DR HEYMACH: After about 18 months, he developed a low-volume recurrence. He had a positive malignant effusion that came back and had some malignant cells in there. Still minimally symptomatic from it and not bulky disease elsewhere. Didn’t develop a CNS recurrence, as we feared he might.
DR LOVE: So we want to talk about new drugs in development, Ram, particularly the LDK compound. But outside a protocol setting, what do you do when somebody progresses? Do you continue the crizotinib/chemotherapy? How do you think through this outside a trial setting?
DR GOVINDAN: So if you have no other choice, I suppose you can change them over to chemotherapy. But I would ask people to seriously rethink about that strategy, because take any second-generation ALK inhibitor, you see the response rates are spectacular. This is not something we see with EGFR-mutant disease. And what is fascinating is that at least with LDK378, and I’m sure we’ll see hopefully in the coming years with other compounds, the response rate does not defer much whether you had previous crizotinib or whether you progressed after crizotinib. So I think really there’s a fascinating story emerging. And I personally think — and I could be wrong — that we’re going to make more or significant progress in ALK-rearranged non-small cell lung cancer in the short term than even EGFR-mutant disease, because the second- and third-generation ALK inhibitors — second-generation ALK inhibitors and all their compounds that are available are actually giving very nice responses. And some of them seem to be very durable. Of course, early data yet. And they do all the things you want. They go to the brain. You’ll see dramatic responses in the brain. The responses are predictable. They are durable. And these patients are very nice. I have patients who are on second-generation ALK inhibitors doing very well. And so I really think we should make every effort to send patients to those trials rather than treat them empirically with chemotherapy.
DR LOVE: Maybe you can follow up on what happened to the patient.
DR HEYMACH: Yes. So obviously one possibility we were considering was chemotherapy. And he had gotten chemoradiotherapy and, as part of that, he had carboplatin and paclitaxel, and then 2 cycles of consolidation chemotherapy at the end of that. I hadn’t given him the chemoradiotherapy. But he hadn’t gotten a pemetrexed-based regimen. We know response rates are high among ALK mutants to pemetrexed. So that was one option, or a clinical study. We didn’t actually have the LDK study open at our institution at that time. So we actually sent him to Colorado for the study. And he ended up going on the LDK378 drug. He’s now more than a year and he’s had a fantastic response and continues to be I think in essentially a CR state, so doing absolutely great on the drug with no evidence of progression at this time.
DR LOVE: Any toxicity or tolerability issues?
DR HEYMACH: I haven’t been seeing him routinely since he’s been getting the drug outside. But at least as far as I can tell, he’s doing great on the drug.