(ESMO) August 11, 2017 - ESMO 2017 is once again the place to be for breaking news on cancer research. ESMO 2017, the annual oncology congress organised by the European Society for Medical Oncology (ESMO) in partnership with the European Association for Cancer Research (EACR) will take place in Madrid, Spain, from 8 to 12 September at IFEMA, Feria de Madrid.

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H. Jack West, MD (Posted: August 14, 2017)

It appears that while the PACIFIC trial of durvalumab consolidation after chemoradiation is being presented at ESMO, we won't see data from either the MYSTIC trial (durvalumab/tremelimumab or durvalumab monotherapy vs. chemo doublet first line for advanced NSCLC) or FLAURA (first line osimertinib vs. erlotinib or gefitinib for EGFR mutation-positive advanced NSCLC). We knew MYSTIC is negative for a PFS benefit, so we should perhaps not be surprised that AZ isn't eager to highlight the results, but I think if there were anything favorable to mitigate the disappointment, they'd have tried to stanch the bleeding by presenting the data. I suspect there will be little to encourage us when AZ ultimately deigns to show us real data. More notable is the omission of FLAURA from the ESMO program, a trial reported as positive for a significant improvement in the primary endpoint of PFS that could potentially change practice and broaden the indication for osimertinib to include first line treatment if the PFS benefit is substantial enough. Unless AZ just doesn't want to compete for the limelight with the PACIFIC trial that will likely cause a Beatlemania-reminiscent hysteria by both being an immunotherapy and being positive, this suggests that the results aren't as captivating as some would have hoped. As an alternative, the IASLC may have promised the moon and the stars to AZ to postpone presentation of a high-impact trial for the first time at the World Conference on Lung Cancer, but I would have anticipated that AZ should want to get positive results out on a potentially practice-changing therapy to as broad an audience as possible, as quickly as possible. We'll eventually see what the data show, but I'm disappointed that two of three important lung cancer trials from which we've heard initial results from recent press releases apparently won't be presented at ESMO. Makes you wonder why they're dragging their feet.

(AstraZeneca) July 31, 2017 - AstraZeneca and MedImmune, its global biologics research and development arm, today announced that the US Food and Drug Administration (FDA) has granted Breakthrough Therapy Designation for Imfinzi (durvalumab) for the treatment of patients with locally-advanced, unresectable non-small cell lung cancer (NSCLC) whose disease has not progressed following platinum-based chemoradiation therapy.

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H. Jack West, MD (Posted: July 31, 2017)

We have learned from a press release that the PACIFIC trial is positive for a significant improvement in PFS after chemo/radiation for patients with locally advanced, unresectable NSCLC. Because this treatment entails an extra year of IV treatment every two weeks and a cost likely in the range of $180-200K per patient, most experts feel that the PFS benefit should be remarkably long and/or be accompanied by a significant improvement in survival. In this setting, demonstrating a 3-4 month delay in relapse without a survival benefit won't offset the cost in terms of time on treatment for patients or cost to society. The entire lung cancer community looks forward to the presentation of the actual trial data at an upcoming meeting -- I hope at ESMO 2017 (where I will be happy to provide commentary on the detailed findings). If the PACIFIC trial achieves these criteria, it should rightfully become adopted as a new standard of care in this setting. It would be ideal, however, if we can determine which patients are most or least likely to benefit from this extended treatment so that we can concentrate these extra efforts and costs on the patients who will truly benefit from them.

(JAMA Oncology) July 27, 2017 - Pemetrexed, a next-in-class antifolate drug, was first approved by the US Food and Drug Administration (FDA) in 2004 in combination with cisplatin for the treatment of pleural mesothelioma.

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H. Jack West, MD (Posted: July 28, 2017)

It's important to note that while the statistics may well be over-interpreted/misinterpreted to imply that pemetrexed demonstrates meaningfully superior efficacy vs. other partner agents for a platinum in advanced non-squamous NSCLC, I and most of my colleagues who have a particular focus and expertise in thoracic oncologists try to be very judicious in our interpretation of the landscape. Few if any of us would consider pemetrexed to be the clear best choice among the various options, and I don't think any expert would consider alternatives to be a wrong choice. That said, there is near uniformity in favoring carbo/pemetrexed +/- bevacizumab in advanced non-squamous NSCLC not because it's overwhelmingly better but because it's just better enough in its therapeutic index to bubble up to the top. We need to choose one regimen, and for nearly all thoracic oncologists who have a full range of options available, the combination of good if not markedly superior efficacy combined with the favorable side effect profile, convenient schedule, and several other factors make it the best option to nearly all of us, even if not by a wide margin. That it is expensive, and specifically more expensive than some very inexpensive and perfectly serviceable alternatives is a separate question. The reality of the situation is that few specialists in thoracic oncology are forced to weigh or even carefully consider the question of the incremental value of pemetrexed over other alternatives. Unless that issue becomes prioritized enough for US oncologists to be incentivized to carefully consider the relative costs of agents, we will focus far more on the patient experience and patient/physician satisfaction without feeling compelled to seek a relative bargain option.