DR GOVINDAN: So I use erlotinib currently. I’ve not switched over to afatinib in all these patients.
And this person, given the response rate we see with erlotinib, I wouldn’t have any hesitation in starting her on erlotinib.
DR LOVE: So — and your reasoning behind that, as opposed to afatinib? I’m sure it’s multifactorial, but maybe you can put out the first top 3.
DR GOVINDAN: Top 3: Number 1, we have not shown that afatinib is superior to erlotinib in these patients, in patients with EGFR-mutant non-small cell lung cancer.
DR LOVE: And we should — in your view is it at least equivalent?
DR GOVINDAN: Appears so from looking at 2 different studies, but —
DR LOVE: That’s not an efficacy reason that you’re choosing erlotinib?
DR GOVINDAN: There is no reason to go to a new drug over erlotinib at the moment.
DR LOVE: And any other issues?
DR GOVINDAN: Second is I get the sense the toxicities are a little bit more with afatinib, particularly diarrhea. I guess we can manage that, but for me to move to a new agent, either it has to be vastly superior or ought to have very low side effects. And I don’t see that with afatinib.
What about this issue, Dave, of toxicity?
DR SPIGEL: We have randomized trials now versus pem and cis/pem, cis/gem, the actual — 2 years ago, the cis/pem randomized trial suggested very high rates of diarrhea. Even low-grade diarrhea we all recognize as a concern. Stomatitis is a big issue, too. Actually, kind of not as well recognized is the randomized trial with gem. The rates of GI side effects were actually much lower reported at last year’s ASCO.
DR LOVE: How about your own experience?
DR SPIGEL: So my own experience is the approved dose may be a hard one for most patients to stay on. And that might be true for erlotinib, too. Right? We routinely lower the dose there. And I think probably when you modify the dose and, certainly, use things like loperamide early, it does become much more manageable. I — clearly, efficacy, none of us know the answer to that.
DR RIELY: The key thing with all of the TKIs is managing toxicity and getting to a dose that’s good. I think that’s — you can get to the dose that you need to get to with afatinib. You can get to the dose you need to get to with erlotinib. I think the drugs are generally probably at a higher dose than they need to be at their recommended starting dose. And if you just — for every individual patient, I think you need to work to the place you need to be on the dose.
DR LOVE: So is there anyone here who would use anything other than erlotinib in this patient? John?
DR HEYMACH: Afatinib’s label is only for first-line, EGFR-mutant non-small cell lung cancer right now. And erlotinib has a much broader label. We don’t know which is better, but from the LUX-Lung 3, one has the sense that they’re comparable at a minimum. They are doing a head-to-head trial of that.
So one consideration is if you start with afatinib, you still have the option of using erlotinib in the second- and third-line studies, potentially in combinations and so forth. So I just feel it leaves more options open if you start with afatinib and then use erlotinib as it’s indicated on the label.
DR LOVE: So you would use afatinib in this lady?
DR HEYMACH: I would certainly consider starting with afatinib, yeah.
DR LOVE: So that — of course, that’s today, Chandra. I imagine when you first saw her that wasn’t an option. What happened next?
DR BELANI: So we started her on erlotinib. I still think that we have much more experience with erlotinib and there is slightly more toxicity with afatinib, so we started her on erlotinib. And she got 6 months of treatment.
DR LOVE: How did she do on the erlotinib?
DR BELANI: She did very well.
DR LOVE: Any dermatologic problems?
DR BELANI: She did have a Grade 1 rash, which then subsequently, after 2 months, it disappeared totally.
DR LOVE: And what happened to the disease?
DR BELANI: The disease initially shrank, but 6 months later she developed increasing liver metastases.
DR LOVE: And what was her state at that time? Was she asymptomatic or starting to become symptomatic?
DR BELANI: She was still asymptomatic.