Adjuvant therapy in non-small cell lung cancer: is targeted therapy joining the standard of care?

ABSTRACT

Introduction

Surgical resection is the standard of care  (SOC) in non-small cell lung cancer (NSCLC) for early-stage. The 5-year overall survival (OS) rates with the use of adjuvant chemotherapy remain low. In advance NSCLC, tailored strategies have become the gold standard. We hope to translate these benefits into preventing recurrences and increasing survival in early-stage NSCLC.

Areas covered

EGFR mutated populations are the most common druggable molecular drivers in advance NSCLC. EGFR tyrosine kinase inhibitors (TKIs) are the SOC in this setting, and we discuss their emerging role as adjuvant therapy.

Expert opinion

The results of the first adjuvant clinical trial with TKIs showed increased DFS in patients with early-stage NSCLC. Despite that using osimertinib (Osm) as an adjuvant treatment seems promising, several open questions need to be answered. If Osm reaches a significant advantage in OS, undergoing 3 years of treatment is worthwhile, but if there is not an OS benefit then maybe DFS is not enough. In the meantime, should we treat patients with Osm as adjuvant therapy until the OS data is available? There is not an easy answer, but most of us are in favor of giving Osm a chance until we have definitive data or better options in early-stage NSCLC.

KEYWORDS:

• NSCLC
• adjuvant therapy
• EGFR
• tyrosine kinase inhibitor
• osimertinib
• erlotinib
• gefitinib

Article highlights

• Although adjuvant chemotherapy has been the standard of care in resected NSCLC, new strategies are needed to increase disease free survival and overall survival.

• Research on predictive or prognostic factors, including biomarkers, in adjuvant NSCLC treatment are necessary to apply a successful and more personalized approach.

• EGFRTKIs have proven efficacy in metastatic NSCLC for patients with EGFR mutations and this has now emerged as an option in the adjuvant setting.

• The use of osimertinib in resected NSCLC stage II-IIIA EGFR-mutated tumors prolongs disease free survival in a large clinical trial.

• Even though there is still uncertainty if it provides benefits of overall survival, the use of osimertinib as an adjuvant therapy is promising.

Declaration of interest

L Raez has received research support from Astra-Zeneca, Merck, Genentech, BI, Pfizer, BMS, Loxo, Lilly Oncology, Nanth Health and Syndax Pharmaceuticals. C Rolfo has served as a speaker for Merck Sharp Dohme, AstraZeneca, and Roche; has research collaborations with Guardant Health; and has served in advisory board activity for Archer, Inivata and MD Serono, Novartis, BMS, and Boston Pharmaceuticals. Nonfinancial support from Guardant Health; research grant from LCRF-Pfizer. A Russo has served in an advisory role for AstraZeneca and Merck Sharp Dohme. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper received no funding.