Systemic treatment in EGFR-ALK NSCLC patients: second line therapy and beyond

Abstract

Lung cancer is the most frequently diagnosed cancer and a leading cause of cancer mortality worldwide, with adenocarcinoma being the most common histological subtype. Deeper understanding of the pathobiology of non-small cell lung cancer (NSCLC) has led to the development of small molecules that target genetic mutations known to play critical roles in progression to metastatic disease and to influence response to targeted therapies. The principle goal of precision medicine is to define those patient populations most likely to respond to targeted therapies. However, the cancer genome landscape is composed of relatively few "mountains" [representing the most commonly mutated genes like KRAS, epidermal growth factor (EGFR), and anaplastic lymphoma kinase (ALK)] and a vast number of "hills" (representing low frequency but potentially actionable mutations). Low-frequency lesions that affect a druggable gene product allow a relatively small population of cancer patients for targeted therapy to be selected.

Keywords: Lung cancer; TKI resistance; anaplastic lymphoma kinase fusions (ALK fusions); epidermal growth factor (EGFR); tyrosine kinase inhibitors (TKIs).

Figure 1

Crosstalk signaling pathways as potential mechanisms of resistance to reversible or irreversible EGFR TKIs. EGFR, epidermal growth factor; TKIs, tyrosine kinase inhibitors.

Figure 2

EML4-ALK signaling pathways and potential mechanisms of resistance to targeted therapies. EML4-ALK, echinoderm microtubule-associated protein-like 4- anaplastic lymphoma kinase.