THERAPIES CIBLEES : INDICATIONS ET TOXICITES
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THERAPIES CIBLEES : INDICATIONS ET TOXICITES 6 Février 2016 Dr Christine Gennigens Oncologie médicale UN PEU D’HISTOIRE… VOLTAIRE 1694-1778 Les mots de Voltaire Les médecins sont des hommes qui prescrivent des médicaments dont ils connaissent peu de choses… pour guérir des maladies qu’ils connaissent encore moins… chez des êtres humains dont ils ne connaissent rien. GUSTAVE ROUSSY 1874-1948 …La difficulté reste toujours de soigner non seulement la tumeur, mais surtout la personne dans son intégralité,… VISION HOLISTIQUE 1 GENERALITES DEFINITIONS • désignées généralement par le terme anglais targeted therapies • utilisent les différences biologiques entre les cellules cancéreuses et les cellules saines • visent les gènes ou protéines fautifs qui contribuent à la croissance et au développement du cancer • Ces médicaments peuvent bloquer durablement la prolifération cellulaire mais ne sont pas nécessairement cytotoxiques…= CYTOSTATIQUES • Souvent synergique avec la chimiothérapie, mais parfois utilisation à la place de la chimiothérapie Qu'estVIEUX ce qu'une thérapie ciblée ? !!! CONCEPTS • Le tamoxifène cible… les récepteurs hormonaux • L'adriamycine cible… la topo isomérase II • La radiothérapie cible… l'ADN • Le bistouri cible… la tumeur • Reposent sur les notions de - RÉCEPTEURS (membranaires ou intracytoplasmiques) - LIGANDS - Activation des protéines, le plus souvent, par phosphorylation via une enzyme appelée KINASE - VOIES DE SIGNALISATION …Une des propriétés « cellulaires » conduisant au développement tumoral… CIBLES ??? stratégies différentes LIGANDS er les ligands des récepteurs membranaires que de la tumeur. RECEPTEURS er les récepteurs membranaires ACTIVATION RECEPTEURS TK her l’activation des récepteurs à activité tyrosine kinase MOYENS ??? « …MAB » ANTICORP MONOCLONAL • Intraveineux • Demi-vie longue • Large molécule ciblant un récepteur membranaire ou son ligand • Activation de la réponse immunitaire de l’hôte (ADCC) • Ne passe pas la barrière hématoencéphalique « …IB » INHIBITEUR TYROSINE KINASE • Per os • Demi-vie courte • Cible un récepteur membranaire à activité TK ou protéine intracytoplasmique • peut être multi-cible • Passe la barrière hémato-encéphalique FACTEURS PREDICTIFS/ PRONOSTIQUES FACTEURS PRONOSTIQUES - Associés à l’évolution spontanée de la maladie, en l’ABSENCE DE TRAITEMENT… - Nécessité d’un traitement adjuvant ? - Risque de toxicité inacceptable face au risque de récidive métastatique ? FACTEURS PREDICTIFS - Prévoit la RÉPONSE À UN TRAITEMENT DONNÉ - Valeur prédictive positive (VPP): identifie les répondeurs - Valeur prédictive négative (VPN): identifie les non-répondeurs N + F. PRONOSTIQUES/HER-2 HER2 facteur pronostic ? Survie des patientes selon lʼétat de HER2 dans cancer du sein N-! Seshadri R et al. J Clin Oncol 1993 ; 11 : 1936-1942! N - F. PREDICTIFS/HER-2 - résistance à l’hormonothérapie - Réponse aux anthracyclines - Réponse aux thérapies anti-HER2 ADDICTION ONCOGENIQUE Addiction to Oncogenes—the Achilles Heal of Cancer A Downloaded from www.sciencemag.org on April 22, 2 sis in another (2–4). in hemat e of prey killed all of the (3, 5). For example, in transgenic mice may be moreleuk depe cell assembly ession of this gene where overexpression of c-myc initiates specific Howeve oncogenes particles The author is at the Herbert Irving Comprehensive the leuke advanced stages Cancer of andCenter, maintains invasiveUniversity, mammary New carcinogrowth-inhibitory Columbia York, NY rest, diff olecular 1 0 0 3mas, 2, Ua SA . E - mof a i lthese : w e itumors n s t e i @apparently c a n c e rc e n t e r. ls underwent rapid subset suppressor genes th columbia.edu et al. (7) rporating and the mice surescape c-Myc dependence The Jain et al. I. Bernard Weinstein by activating s relevantsingle to recent endogenous ras oncogenes (15). question still under studies present an cancer cell frequently contains A tantalizing www.sciencemag.org SCIENCE VOL 297 5 JULY debate 2002is mutations als of a drug (thatin multiple genes, gross whether an oncogene that is crucial respectfor to the new appr chromosomal abnormalities, and initial development of a specific tumor is rease widespread activity ofchanges the in its gene expression Differentiated Clinical evidence th quired for maintaining the malignant phenoeating patients with in cancer research is that typecell by s profile. An axiom of that tumor. The study byists Jainisetprovided al. on B,C,D... the multistage process of tumor formation (1) page 102 of this issue (5) addresses this ques(CML), who carry the Her-2/neu rece is driven by progressive acquisition of actition. By unraveling the molecular circuitry used toof successfull vating mutations in that maintains the biologic properties candominant growth-encer cells, we will be better ablethe to predict se- therap Enhanced online at t all of these results striking genes (oncolective molecular targets for cancer therapy. www.sciencemag.org/cgi/ hancing A,B,C,D... mice with leukemia imatinib mesylate content/full/297/5578/63 genes) and inactivatJain and colleagues (5) engineered a condiing mutations in retional transgenic mouse to overexpress the se models the engiBcr-Abl oncogene cessive growth-inhibitory genes (tumor supmyc oncogene, which induced formation of Cancer cell n unusually potent the antitumor effec pressor genes) (2). Epigenetic (nonmutationhighly malignant B,C,D... osteogenic sarcoma. They al) Furthermore, abnormalities leading to increased or de- Apoptosis discovered that brief loss of myc ocess. ingoverexpresthe p53 tumor creased expression of these genes, respectivesion caused the tumor cells to differentiate iner additional genetic be due to tumor sup ly, are also important for tumorigenesis to mature osteocytes that formed histologicalgression in the hu- discovery of oncogenes ly normal bone. It is also intriguingThe of o (2–4).than Since thatnotions subabout 20 years ago, more than 100 oncogenes sequent reactivation of myc, rather than restorentire carcinogenic mor suppressor hyp and at least 15 tumor suppressor genes have Cancer ing tumor would be predicted, inA one-step remedy. cells growth acquireasabnorLa cellule cancéreuse devient dépendante, months than in identifying new c been rather identified, and the list keeps growing. stead induced apoptosis of the tumor cells. malities in multiple oncogenes and tumor supand tumor suppressor genes are These findings are consistent otherchange nce Oncogenes is accumulating thewith myriad pressor genes (A, B, C, and D). Inactivation of a « addicte » d’un ou qq oncogènes pour important not only for cell proliferation but data showing that cancer cells are often “admanalso cancer cells is vealed by microarra for cell fate determination (differentiato” (that is, physiologically dependent single critical oncogenedicted (A) can induce cancer survivre et conserver son phénotype tumoral their effects on) the continued activity of specific activatnt ontion, thesenescence, continuedand apoptosis), cers (19). However, cells to differentiate into cells with a normal phe- ce/onc Table 3 Clinical evidence of oncogene addiction. Target Disease Agent Regimen Reference HER-2 Breasta Trastuzumab Combination Slamon et al. (2001)28,b, Piccart-Gebhart et al. (2005)29,b BCR/ABL Chronic myeloid leukemiaa Imatinib Monotherapy Hughes et al. (2003)31 C-KIT Gastrointestinal stromal tumora Imatinib Monotherapy Demetri et al. (2002)33 EGFR NSCLCa Gefitinib, erlotinib Monotherapy Shepherd et al. (2005)32,b, Taron et al. (2005)35, Lynch et al. (2004)36 EGFR Head and neck, colorectuma Cetuximab Combination Baselga et al. (2005)39, Cunningham et al. (2004)40 EGFR Pancreasa Erlotinib Combination Moore (2005)34 VEGF Breast, colorectuma, kidney Bevacizumab Combination Miller et al. (2005)41, Hurwitz et al. (2004)42,b, Yang et al. (2003)43 VEGFR, B-Raf Kidneya Sorafenib Monotherapy Stadler (2005)55 Treatment regimen indicates agent alone (monotherapy) or in combination with cytotoxic agents (combination). aFDA-approved; bPhase III evidence demonstrates improved disease-free or overall survival rates. Abbreviations: NSCLC, non-small-cell lung cancer; VEGFR, vascular endothelial growth factor receptor. 2 FAMILLE EGFR… Epidermal Growth Factor Receptor EGFR et la famille HER FAMILLE INDICATIONS EGFR (HER1) • Cancer du colon : panitumumab (Vectibix®), cetuximab (Erbitux®) • Cancer du poumon (NSCLC) : erlotinib (Tarceva®), gefitinib (Iressa®), afatinib (Gilotrif®) • Cancer ORL: cetuximab • Cancer du sein : lapatinib (Tyverb®) INDICATIONS HER2 • Cancer du sein : Trastuzumab (Herceptin®); TDM-1 (Kadcyla®); Pertuzumab (Perjeta®); Lapatinib • Cancer de l’estomac : Trastuzumab CANCER POUMON ARTICLE DE 1985… from histologic to molecular based. HISTOLOGIQUE MOLECULAIRE traitement spécifique s mécanismes de résistance aux traitements spécifiques CLASS. MOLECULAIRE ADENOCARCINOME EGFR = 35-40% - Non fumeurs - Femmes - asiatiques EN PRATIQUE… EGFR ALK "5/13 /&2:+>)0=42@:=/91/C;=;=0@>>+21;=212& 1;=>=0:8@@:;=4:+>+!;=;@:=/=;=@=;2@;*>C4=)+;>2/2&+8@==7=4>=94: ;= @1=:2001>+21=@= 567 MUTATIONS EXCLUSIVES (+TY"TY(+Y"S"=EGC+Y,L=(+SCG?(+PY+TYC]ZZ=GETYY TGEZY TTG"=,+TY ]Y TZZ]ZY Z7=Q]+PY ETY B+Y "(S+Y (+TY S,T=TZE"+Y Z;,SL+]Z=Q]+Y S,T]BZ+Y (]Y 2=ZY Q]+Y B+TY C]Z< Z=GETYY+ZYB+TYC]ZZ=GETY(+YBRYTGEZYLS+TQ]+YC]< ERLOTINIB = Tarceva® • Première ligne métastatique si EGFR positif et mutation • Seconde ligne ou après… si EGFR positif, échec 1ière ligne CT GEFITINIB = Iressa® AFATINIB = Gilotrif® • Première ligne métastatique si EGFR positif et mutation new england journal of medicine The 1°) Analyse des mutations du gène EGFR dans les ADK du poumon established in 1812 september 3, 2009 vol. 361 no. 10 Etude IPASS : gefitinib (Iressa ®) enCarboplatin–Paclitaxel 1ère ligne en monothérapie (étude de III vs Carboplatine/Paclitaxel) Gefitinib or inphase Pulmonary Population d’origine asiatique Adenocarcinoma Mok et al. NEJM, 2009 ASIE Tony S. Mok, M.D., Yi-Long Wu, M.D., F.A.C.S., Sumitra Thongprasert, M.D., Chih-Hsin Yang, M.D., Ph.D., Da-Tong Chu, M.D., Nagahiro Saijo, M.D., Ph.D., Patrapim Sunpaweravong, M.D., Baohui Han, M.D., Benjamin Margono, M.D., Ph.D., F.C.C.P., Yukito Ichinose, M.D., Yutaka Nishiwaki, M.D., Ph.D., Yuichiro Ohe, M.D., Ph.D., Jin-Ji Yang, M.D., Busyamas Chewaskulyong, M.D., Haiyi Jiang, M.D., Emma L. Duffield, M.Sc., Claire L. Watkins, M.Sc., Alison A. Armour, F.R.C.R., and Masahiro Fukuoka, M.D., Ph.D. Mutations « activatrices » d’EGFR (del exon 19 – mut L858R) = facteur prédictif de répons A BS TR AC T BACKGROUND Previous, uncontrolled studies have suggested that first-line treatment with gefitinib would be eff icacious in selected patients with non–small-cell lung cancer. METHODS In this phase 3, open-label study, we randomly assigned previously untreated patients in East Asia who had advanced pulmonary adenocarcinoma and who were nonsmokers or former light smokers to receive gefitinib (250 mg per day) (609 patients) or carboplatin (at a dose calculated to produce an area under the curve of 5 or 6 mg per milliliter per minute) plus paclitaxel (200 mg per square meter of body-surface area) (608 patients). The primary end point was progression-free survival. RESULTS The 12-month rates of progression-free survival were 24.9% with gef itinib and 6.7% with carboplatin–paclitaxel. The study met its primary objective of showing the noninferiority of gef itinib and also showed its superiority, as compared with carboplatin– paclitaxel, with respect to progression-free survival in the intention-to-treat population (hazard ratio for progression or death, 0.74; 95% confidence interval [CI], 0.65 to 0.85; P<0.001). In the subgroup of 261 patients who were positive for the epidermal growth factor receptor gene (EGFR) mutation, progression-free survival was significantly longer among those who received gefitinib than among those who received carboplatin–paclitaxel (hazard ratio for progression or death, 0.48; 95% CI, 0.36 to 0.64; P<0.001), whereas in the subgroup of 176 patients who were negative for the mutation, progression-free survival was significantly longer among those who received carboplatin–paclitaxel (hazard ratio for progression or death with gefitinib, 2.85; 95% CI, 2.05 to 3.98; P<0.001). The most common adverse events were rash or acne (in 66.2% of patients) and diarrhea (46.6%) in the gef itinib group and neurotoxic effects (69.9%), neutropenia (67.1%), and alopecia (58.4%) in the carboplatin–paclitaxel group. CONCLUSIONS From the State Key Laboratory in Oncology in South China, Sir YK Pao Centre for Cancer, Department of Clinical Oncology, Chinese University of Hong Kong, Hong Kong (T.S.M.), Guangdong General Hospital, Guangzhou (Y-L.W., J.-J.Y.), Cancer Hospital, Chinese Academy of Medical Sciences, Beijing (D.-T.C.), and Shanghai Chest Hospital, Shanghai (B.H.) — all in China; Maharaj Nakorn Chiang Mai Hospital, Chiang Mai University, Chiang Mai (S.T., B.C.), and Prince of Songkla University, Songkla (P.S.) — both in Thailand; National Taiwan University Hospital, Taipei, Taiwan (C.-H.Y.); National Cancer Center Hospital East, Chiba (N.S., Y.N.), National Kyushu Cancer Center, Fukuoka (Y.I.), National Cancer Center Hospital, Tokyo (Y.O.), AstraZeneca, Osaka (H.J.), and Kinki University School of Medicine, Osaka (M.F.) — all in Japan; Dr. Soetomo Hospital, Surabaya, Indonesia (B.M.); and AstraZeneca, Macclesf ield, United Kingdom (E.L.D., C.L.W., A.A.A.). Address reprint requests to Dr. Mok at the Department of Clinical Oncology, Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, HKSAR, China, or at [email protected]. This article (10.1056/NEJMoa0810699) was published on August 19, 2009, and was last updated on September 4, 2009, at NEJM.org. PFS = 10.8/5.4 mois Gef itinib is superior to carboplatin–paclitaxel as an initial treatment for pulmonary adenocarcinoma among nonsmokers or former light smokers in East Asia. The presence in the tumor of a mutation of the EGFR gene is a strong predictor of a better outcome with gef itinib. (ClinicalTrials.gov number, NCT00322452.) N Engl J Med 2009;361:947-57. Copyright © 2009 Massachusetts Medical Society. exon 19 or aminoacid substitution (leucine t at codon 858 [L858R]) clustered around the AT Erlotinib versus standard chemotherapy as first-line treatment for European patients with advanced EGFR Articles pocket of the tyrosine kinase domain—are mutation-positive non-small-cell lung cancer (EURTAC): a multicentre, open-label, randomised phase 3 trial 10–26% of non-small-cell lung cancer Rafael Rosell, Enric Carcereny, Radj Gervais, Alain Vergnenegre, Bartomeu Massuti, Enriqueta Felip, Ramon Palmero, Ramon Garcia-Gomez, Cinta Pallares, Jose Miguel Sanchez, Rut Porta, Manuel Cobo, Pilar Garrido, Flavia Longo, Teresa Moran, Amelia Insa, Filippo De Marinis, Romain Corre, Isabel Bover, Alfonso Illiano, Eric Dansin, Javier de Castro, Michele Milella, Noemi Reguart, Giuseppe Altavilla, Ulpiano Jimenez, Mariano Provencio, Miguel Angel Moreno, Josefa Terrasa, Jose Muñoz-Langa, Javier Valdivia, Dolores Isla, Manuel Domine, Olivier Molinier, Julien Mazieres, Nathalie Baize, Rosario Garcia-Campelo, Gilles Robinet, Delvys Rodriguez-Abreu, Guillermo Lopez-Vivanco, Vittorio Gebbia, Lioba Ferrera-Delgado, Pierre Bombaron, Reyes Bernabe, Alessandra Bearz, Angel Artal, Enrico Cortesi, Christian Rolfo, Maria Sanchez-Ronco, Ana Drozdowskyj, Cristina Queralt, Itziar de Aguirre, Jose Luis Ramirez, Jose Javier Sanchez, Miguel Angel Molina, Miquel Taron, Luis Paz-Ares, on behalf of the Spanish Lung Cancer Group in collaboration with the Groupe Français de Pneumo-Cancérologie and the Associazione Italiana Oncologia Toracica www.thelancet.com/oncology Vol 13 February 2012 Summary Background Erlotinib has been shown to improve progression-free survival compared with chemotherapy when given as first-line treatment for Asian patients with non-small-cell lung cancer (NSCLC) with activating EGFR mutations. We aimed to assess the safety and efficacy of erlotinib compared with standard chemotherapy for first-line treatment of European patients with advanced EGFR-mutation positive NSCLC. A 1·0 Lancet Oncol 2012; 13: 239–46 Published Online January 26, 2012 DOI:10.1016/S14702045(11)70393-X See Comment page 216 Erlotinib (n=86) Catalan Institute of Oncology, Chemotherapy (n=87) Badalona, Spain (R Rosell MD, E Carcereny MD, T Moran MD, HR 0·37 (95% CI 0·25–0·54); log-rank C Queralt p<0·0001 PhD, I de Aguirre PhD, Methods We undertook the open-label, randomised phase 3 EURTAC trial at 42 hospitals in France, Italy, and Spain. Eligible participants were adults (>18 years) with NSCLC and EGFR mutations (exon 19 deletion or L858R mutation in exon 21) with no history of chemotherapy for metastatic disease (neoadjuvant or adjuvant chemotherapy ending ≥6 months before study entry was allowed). We randomly allocated participants (1:1) according to a computer-generated allocation schedule to receive oral erlotinib 150 mg per day or 3 week cycles of standard intravenous chemotherapy of cisplatin 75 mg/m² on day 1 plus docetaxel (75 mg/m² on day 1) or gemcitabine (1250 mg/m² on days 1 and 8). Carboplatin (AUC 6 with docetaxel 75 mg/m² or AUC 5 with gemcitabine 1000 mg/m²) was allowed in patients unable to have cisplatin. Patients were stratified by EGFR mutation type and Eastern Cooperative Oncology Group performance status (0 vs 1 vs 2). The primary endpoint was progression-free survival (PFS) in the intention-to-treat population. We assessed safety in all patients who received study drug (≥1 dose). This study is registered with ClinicalTrials.gov, number NCT00446225. PFS probability 0·8 J L Ramirez PhD, M Taron PhD); Pangaea Biotech, USP Dexeus University Institute, Barcelona, Spain (R Rosell, M A Molina PhD, M Taron); Centre François Baclesse, Caen, France (R Gervais MD); Hopital du Cluzeau, Limoges, France (Prof A Vergnenegre MD); Hospital General de Alicante, Alicante, Spain (B Massuti MD); Hospital Vall d’Hebron, Barcelona, Spain (E Felip MD); Catalan Institute of Oncology, Bellvitge, Spain (R Palmero MD); Hospital Gregorio Marañon, Madrid, Spain (R Garcia-Gomez MD); Hospital Sant Pau, Barcelona, Spain (C Pallares MD); Hospital 12 de Octubre, Madrid, Spain (J M Sanchez MD); MD Anderson, Madrid, Spain (J M Sanchez); Catalan Institute of Oncology, Girona, Spain (R Porta MD); Hospital Carlos Haya, Malaga, Spain (M Cobo MD); Hospital Ramon y Cajal, Madrid, Spain (P Garrido MD); Azienda Policlinico Umberto I, Rome, Italy (F Longo MD); Hospital Clinico, Valencia, Spain (A Insa MD); Azienda Ospedaliera Camillo Forlanini, Rome, Italy (F De Marinis MD); CHU Rennes Hopital EUROPE 0·6 Findings Between Feb 15, 2007, and Jan 4, 2011, 174 patients with EGFR mutations were enrolled. One patient received treatment before randomisation and was thus withdrawn from the study; of the remaining patients, 86 were randomly assigned to receive erlotinib and 87 to receive standard chemotherapy. The preplanned interim analysis showed that the study met its primary endpoint; enrolment was halted, and full evaluation of the results was recommended. At data cutoff (Jan 26, 2011), median PFS was 9·7 months (95% CI 8·4−12·3) in the erlotinib group, compared with 5·2 months (4·5−5·8) in the standard chemotherapy group (hazard ratio 0·37, 95% CI 0·25−0·54; p<0·0001). Main grade 3 or 4 toxicities were rash (11 [13%] of 84 patients given erlotinib vs none of 82 patients in the chemotherapy group), neutropenia (none vs 18 [22%]), anaemia (one [1%] vs three [4%]), and increased aminotransferase concentrations (two [2%] vs 0). Five (6%) patients on erlotinib had treatment-related severe adverse events compared with 16 patients (20%) on chemotherapy. One patient in the erlotinib group and two in the standard chemotherapy group died from treatment-related causes. 0·4 0·2 0 0 3 Number at risk Erlotinib 86 Introduction Chemotherapy 87 63 49 6 9 12 15 18 21 Time (months) 24 27 30 Interpretation Our findings strengthen the rationale for routine baseline tissue-based assessment of EGFR mutations in patients with NSCLC and for treatment of mutation-positive patients with EGFR tyrosine-kinase inhibitors. Funding Spanish Lung Cancer Group, Roche Farma, Hoffmann-La Roche, and Red Temática de Investigacion Cooperativa en Cancer. PFS = 9.7/5.2 mois 54 20 32 8 Mutations in EGFR—either small in-frame deletions in exon 19 or aminoacid substitution (leucine to arginine at codon 858 [L858R]) clustered around the ATP-binding pocket of the tyrosine kinase domain—are present in 21 5 17 4 9 3 7 1 4 0 2 0 tumours1 and are associated with response to gefi tinib and erlotinib.2–4 Studies of lung cancer cell lines and transgenic mice with EGFR mutations have shown the oncogenic transformation potential of these mutations, with enhanced response to EGFR 2 0 33 36 0 0 0 0 cl th an Ev 1. in th di W ra w re as In Funding Boehringer Ingelheim. Afatinib versus cisplatin-based chemotherapy for EGFR Introduction mutation-positive lung adenocarcinoma (LUX-Lung 3 and Patients with lung adenocarcinoma harbou LUX-Lung 6): analysis of overall survival dataare from two mutations highly responsive to treatment tyrosine kinase inhibitors such as gefitinib, e randomised, phase 3 trials James Chih-Hsin Yang*, Yi-Long Wu*, Martin Schuler, Martin Sebastian, Sanjay Popat, Nobuyuki Yamamoto, Caicun Zhou, Cheng-Ping Hu, Kenneth O’Byrne, Jifeng Feng, Shun Lu, Yunchao Huang, Sarayut L Geater, Kye Young Lee, Chun-Ming Tsai, Vera Gorbunova, Vera Hirsh, Jaafar Bennouna, Sergey Orlov, Tony Mok, Michael Boyer, Wu-Chou Su, Ki Hyeong Lee, Terufumi Kato, Dan Massey, Mehdi Shahidi, www.thelancet.com/oncology Vol 16 February 2015 Victoria Zazulina, Lecia V Sequist Summary Background We aimed to assess the effect of afatinib on overall survival of patients with EGFR mutation-positive lung adenocarcinoma through an analysis of data from two open-label, randomised, phase 3 trials. Methods Previously untreated patients with EGFR mutation-positive stage IIIB or IV lung adenocarcinoma were enrolled in LUX-Lung 3 (n=345) and LUX-Lung 6 (n=364). These patients were randomly assigned in a 2:1 ratio to receive afatinib or chemotherapy (pemetrexed-cisplatin [LUX-Lung 3] or gemcitabine-cisplatin [LUX-Lung 6]), stratified by EGFR mutation (exon 19 deletion [del19], Leu858Arg, or other) and ethnic origin (LUX-Lung 3 only). We planned analyses of mature overall survival data in the intention-to-treat population after 209 (LUX-Lung 3) and 237 (LUX-Lung 6) deaths. These ongoing studies are registered with ClinicalTrials.gov, numbers NCT00949650 and NCT01121393. Lancet Oncol 2015; 16: 1 Published Online January 12, 2015 http://dx.doi.org/10.101 S1470-2045(14)71173-8 PFS = 11.1/6.9 mois Findings Median follow-up in LUX-Lung 3 was 41 months (IQR 35–44); 213 (62%) of 345 patients had died. Median follow-up in LUX-Lung 6 was 33 months (IQR 31–37); 246 (68%) of 364 patients had died. In LUX-Lung 3, median overall survival was 28·2 months (95% CI 24·6–33·6) in the afatinib group and 28·2 months (20·7–33·2) in the pemetrexed-cisplatin group (HR 0·88, 95% CI 0·66–1·17, p=0·39). In LUX-Lung 6, median overall survival was 23·1 months (95% CI 20·4–27·3) in the afatinib group and 23·5 months (18·0–25·6) in the gemcitabine-cisplatin group (HR 0·93, 95% CI 0·72–1·22, p=0·61). However, in preplanned analyses, overall survival was significantly longer for patients with del19-positive tumours in the afatinib group than in the chemotherapy group in both trials: in LUX-Lung 3, median overall survival was 33·3 months (95% CI 26·8–41·5) in the afatinib group versus 21·1 months (16·3–30·7) in the chemotherapy group (HR 0·54, 95% CI 0·36–0·79, p=0·0015); in LUX-Lung 6, it was 31·4 months (95% CI 24·2–35·3) versus 18·4 months (14·6–25·6), respectively (HR 0·64, 95% CI 0·44–0·94, p=0·023). By contrast, there were no significant differences by treatment group for patients with EGFR Leu858Arg-positive tumours in either trial: in LUX-Lung 3, median overall survival was 27·6 months (19·8–41·7) in the afatinib group versus 40·3 months (24·3–not estimable) in the chemotherapy group (HR 1·30, 95% CI 0·80–2·11, p=0·29); in LUX-Lung 6, it was 19·6 months (95% CI 17·0–22·1) versus 24·3 months (19·0–27·0), respectively (HR 1·22, 95% CI 0·81–1·83, p=0·34). In both trials, the most common afatinib-related grade 3–4 adverse events were rash or acne (37 [16%] of 229 patients in LUX-Lung 3 and 35 [15%] of 239 patients in LUX-Lung 6), diarrhoea (33 [14%] and 13 [5%]), paronychia (26 [11%] in LUX-Lung 3 only), and stomatitis or mucositis (13 [5%] in LUX-Lung 6 only). In LUX-Lung 3, neutropenia (20 [18%] of 111 patients), fatigue (14 [13%]) and leucopenia (nine [8%]) were the most common chemotherapy-related grade 3–4 See Comment page 118 *Contributed equally National Taiwan Univer Hospital and National T University, Taipei, Taiw (Prof J C-H Yang MD); Guangdong Lung Cance Institute, Guangdong G Hospital and Guangdon Academy of Medical Sc Guangzhou, China (Prof Y-L Wu MD); West Cancer Center, Universi Hospital Essen, Univers Duisburg-Essen, Essen, Germany (Prof M Schule Johann Wolfgang Goeth University Medical Cen Frankfurt am Main, and University Medical Cen the Johannes Gutenber University Mainz, Main Germany (M Sebastian M Royal Marsden Hospita London, UK (S Popat FR Wakayama Medical Uni Wakayama, Japan (Prof N Yamamoto MD); Shanghai Pulmonary H Tongji University, Shan China (Prof C Zhou MD); NICHES THERAPEUTIQUES Today (2013) Targets in the future Targets today EGFR ALK ROS1 KRAS and others 2008 Adenocarcinoma 2000 Non-small-cell lung cancer 1990 Lung cancer BRAF Large-cell carcinoma HER2 RET DDR2 MET and others FGR1 PI3K Squamous cell carcinoma Small-cell lung cancer Adenocarcinoma Large-cell carcinoma Squamous cell carcinoma without oncogenic alteration Adenocarcinoma and treatable oncogenic alterations with approved drugs (EGFR mutation and ALK translocation) Small-cell lung cancer Squamous cell carcinoma with oncogenic alteration Figure 1: Evolution of lung cancer histology over time SURVIE GLOBALE Evolution du traitement des CBNPC métastatiques 30 ans 3 ans Adapté de Pao et al. Nat Rev C
