For Lung Cancer, Precision Medicine is Changing the Game

By Kathryn F. Mileham, MD, FACP, Chief, Section of Thoracic Medical Oncology

Precision medicine isn’t a vision anymore: At Levine Cancer Institute (LCI), we’ve embraced it as a front-line approach for treating many patients with lung cancer. The combination of molecular testing and targeted drugs is helping us match patients with therapies, like osimertinib or alectinib, which deliver the best chance of a good outcome. This is providing many patients with treatment plans that are not only superior in response but also lower in toxicity – illustrating how precision medicine transforms care.

Pinpointing Lung Cancer Mutations

Precision medicine starts with pinpointing the mutations that drive a patient’s cancer. We use comprehensive gene panels to look for every mutation that could be relevant to each patient’s cancer, not just the most likely mutations. This gives patients every opportunity to be matched with therapy that targets their mutation.

For patients diagnosed with metastatic non-squamous non-small cell lung cancer, this testing at time of diagnosis includes screening for four key mutations – EGFR, ALK, ROS1 and BRAF. The presence of one of these mutations can predict whether the patient will respond to targeted therapies. We also test tumors of all patients with metastatic non-small cell lung cancer for PD-L1 expression to determine when and how immunotherapy, such as pembrolizumab, should be integrated into treatment.

Our Molecular Tumor Board also convenes weekly to review every large panel genomics report received. The multidisciplinary team includes experts from translational research, tissue procurement, genetics, research and medical oncology to evaluate and deliver detailed recommendations for treatment.

Fast Molecular Testing Results

We’ve made it a priority to deliver our test results quickly, usually within seven to 10 days – much faster than most centers. This means the results are often available at a patient’s first medical oncology appointment, enabling our doctors to identify the most appropriate therapies and start treatment as soon as possible. This gives patients peace of mind – and prevents doctors from having to change course after they learn more about a patient’s cancer.

Innovative Lung Cancer Therapies

For those patients with EGFR, ALK, ROS1 or BRAF aberrations, oral therapies are available that are more effective and more tolerable than traditional therapies.

For example, we recommend osimertinib as first-line treatment for patients with metastatic non-small cell lung cancer whose tumors have EGFR exon 19 deletions or exon 21 L858R mutations. The FLAURA trial showed that this drug was associated with a 54 percent reduction in the risk of progression or death compared with standard therapy.

This benefit of osimertinib was consistent even in patients with known or treated central nervous system metastasis when compared with the overall population. Patients potentially can be spared from radiation to the brain or at least be considered for a more focal intervention. And it’s just one of several targeted, FDA-approved therapies available to lung cancer patients at LCI.

Building a Brighter Future

Many other mutations in lung cancer have been identified, and the next wave of targeted therapies is already in the pipeline. LCI is moving these therapies forward by participating in a wide variety of clinical trials – including Phase I trials of novel therapies or new combinations of therapies.

LCI is also a site for the ASCO TAPUR Study, a non-randomized clinical trial providing patients access to FDA-approved targeted anti-cancer drugs matched to the genomic profile of the cancer, regardless of the current FDA label. In other words, if a drug is effective in one type of cancer because of a mutation, then this trial provides an opportunity to use that same drug in another type of cancer because of the same mutation.

These trials are bringing us closer to a day when we can offer targeted therapies not only against a much broader array of cancers, but also against the mutations that drive drug resistance. Our goal is to be able to give patients a series of agents, most of which are oral, that continuously contain their cancer and significantly extend their lives.

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