Article and Video CATEGORIES

Cancer Journey

Search By

Dr. Jack West is a medical oncologist and thoracic oncology specialist who is the Founder and previously served as President & CEO, currently a member of the Board of Directors of the Global Resource for Advancing Cancer Education (GRACE)

 

Iressa for Elderly and/or Poor Performance Status Patients with an EGFR Mutation
Author
Howard (Jack) West, MD

Several years ago, we learned that EGFR tyrosine kinase inhibitors (TKIs) were not a very helpful strategy for an unselected population of frail patients in the US, clearly inferior to standard chemotherapy (see prior posts here and here). This work was in patients who hadn't been tested for molecular markers like EGFR mutations, and our interpretation of the previous US-based trial left us with the conclusion that an EGFR TKI like tarceva (erlotinib) or iressa (gefitinib) was an inferior chemotherapy alternative and apparently ineffective treatment for the majority of patients with a marginal performance status, but it could still be an effective option for patients selected to be especially likely to benefit from this class of agents, like patients with an EGFR mutation.

This was the subject of pure speculation until now. A manuscrupt by Inoue and colleagues (abstract here) has just been published that describes the experience of treating patients with an EGFR mutation and who are either elderly or have a poor performance status or both with an EGFR TKI (iressa at the standard 250 mg/day) as first line therapy. Specifically, they enrolled 30 patients who either had a poor performance status (3 or 4 on a scale of 0 to 5 where 0 is asymptomatic and 5 is dead: details here), or were 70 or older with a marginal performance status (2 -4) or 80 or older with any symptoms (1-4). It's worth noting that there are relatively few studies that include patients with a performance status of 2, and almost none that have included patients with a performance status of 3, who spend more than half of their day in bed and can't take care of many of their activities of daily living.

The exciting thing that they found was that these patients responded to gefitinib (response rate of 66%, right in line with the typical results for a population with an EGFR mutation) and had a much more favorable median survival, 18 months, than you'd expect for patients with a marginal or poor performance status (likely in the 2-6 month range). In the curves below, the yellow one shows the survival of a comparable group of Japanese frail patients who didn't have an EGFR mutation but also received iressa as first line therapy:

Poor PS EGFR Mut OS (Click to enlarge)

What was also impressive was that this very favorable response rate and median survival was associated with a very significant improvement in performance status for two thirds of the patients, as shown here (downward lines are favorable, since a lower performance status is more independent and less symptomatic):

PS improvement for EGFR Mutation patients on Gefitinib

It's important to highlight that his was a Japanese study and that we've seen major differences between Asian and North American populations in lung cancer outcomes, especially with regard to EGFR inhibitors. However, thus far it has really appeared that the differences are due primarily to differences in the molecular markers of tumors, so it's very likely that patients with the EGFR mutation positive tumors have a similar response to EGFR TKIs everywhere. Consequently, it seems likely that the previously noted unimpressive results with an EGFR inhibitor apply to the majority of poor performance status patients in North America, since only about 10% would be expected to carry an EGFR mutation. But for those who do have one, this study out of Japan would suggest that they have a high probability of a good response and improvement in symptoms, along with a prolonged survival, from early administration of an EGFR inhibitor.

The key appears to be in separating the major beneficiaries from the ones who won't benefit and may even be harmed from this approach. But this work provides the hope of treating certain elderly and/or very frail patients with an EGFR TKI and getting dramatic results.

Next Previous link

Previous PostNext Post

Related Content

Image
Lung Cancer OncTalk 2023
Video
At our live event, Lung Cancer OncTalk 2023, Dr. Jeff Yang, discusses different surgical procedures used to treat early-stage lung cancer and different approaches to removing cancerous tissue from the lung. 
Image
Lung Cancer OncTalk 2023
Video
At our live event, Lung Cancer OncTalk 2023, Dr. Millie Das, discusses different Studies and Trials for NSCLC. Dr. Das specializes in the treatment of thoracic malignancies. She sees and treats patients both at the Stanford Cancer Center and at the Palo Alto VA Hospital. She is the Chief of Oncology at the Palo Alto VA and is an active member of the VA National Lung Cancer Working Group and Lung Cancer Precision Oncology Program. Learn more about Dr. Das here.
Image
The Importance of Early Detection 2023
Video
Drs. Meredith McKean, Dr. Doug Micalizzi and patient advocate and lung cancer survivor, Ivy Elkins, discuss the importance of early detection and treatment across cancer types, including skin, lung, and breast. To watch the complete playlist click here.

Forum Discussions

Hi Blaze,

 

As much as I hate to say it, Welcome back Blaze.  It sounds like you're otherwise feeling good and enjoying life which is a wonderful place to be. ...

Waiting for my appointment with oncologist this morning. Thank you for the response. It helps. <3

It sounds like you’re thinking of this in a very appropriate way. Specifically, it sounds like the growth of the nodule is rather modest, though keep in mind that the change...

Hi and welcome to GRACE.  I'm sorry your mom is having this difficulty.  An indwelling catheter is used when the pleura space continually fills and the catheter is always there to...

Hi Oaktowngrrl,  Welcome to Grace.  I'm so sorry you're going through this.

 

 Finding a reputable dedicated thoracic surgeon for lung surgery might be difficult, as it is a complex and...

Recent Comments

JOIN THE CONVERSATION
Could you
By Maeve785 on
It sounds like you’re…
By Dr West on
Thank you Janine
By blaze100 on
Hi Blaze,

 

As much as I…
By JanineT GRACE … on