Thread by @ShrutiPatelMD

@TumorBoardTues 1/16 #TumorBoardTuesday #LungCancer #OncTwitter

38yo 👩🏻with remote 8 pk-yr 🚬hx
CP & diarrhea
PMH: None
🩻: 2 cm focal consolidations in the LLL
PET: GGO in LLL SUV 4.5
🔪+ mediastinal staging
🔬pT2a, pN1 (Stage IIB) lung adenoCa
🤨What adjuvant systemic tx would YOU give next?

@TumorBoardTues 2/16 #TumorBoardTuesday #LCSM #LungCancer

🧪 Resected 🫁 tissue tested
🦠 Tissue NGS and IHC was sent 🧬
🔬 NGS: EGFR exon 19 deleted
🔬 PD-L1 52%

🤨 What adjuvant treatment plan do you initiate next?

@TumorBoardTues 3/16 #TumorBoardTuesday #LungCancer
👩🏽‍🏫Mini tweetorial 1 👩🏽‍🏫

🚩🚩🚩 for EGFR mutations

🚩 Asian >> Western - 47.9% vs 19.2% according to metaA
🚩 Higher in NEVER smoker 🚭
🚩 More prevalent in females
🚩 Pathologic Subtype (adeno>>SCC)

@TumorBoardTues 4/16 #TumorBoardTuesday
👩🏽‍🏫Mini tweetorial 2👩🏽‍🏫

Different Types of EGFR mutations

​​✅Classic Activating EGFR Mut
▫️L858R, del19 Outside US
✅Uncommon EGFR Muts
▫️G719X, L861Q, S768I
✅EGFR Exon 20 Insertions

MOA: EGFR ⏫→ PI3K/RAS/JAK pathway ⏫→ uncontrolled cell growth

@TumorBoardTues @AnaVManana @JoelNealMD @HwakeleeMD @esinghimd @GlopesMd @Latinamd @jmsuga @IbiayiMD @DrSteveMartin @CBelaniMD 4.5/16 #TumorBoardTuesday #LungCancer
👩🏽‍🏫Mini tweetorial 2.5👩🏽‍🏫

⚠️Type of EGFR mut can change treatment plan⚠️

​​✅ Classic Activating EGFR Mut ⇒ osi
✅ Uncommon EGFR Muts ⇒ osi
✅ EGFR exon 20 insertion ⇒ amivantamab

📚 Osimertinib in tx of #NSCLC doi.org/10.2147/LCTT.S…

@TumorBoardTues @AnaVManana @JoelNealMD @HwakeleeMD @esinghimd @GlopesMd @Latinamd @jmsuga @IbiayiMD @DrSteveMartin @CBelaniMD 5/16 #TumorBoardTuesday
👩🏽‍🏫Mini tweetorial 3
✨Initial EGFR Adjuvant Trials✨

ADJUVANT: Adjuvant gefitinib = improved DFS over SOC chemo ⇒ BUT DFS advantage didn’t show major OS difference

📚OS data of Gefitinib v chemo for adj tx in EGFR mut #NSCLC doi.org/10.1200/JCO.20…

@TumorBoardTues @AnaVManana @JoelNealMD @HwakeleeMD @esinghimd @GlopesMd @Latinamd @jmsuga @IbiayiMD @DrSteveMartin @CBelaniMD 6/16 #TumorBoardTuesday
👩🏽‍🏫Mini tweetorial 4
✨Initial EGFR Adjuvant Trials ✨
RADIANT: DFS no major difference btwn 50.5 mo w erlotinib vs 48.2 mo placebo.

📚DFS of erlotinib v chemo for adj tx in EGFRm #NSCLC doi.org/10.1200/JCO.20…

♦️1st gen TKIs trial negative for OS benefit

@TumorBoardTues @AnaVManana @JoelNealMD @HwakeleeMD @esinghimd @GlopesMd @Latinamd @jmsuga @IbiayiMD @DrSteveMartin @CBelaniMD 7/16 #TumorBoardTuesday #LCSM
👩🏽‍🏫Mini tweetorial 5 👩🏽‍🏫
✨Initial Adjuvant Trials in EGFR✨

Subgroup analysis:
👉🏽 adjuvant gefitinib >>>> efficacy if treatment was >18 months
👉🏽 led to the starting point for the dosing schedule of ADAURA with 3 years total treatment

TLDR ⤵️

@TumorBoardTues @AnaVManana @JoelNealMD @HwakeleeMD @esinghimd @GlopesMd @Latinamd @jmsuga @IbiayiMD @DrSteveMartin @CBelaniMD @n8pennell @jillfeldman4 @JackWestMD @FawziAbuRous @ADesaiMD @drRTee @CharuAggarwalMD @CatherineShuMD @VivekSubbiah @DevikaDasMD 8/16 #TumorBoardTuesday
👩🏽‍🏫Mini tweetorial 6 👩🏽‍🏫

✨ADAURA - Osimertinib in Adjuvant Setting ✨

📍DFS @ 2y: 90% of Stage II-IIA pts v 44% in placebo
📍⬇️ locoregional & distant relapses + ⬇️ CNS recurrence events with osi
📍DFS benefit with osi irrespective of adjuvant chemo

@TumorBoardTues @AnaVManana @JoelNealMD @HwakeleeMD @esinghimd @GlopesMd @Latinamd @jmsuga @IbiayiMD @DrSteveMartin @CBelaniMD @n8pennell @jillfeldman4 @JackWestMD @FawziAbuRous @ADesaiMD @drRTee @CharuAggarwalMD @CatherineShuMD @VivekSubbiah @DevikaDasMD 9/16 #TumorBoardTuesday #LungCancer #LCSM
👩🏽‍🏫Mini tweetorial 7 👩🏽‍🏫

✨✨Adverse Effects - ADAURA ✨✨
👤 generally well tolerated medication
❌ serious AE occuring in 16% osi vs 12% placebo

ADAURA: doi.org/10.1056/NEJMoa…

@TumorBoardTues @AnaVManana @JoelNealMD @HwakeleeMD @esinghimd @GlopesMd @Latinamd @jmsuga @IbiayiMD @DrSteveMartin @CBelaniMD @n8pennell @jillfeldman4 @JackWestMD @FawziAbuRous @ADesaiMD @drRTee @CharuAggarwalMD @CatherineShuMD @VivekSubbiah @DevikaDasMD @EleanorKMishra @DrBalukuJoseph @brucekirenga @FredrikThege @cwilliamszf @LeQuesneLab @drtclay @DrAnnaMcGuire @ksivaprasadk 10/16 #TumorBoardTuesday
👩🏽‍🏫Mini tweetorial 8👩🏽‍🏫
✨Osimertinib in Adjuvant Setting✨

🤨Unanswered Q’s

⏳Duration
💊Adjuvant tx necessary
💸Cost
🌈OS benefit
🌍Access⬇️income countries

👀below &🎧by @CBelaniMD @n8pennell @jillfeldman4 @JackWestMD

https://twitter.com/IASLC/status/1280567117868183552?s=20&t=0_GYq-Te46We2Sdg4hozHQ

@TumorBoardTues @AnaVManana @JoelNealMD @HwakeleeMD @esinghimd @GlopesMd @Latinamd @jmsuga @IbiayiMD @DrSteveMartin @CBelaniMD @n8pennell @jillfeldman4 @JackWestMD @FawziAbuRous @ADesaiMD @drRTee @CharuAggarwalMD @CatherineShuMD @VivekSubbiah @DevikaDasMD @EleanorKMishra @DrBalukuJoseph @brucekirenga @FredrikThege @cwilliamszf @LeQuesneLab @drtclay @DrAnnaMcGuire @ksivaprasadk 11/16 #TumorBoardTuesday #LCSM
Back to our case 🔎

👩🏻 Patient returns to clinic to discuss adjuvant options
💭 1L chemo vs osi mono only

📍Chemo STILL recommended as we have OS data for this therapy (unlike osi).
📍SOC chemo still has role in adjuvant setting‼️

@TumorBoardTues @AnaVManana @JoelNealMD @HwakeleeMD @esinghimd @GlopesMd @Latinamd @jmsuga @IbiayiMD @DrSteveMartin @CBelaniMD @n8pennell @jillfeldman4 @JackWestMD @FawziAbuRous @ADesaiMD @drRTee @CharuAggarwalMD @CatherineShuMD @VivekSubbiah @DevikaDasMD @EleanorKMishra @DrBalukuJoseph @brucekirenga @FredrikThege @cwilliamszf @LeQuesneLab @drtclay @DrAnnaMcGuire @ksivaprasadk @ANavarro_MD @DasMillie11 @JulieBrahmer @Jbauml @StephenVLiu @gdurm @Surbhi_Singhal2 @DivyaGuptaMD @visheshkhanna 12/16 #TumorBoardTuesday
💊patient completed adjuvant chemo & began 80mg osimertinib daily
🏥Presents to clinic 2 months later for f/u

🚨Osi SE - THINGS TO MONITOR FOR 🚨

👺Rash, Acne, Dry Skin
💩Diarrhea
🖐🏽Paronychia
🥃Hepatic
🫁Pneumonitis
🫀LVEF, QTc

@TumorBoardTues @AnaVManana @JoelNealMD @HwakeleeMD @esinghimd @GlopesMd @Latinamd @jmsuga @IbiayiMD @DrSteveMartin @CBelaniMD @n8pennell @jillfeldman4 @JackWestMD @FawziAbuRous @ADesaiMD @drRTee @CharuAggarwalMD @CatherineShuMD @VivekSubbiah @DevikaDasMD @EleanorKMishra @DrBalukuJoseph @brucekirenga @FredrikThege @cwilliamszf @LeQuesneLab @drtclay @DrAnnaMcGuire @ksivaprasadk @ANavarro_MD @DasMillie11 @JulieBrahmer @Jbauml @StephenVLiu @gdurm @Surbhi_Singhal2 @DivyaGuptaMD @visheshkhanna 12.5/16 #TumorBoardTuesday
Osi SE cont’d

🚨ALWAYS ADDRESS FERTILITY CONCERNS🚨

Osi can ⬇️fertility in 🙋‍♀️💁‍♂️pts
🙋‍♀️: likely reversible ⇒ rec: contraception during rx + 6 weeks after final dose
💁‍♂️: unknown reversibility ⇒ rec: contraception during rx + 4 months after final dose

@TumorBoardTues @AnaVManana @JoelNealMD @HwakeleeMD @esinghimd @GlopesMd @Latinamd @jmsuga @IbiayiMD @DrSteveMartin @CBelaniMD @n8pennell @jillfeldman4 @JackWestMD @FawziAbuRous @ADesaiMD @drRTee @CharuAggarwalMD @CatherineShuMD @VivekSubbiah @DevikaDasMD @EleanorKMishra @DrBalukuJoseph @brucekirenga @FredrikThege @cwilliamszf @LeQuesneLab @drtclay @DrAnnaMcGuire @ksivaprasadk @ANavarro_MD @DasMillie11 @JulieBrahmer @Jbauml @StephenVLiu @gdurm @Surbhi_Singhal2 @DivyaGuptaMD @visheshkhanna 13/16 #TumorBoardTuesday
🙏🏽Pt doing well, only Sx is mild diarrhea.

Per ADAURA ⤵️
💩 Diarrhea most common SE💩
Any grade: 46%
Grade 3: 2%

🫧Lifestyle changes recommended

🍽Nutritionist
📔BM diary
💊PRN anti-diarrheal medication

@TumorBoardTues @AnaVManana @JoelNealMD @HwakeleeMD @esinghimd @GlopesMd @Latinamd @jmsuga @IbiayiMD @DrSteveMartin @CBelaniMD @n8pennell @jillfeldman4 @JackWestMD @FawziAbuRous @ADesaiMD @drRTee @CharuAggarwalMD @CatherineShuMD @VivekSubbiah @DevikaDasMD @EleanorKMishra @DrBalukuJoseph @brucekirenga @FredrikThege @cwilliamszf @LeQuesneLab @drtclay @DrAnnaMcGuire @ksivaprasadk @ANavarro_MD @DasMillie11 @JulieBrahmer @Jbauml @StephenVLiu @gdurm @Surbhi_Singhal2 @DivyaGuptaMD @visheshkhanna 14/16 #TumorBoardTuesday
📌ADAURA trial treated patients for 3 years or until disease progress or poor tolerability
📌Duration is from prior subgroup analysis of TKIs trials suggesting more benefit if therapy was >18 months
📌Question remains if < 3 years could ever be explored

@TumorBoardTues @AnaVManana @JoelNealMD @HwakeleeMD @esinghimd @GlopesMd @Latinamd @jmsuga @IbiayiMD @DrSteveMartin @CBelaniMD @n8pennell @jillfeldman4 @JackWestMD @FawziAbuRous @ADesaiMD @drRTee @CharuAggarwalMD @CatherineShuMD @VivekSubbiah @DevikaDasMD @EleanorKMishra @DrBalukuJoseph @brucekirenga @FredrikThege @cwilliamszf @LeQuesneLab @drtclay @DrAnnaMcGuire @ksivaprasadk @ANavarro_MD @DasMillie11 @JulieBrahmer @Jbauml @StephenVLiu @gdurm @Surbhi_Singhal2 @DivyaGuptaMD @visheshkhanna 15/16 #TumorBoardTuesday
🎂Does age matter?

Elder pts safety data:
✅generally well tolerated
✅grade ≥2💥NOT💥more frequent in older adult compared with younger pts (except🖐🏽Paronychia)

‼️Remember⬆️🫀comorbidities⚠️d/t🫀failure risk‼️
✅geriatric assessment before & after🔪

@TumorBoardTues @AnaVManana @JoelNealMD @HwakeleeMD @esinghimd @GlopesMd @Latinamd @jmsuga @IbiayiMD @DrSteveMartin @CBelaniMD @n8pennell @jillfeldman4 @JackWestMD @FawziAbuRous @ADesaiMD @drRTee @CharuAggarwalMD @CatherineShuMD @VivekSubbiah @DevikaDasMD @EleanorKMishra @DrBalukuJoseph @brucekirenga @FredrikThege @cwilliamszf @LeQuesneLab @drtclay @DrAnnaMcGuire @ksivaprasadk @ANavarro_MD @DasMillie11 @JulieBrahmer @Jbauml @StephenVLiu @gdurm @Surbhi_Singhal2 @DivyaGuptaMD @visheshkhanna 16/16 #TumorBoardTuesday #LungCancer #LCSM
🫁🫁Case outcome 🫁🫁

Fast forward 15 months

👩🏻 Patient: on 80mg osimertinib daily
🙏🏽 No new SE or dose adjustments
🎉 scans: NED 🙌🏽

🧑‍💻Thoracic oncologists: desperately awaiting OS data