Treatment Tips for Challenging EGFR-Mutant Lung Cancers

Mark G. Kris, MD


November 23, 2021

This transcript has been edited for clarity.

This is Mark Kris from Memorial Sloan Kettering, giving a commentary on a meeting I attended a few days ago. Every year, oncologists, mainly medical oncologists from the New York metro area, get together for a conference. As part of the conference, we have a session on challenging cases, where six doctors present what they thought were challenging cases they'd seen in the past year. What struck me this year was that four of those six cases were patients with EGFR-mutant cancers. More and more for thoracic oncologists, people with EGFR-mutant disease are some of our most challenging. Why is that?

The first reason is they blessedly live a long time. We care for them for a long period of time, they have many fits and starts in their care, and we have many decisions to make. We are put on the spot over and over again.

The other good thing is that many things help. But the negative is also that many things help. We have to spend a large amount of time figuring things out. Because we know that things work, we're very disappointed when they don't — it's almost unexpected — and our patients feel the same.

The last thing we have to remember is that for so many patients, and particularly, those with EGFR-mutant disease, it is a much more difficult time when the cancer recurs than even when it's diagnosed. I have to remind even myself when I'm faced with a documented recurrence that I have to say to the patient that this is tougher than when the cancer was first diagnosed. I have a couple of thoughts on this.

First, please get everything you can out of the treatment that has gotten the patient to that point. Don't rush to change treatment if the patient is fit, they're back to their normal life, and there's no untoward side effect or dangerous side effect. Think long and hard about continuing that patient on their treatment for all you can.

The second thing is, don't be hesitant to rebiopsy those cancers and get tissue. That's our best chance to get all the information available to find additional chances for benefit. Let's say you find an ALK fusion; it opens up a new door that you wouldn't have by just looking at the standards of care.

Next, please, when you do change, change that systemic therapy wisely. Also, please remember that the oligo situation — oligometastasis, oligoprogression, oligorecurrence — all of those things give you an opportunity to use a local therapy and stay on a successful systemic therapy. I urge you to use them all.

Don't forget bevacizumab. It's a drug that helps, particularly patients with CNS disease and patients with effusions. It's a really good option that's kind of fallen out of our care. Remember also that the checkpoint inhibitors are less likely to help, and they're probably at the bottom of our list of options for patients. Don't rush to use those drugs. I'm sure that there is a place for them in some patients. It's less likely to help than bevacizumab, chemotherapy, or another targeted therapy.

Last, please remember that using EGFR-targeted drugs with successful local therapies is a strategy not only to lengthen life but also to increase cure. Think about using EGFR-targeted drugs with radiation or with surgery.

Indeed, patients with EGFR-mutant lung cancers are our most challenging cases. They make us work hard, but the rewards can be very great. Let's acknowledge how tough these decisions are and use all the tools that we have to try to help these patients.

Mark G. Kris, MD, is chief of the thoracic oncology service and the William and Joy Ruane Chair in Thoracic Oncology at Memorial Sloan Kettering Cancer Center in New York City. His research interests include targeted therapies for lung cancer, multimodality therapy, the development of new anticancer drugs, and symptom management with a focus on preventing emesis.

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