Robert Pirker, MD, Medical University of Vienna, Vienna, Austria
Interview:Robert Pirker, MD, Medical University of Vienna, Vienna, Austria
Which of the recent advances in the field of NSCLC would you deem most important from the clinical point of view?
Medical science in oncology has moved on to specific, molecularly targeted treatments. Personalised medicine is based on molecular alterations of the tumour cells. Chemotherapy has been around for decades, and I believe that it will stay on for many more decades to come. However, in the long run, targeted agents will be increasingly available, either as a single modality or in combination with chemotherapy. The classification of lung cancer has changed markedly. Besides histology, subtyping of histology has been included, and more importantly, there are molecular parameters we should assess.
Are new treatments being implemented in the clinic to a sufficient degree?
Here I would like to refer to a study we did in Central and Eastern European countries. We evaluated whether patients with advanced NSCLC receive testing for EGFR mutations in a real-world setting, and the kind of treatment strategy prescribed in those with EFGR-mutation-positive disease. The study shows that EGFR testing is a reality in these countries. EGFR-mutation positivity was present in 14% of patients with advanced NSCLC; these were of course mainly patients with adenocarcinomas. Also, importantly, we have shown that the treatment is conducted according to the guidelines. This means that the majority of the EGFR-mutation-positive patients will receive EGFR-directed TKIs, such as afatinib, erlotinib or gefitinib, in the first-line setting. Moreover, patients without EGFR mutations are treated with chemotherapy rather than with EGFR-directed TKIs.
Will findings presented at the ASCO Congress change the future of NSCLC therapy?
In some areas, they will. For example, second-generation TKIs are already in use in patients with EGFR-mutation-positive disease, but in the future, third-generation TKIs will be available as well, particularly for patients with resistance mutations. Also, because of the LUX-Lung 8 trial that has clearly demonstrated benefits from afatinib compared to erlotinib in squamous cell carcinoma, we will probably be able to prescribe second-line afatinib for our patients with advanced squamous cell tumours. The difference observed between the two arms of the trial is statistically significant, but I think that it is also of clinical relevance. One of the next steps will be the identification of those patients who benefit most. There will be research efforts with respect to predictive factors in afatinib-treated patients with squamous cell carcinoma. In general predictive factors are an important future area.
Another trial evaluated the value of whole brain radiotherapy in addition to stereotactic radiotherapy in patients with brain metastases. This is a simple question, but it is clinically relevant. The study demonstrated that there is no survival benefit by adding whole brain radiotherapy to stereotactic radiotherapy in patients with up to three brain metastases. These results will also change my practice, although in the clinic, we already go along these lines in the vast majority of patients.
The major news is that immunotherapy that is actually working is now available. Attempts were made in this field in the past, but they always failed. Immune checkpoint inhibitors now have demonstrated that they can improve outcomes in patients with various diseases. Two trials have shown a survival benefit in patients with advanced NSCLC, who had previously been treated with chemotherapy. From my point of view, this is an important improvement.