immediately after four cycles of first line chemo for advanced NSCLC. These results were impressive enough that it would make us consider switching to a “maintenance” approach of giving second line treatment, in this case with taxotere, immediately after 4 cycles of first line chemo in non-progressing patients.

There were a few limitations to that work. First, some prior, generally smaller studies didn’t clearly support the conclusion that maintenance or early second line chemo is definitely superior. Because of that, most experts felt that it would be helpful to get another study that supported maintenance chemo before we declared it a standard of care. Second, the prior trial waited a full three months before doing a repeat scan that would trigger a start of chemo in the delayed chemo arm — and about 1/3 of the patients on that arm were too sick to get chemo by the time they were found to have progression. That’s too long, in my opinion, to wait before checking for progression, which is often found radiographically before a patient gets too sick for chemo. With so many people in the delayed chemo arm not getting it, the trial was in some ways a study of everyone getting immediate chemo vs. 2/3 getting delayed chemo — not fair.

But yesterday there was a press conference sponsored by ASCO to highlight the results of a trial sponsored by Eli Lilly and being presented at the oral presentation on advanced lung cancer at ASCO in two weeks (abstract here), and this result added to the prior study will likely change the standard of care, in my opinion. The new trial, called JMEN by Lilly (every common has their own cryptic coding for trial names, and I don’t know if ANYONE really knows what JMEN refers to — it’s not an acronym), asked a very similar quesiton to the one from last year — does maintenance chemo (or early second line chemo, depending on your point of view) improve progression-free survival, the time before someone shows cancer progression and needs to change treatment plans? Continue reading

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