- Email: [email protected]
MET Inhibition with Dacomitinib and Crizotinib in Advanced Non–Small Cell Lung Cancer: Results of a Phase I Study
ORIGINAL ARTICLE
Combined Pan-HER and ALK/ROS1/MET Inhibition with Dacomitinib and Crizotinib in Advanced Non–Small Cell Lung Cancer: Results of a Phase I Study Pasi A. Jänne, MD, PhD,a,b,* Alice T. Shaw, MD, PhD,c D. Ross Camidge, MD, PhD,d Giuseppe Giaccone, MD, PhD,e S. Martin Shreeve, MD, PhD,f Yiyun Tang, PhD,f Zelanna Goldberg, MD,f Jean-François Martini, PhD,f Huiping Xu, PhD,f Leonard P. James, MD, PhD,g Benjamin J. Solomon, M.B.B.S., PhDh a
Lowe Center for Thoracic Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts Belfer Center for Applied Cancer Science, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts c Massachusetts General Hospital, Boston, Massachusetts d University of Colorado Denver, Colorado e Georgetown University, Washington, District of Columbia f Pfizer Oncology, La Jolla, California g Pfizer Oncology, New York, New York h Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia b
Received 22 December 2015; accepted 26 January 2016 Available online - 17 February 2016
ABSTRACT Introduction: This phase I study investigated the activity of the irreversible pan-human epidermal growth factor receptor inhibitor dacomitinib in combination with the mesenchymal-epithelial transition factor/anaplastic lymphoma kinase/ROS proto-oncogene 1, receptor tyrosine kinase inhibitor crizotinib in advanced non–small cell lung cancer. Methods: Patients with progression after at least one line of chemotherapy or targeted therapy received dacomitinib once daily and crizotinib once daily or twice daily, with doses escalated until intolerable toxicity; the expansion cohorts received the maximum tolerated dose of the combination. The primary objective was to define the recommended phase II dose; secondary objectives included assessment of safety and activity of the combination in epidermal growth factor receptor inhibitor-resistant patients and correlation with tumor biomarkers. Results: Seventy patients were treated in the doseescalation (n ¼ 33) and expansion phases (n ¼ 37), with the maximum tolerated dose defined as dacomitinib, 30 mg once daily, plus crizotinib, 200 mg twice daily. Grade 3 or 4 treatment-related adverse events were reported in 43% of patients: the most common were diarrhea (16%), rash (7%), and fatigue (6%). There were 16 deaths; none were considered treatment related. One patient (1%) had a partial response; 46% had stable disease. Most of the tumor samples analyzed had activating
epidermal growth factor receptor gene (EGFR) mutations (18 of 20 [90%]); 50% (10 of 20) had a concurrent resistance mutation. Only one sample showed MMNG HOS Transforming gene (MET) amplification (the patient had progressive disease), whereas 59% (13 of 22) and 47% (14 of 30) had high levels of expression of epidermal growth factor receptor and mesenchymal-epithelial transition factor on the basis of H-scores, respectively. There was no apparent association between biomarker expression and antitumor activity.
*Corresponding author. Disclosure: Dr. Jänne reports receiving grants and research support from Astellas and AstraZeneca; receiving consulting fees from Astra Zeneca, Roche, Genentech, Merrimack, Chugai, and Clovis Oncology; and holding stock in Gatekeeper. Dr. Shaw reports receiving grants and personal fees from Pfizer, Novartis, Ariad, Chugai, Genentech, DaiichiSankyo, and Ignyta. Dr. Camidge reports receiving consulting fees from Pfizer. Drs. Shreeve, Tang, Goldberg, Martini, Xu, and James were employees of Pfizer at the time this work was conducted and held Pfizer stock. Dr. Solomon reports receiving consulting fees from Pfizer, Novartis, Roche, Merck Sharpe & Dohme, AstraZeneca, and BMS; receiving research funding from Pfizer; holding patent/ intellectual property with Biodesix; and receiving travel, accommodation, and other expenses from Roche and AstraZeneca. The remaining author declares no conflict of interest. Address for correspondence: Pasi A. Jänne, MD, PhD, Lowe Center for Thoracic Oncology, Dana-Farber Cancer Institute, 450 Brookline Ave., LC4114, Boston, MA 02215. E-mail: [email protected] ª 2016 International Association for the Study of Lung Cancer. Published by Elsevier Inc. All rights reserved. ISSN: 1556-0864 http://dx.doi.org/10.1016/j.jtho.2016.01.022
Journal of Thoracic Oncology
Vol. 11 No. 5: 737-747
738 Jänne et al
Conclusion: The combination of dacomitinib and crizotinib showed limited antitumor activity in patients with advanced non–small cell lung cancer and was associated with substantial toxicity. 2016 International Association for the Study of Lung Cancer. Published by Elsevier Inc. All rights reserved. Keywords: Non–small cell; Dacomitinib; Crizotinib; EGFR TKI resistance; Biomarkers
Introduction In non–small cell lung cancer (NSCLC), the presence of specific activating mutations in the epidermal growth factor receptor gene (EGFR) is predictive of benefit from treatment with epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs).1–5 Sensitizing mutations have been reported to occur in 8% to 17% of nonAsian patients,1,6,7 with frequencies of 30% reported in Asian patients.1 For patients with advanced EGFRmutant lung cancer, EGFR TKIs are the standard of care,8 offering marked improvements in clinical outcomes compared with standard chemotherapy.9 Development of resistance to EGFR TKIs, however, is inevitable,10 most frequently through the acquisition of a T790M mutation in EGFR (responsible for an estimated 50% to 60% of cases11). Upregulation or activation of other receptor tyrosine kinases (RTKs) such as mesenchymalepithelial transition factor (MET) through gene amplification has also been observed, with earlier reports putting the frequency of MMNG HOS Transforming gene (MET) amplification at 15% to 22%12–15 and more recent analyses reporting frequencies of 5%.16,17 Both EGFR mutations and MET amplification have been detected in the same tumor and individually in independent tumors from the same individual,12,13,18 suggesting that heterogeneity may play an important role in resistance. Dacomitinib and crizotinib are active against EGFRmutated and MET-activated tumors, respectively.19–25 Dacomitinib is a highly selective irreversible secondgeneration inhibitor of the human epidermal growth factor receptor (HER) family of RTKs—including EGFR (HER1)—and was effective in preclinical models that showed resistance to the first-generation EGFR TKIs gefitinib or erlotinib, including those expressing the T790M resistance mutation.19,20 In the clinic, dacomitinib has demonstrated efficacy in a phase II trial in EGFR TKI–naive patients with advanced NSCLC who were selected on the basis of clinical or molecular criteria.26 In phase III trials, dacomitinib has not demonstrated superiority over placebo or erlotinib in unselected patients who were previously treated with chemotherapy.27,28 Crizotinib, an inhibitor of MET, anaplastic lymphoma
Journal of Thoracic Oncology
Vol. 11 No. 5
kinase, and ROS proto-oncogene 1 (ROS1), was first approved by the U.S. Food and Drug Administration in 2011 for the treatment of advanced anaplastic lymphoma kinase gene (ALK)-positive NSCLC.29 A fast and durable response with crizotinib was achieved in a patient with MET amplification but negative for ALK.21 Several other case reports have also shown a response to crizotinib in patients with tumors bearing MET amplification and/or MET mutations.22–24,30 In a cohort of 14 patients with NSCLC and MET amplification treated with crizotinib, five were shown to have objective responses (ORs).25 In vitro studies and an in vivo study using a transgenic mouse lung tumor model expressing EGFR-mutant Del19-T790M or L858R-T790M, each with concurrent MET overexpression, have shown synergistic effects between MET and EGFR inhibition when combined.31–33 A second study also demonstrated synergy of crizotinib and newer-generation EGFR TKIs in mouse tumor models, although toxicity was an issue when crizotinib was combined with afatinib at higher doses.34 These data suggested that patients in whom resistance to EGFR TKIs has developed through MET amplification or upregulation may benefit from combined inhibition of MET and EGFR. This report describes the results of a phase I study of the combination of dacomitinib and crizotinib in patients with NSCLC after failure of at least one prior chemotherapy regimen or EGFR TKI (ClinicalTrials.gov identifier: NCT01121575). The study consisted of two phases: a dose-escalation phase and an expansion phase.
Patients and Methods Patient Population The study enrolled adults aged 18 years or older with histologically proven locally advanced or metastatic NSCLC after failure of prior chemotherapy or targeted therapy (dose-escalation phase) or acquired resistance to erlotinib or gefitinib (expansion phase). Acquired resistance was defined as progression after an initial response (complete or partial response [PR]) or stable disease (SD) for at least 6 months while receiving single-agent erlotinib or gefitinib. Other key eligibility criteria were an Eastern Cooperative Oncology Group performance status of 0 to 2, adequate organ function, and at least one measurable or evaluable lesion. Exclusion criteria included participation in other studies or lung cancer treatment within 2 weeks of the study’s start, interstitial fibrosis or lung disease, brain metastases unless neurologically stable, cardiac abnormalities or uncontrolled hypertension, and prior malignancy (other than NSCLC) within the past 3 years. Each patient gave written informed consent to their participation in the study.
May 2016
Study Design and Treatment This was a multicenter, open-label, nonrandomized, dose-escalation phase I study with an expansion phase (Supplementary Fig. 1). Patients enrolled in the doseescalation phase were initially dosed at 30 mg of dacomitinib once daily and 200 mg of crizotinib twice daily (twice daily, dose level 1). The first cycle was defined as 28 days, with subsequent cycles defined as 21 days. The dose was escalated or reduced until the maximum tolerated dose (MTD) was determined as described in Supplementary Methods; other planned dose levels are shown in Supplementary Table 1. The MTD was defined as the dose level of combined dacomitinib and crizotinib at which none or one of six patients presented with a dose-limiting toxicity (DLT) during cycle 1 of treatment, with the next highest dose being the maximally administered dose at which two or more patients experienced DLTs. The expansion phase comprised two cohorts that ran concurrently. A new tumor biopsy was required for enrollment, with further samples optional. In expansion cohort 1, patients received combined dacomitinib and crizotinib orally on a continuous daily schedule. To evaluate the effect of dacomitinib on crizotinib pharmacokinetics (PK), patients received single-agent crizotinib on a continuous daily schedule for a 10- to 14-day lead-in period before introduction of dacomitinib. In expansion cohort 2, patients were initially treated with dacomitinib only until progression and then received combined dacomitinib and crizotinib; the effect of crizotinib on dacomitinib PK was assessed in this cohort. The primary objective of the study was to define the recommended phase II dose of combined dacomitinib and crizotinib in patients with advanced NSCLC. Secondary objectives were to assess the overall safety and tolerability of the combination, the antitumor activity of combined treatment, and the PK of the single agents and the combination; to analyze baseline biomarkers in tumors and blood in patients with acquired resistance to erlotinib or gefitinib and the effect of combined dacomitinib and crizotinib on biomarkers in these patients; and to explore mechanisms of resistance to EGFRtargeted therapy. The study was conducted according to the principles of the Declaration of Helsinki and complied with International Conference on Harmonisation Good Clinical Practice Guidelines. The protocol was approved by the relevant institutional review boards or independent ethics committees.
Assessments Adverse events (AEs) were graded using National Cancer Institute Common Terminology Criteria for Adverse Events (version 4.02) and were monitored until
Pan-HER and ALK/ROS1/MET Inhibition in NSCLC
739
at least 28 days after the last dose of the study drug. Other safety assessments included determination of laboratory parameters, physical examination, measurement of vital signs, electrocardiograms, and ophthalmology examinations. Disease was assessed at baseline and every other cycle, beginning on day 1 of cycle 3. Computed tomography or magnetic resonance imaging was performed whenever disease progression was suspected or to confirm an OR lasting at least 4 weeks after first documentation. Antitumor activity was assessed by investigators according to Response Evaluation Criteria in Solid Tumors v1.1. Brain and bone scans were performed regularly if brain or bone metastases were detected at screening or if clinically indicated.
PK PK-evaluable patients are described in Supplementary Methods. Blood samples were collected on day 1 (the day before day 1 of cycle 1 of combination treatment) and day 1 of cycle 2 in the expansion cohorts to evaluate the possible effects of crizotinib and dacomitinib on each other. Plasma crizotinib and dacomitinib concentrations were determined separately using validated, sensitive, and specific high-performance liquid chromatography tandem mass spectrometry methods. PK parameters were estimated using noncompartmental analysis.
Biomarker Studies Tumor tissue biopsies from the expansion cohorts were evaluated for genetic and/or protein markers, including EGFR, erb-b2 receptor tyrosine kinase 2 gene (HER2), and Kirsten rat sarcoma viral oncogene homolog gene (KRAS) mutations. MET, EGFR, and HER2 amplification was assessed by fluorescence in situ hybridization (FISH); hepatocyte growth factor ([HGF] the ligand for MET), EGFR, and MET expression were measured by immunohistochemical (IHC) analysis; and ALK gene fusions were identified by FISH. Blood samples were taken for determination of soluble MET (s-MET) protein levels, which were measured by enzyme-linked immunosorbant assay. Staining intensity for EGFR, HGF, and MET were evaluated using IHC assays on a semiquantitative scale, and the percentage of neoplastic cells staining at each of the following four levels was recorded: 0 (unstained), 1þ (weak staining), 2þ (moderate staining), and 3þ (strong staining). An H-score was calculated using the following formula: (3 % cells staining at 3þ) þ (2 % cells staining at 2þ) þ (1 % cells staining at 1þ), yielding a possible range of 0 to 300. For the purposes of stratification, low and high expression were defined as H-scores of less than 150 or 150 or higher, respectively.
740 Jänne et al
The total percentage of positive cells (i.e., cells scoring 1þ), H-score, and percentage of cells staining 2þ and/ or 3þ were used for further statistical analyses. In the FISH assay, a standard cutoff of 2.1 for the ratio of target gene-specific signal to the centromere-specific signal was used to identify amplification events. ALK rearrangement was defined as positive in samples displaying more than 15% cells with rearrangements.
Statistical Analyses The safety analysis population included all patients who received at least one dose of study drug, of whom response-evaluable patients were those with an adequate baseline tumor assessment. OR rates (the proportion of response-evaulable patients with confirmed complete responses or PRs) were summarized with the corresponding two-sided 95% confidence interval (CI) calculated using the exact method based on the F distribution. If patients’ tumor remained stable for 6 weeks or longer after the first dose in the absence of an OR, their best overall response was classified as SD. Progression-free survival (PFS) was summarized using the Kaplan Meier method; the Brookmeyer-Crowley method was used to provide 95% CIs for estimates of the medians. The 95% CI for PFS at specific time points was calculated using the normal approximation to the log-transformed cumulative hazard rate on the basis of Greenwood’s estimate of the variance of PFS. All other data were summarized using descriptive statistics.
Results Patients Between August 2010 and February 2014, three centers in the United States and one in Australia enrolled 70 patients, including 33 patients in the dose-escalation phase and 37 patients in the expansion phase (cohort 1, n ¼ 25; cohort 2, n ¼ 12). All 70 patients received at least one dose of either or both study drugs and were therefore included in the safety analysis population; three patients in the expansion phase did not receive the combination. The response-evaluable population included 67 patients (96%): 33 in the dose-escalation phase and 34 in the expansion phase. Approximately half the patient population were never-smokers (51% [Table 1]). Nearly all patients (99%) had metastatic disease, most (90%) had an Eastern Cooperative Oncology Group performance status of 0 of 1, and 40% had received three or more prior lines of systemic therapy. Overall, 93% of patients had been previously treated with either erlotinib (90%) or gefitinib (3%); only five patients in the dose-escalation phase had received no prior EGFR TKI. Eight patients (11%) had received prior crizotinib, including seven in the
Journal of Thoracic Oncology
Vol. 11 No. 5
dose-escalation phase. Median treatment duration (range) was 52.5 days (2–287) for dacomitinib and 51.0 days (2–295) for crizotinib.
Safety In the dose-escalation phase (Supplementary Fig. 1), the dosing cohorts studied comprised patients receiving dacomitinib, 30 mg once daily, and crizotinib, 200 mg twice daily (n ¼ 14); dacomitinib, 30 mg once daily, and crizotinib, 250 mg twice daily (n ¼ 7); dacomitinib, 45 mg once daily, and crizotinib, 200 mg twice daily (n ¼ 6); and dacomitinib, 45 mg once daily, and crizotinib, 250 mg once daily (n ¼ 6). Three patients had DLTs: grade 3 increased alanine aminotransferase level (at dacomitinib, 45 mg once daily, and crizotinib, 200 mg twice daily, n ¼ 1), grade 3 diarrhea (at dacomitinib, 45 mg once daily, and crizotinib, 200 mg twice daily, n ¼ 1), and grade 3 mucosal inflammation (at dacomitinib, 30 mg once daily, and crizotinib, 250 mg twice daily, n ¼ 1). All three DLTs resolved. The MTD for the combination was therefore identified as dacomitinib, 30 mg once daily, and crizotinib, 200 mg twice daily, (dose level 1) and used in the expansion phase. In the study overall, 66 patients (94%) had at least one treatment-related AE (Table 2). The most common events were diarrhea (74%), nausea (57%), vomiting (41%), decreased appetite (39%), and fatigue (37%). Twenty-seven (39%) and three (4%) patients had grade 3 or 4 treatment-related AEs, respectively, of which diarrhea (16%), rash (7%), and fatigue (6%) were the most frequent (all grade 3). Across both study phases, 46 (66%) and 43 (61%) patients had at least one interruption in dacomitinib or crizotinib dosing, respectively. Six patients had a dose reduction: four in the dose-escalation phase (three reductions in dacomitinib and one in crizotinib) and two in expansion cohort 1 (one reduction in crizotinib and one in both dacomitinib and crizotinib). Eighteen patients (26%) permanently discontinued treatment (either dacomitinib or crizotinib or both) during the combination treatment period because of AEs of any cause, which were considered treatment-related in eight patients (11%). Ten patients (14%) had treatment-related serious AEs, which consisted of diarrhea (n ¼ 4); nausea, dehydration, and hyperuricemia (n ¼ 2 each); and hypersensitivity, increased blood creatinine level, acute respiratory distress syndrome, pulmonary embolism, and hypotension (n ¼ 1 each). Overall, 29 patients (41%) had serious AEs of any cause, with diarrhea (6%), disease progression (6%), and hypoxia (4%) the only events to occur in 4% of patients or more. During the combination treatment period, 15 patients (21%) died: seven during the dose-escalation phase
May 2016
Pan-HER and ALK/ROS1/MET Inhibition in NSCLC
741
Table 1. Patient Demographics and Baseline Disease Characteristics (Safety Analysis Population) Escalation Cohort Expansion Cohort 1 Expansion Cohort 2 Expansion Total Overall Total (n ¼ 33) (n ¼ 25) (n ¼ 12) (n ¼ 37) (N ¼ 70) Age, y Median 59.0 Range 38–78 Sex, n (%) Male 15 (45) Female 18 (55) Race, n (%) White 27 (82) Black 0 Asian 6 (18) Other 0 Smoking classification, n (%) Never smoked 12 (36) Current smoker 1 (3) Former smoker 20 (61) ECOG performance status, n (%) 0 8 (24) 1 21 (64) 2 4 (12) Time since diagnosis, y Median 2.1 Range 0.5–10.3 Histology, n (%) Adenocarcinoma 26 (79) Bronchioloalaveolar carcinoma 2 (6) Adenosquamous carcinoma 1 (3) Squamous cell carcinoma 1 (3) Large cell carcinoma 1 (3) Other 2 (6) No. prior systemic therapy regimens, n (%) 1 9 (27) 2 6 (18) 3 18 (55) Prior EGFR/HER TKI, n (%) Erlotinib 26 (79) 2 (6) Gefitiniba Dacomitinib 0 1 (3) Otherb Prior crizotinib 7 (21)
60.0 42–82
57.5 39–76
60.0 39–82
59.5 38–82
9 (36) 16 (64)
3 (25) 9 (75)
12 (32) 25 (68)
27 (39) 43 (61)
21 (84) 0 4 (16) 0
9 1 1 1
(75) (8) (8) (8)
30 (81) 1 (3) 5 (14) 1 (3)
57 (81) 1 (1) 11 (16) 1 (1)
18 (72) 2 (8) 5 (20)
6 (50) 0 6 (50)
24 (65) 2 (5) 11 (30)
36 (51) 3 (4) 31 (44)
4 (16) 19 (76) 2 (8)
2 (17) 9 (75) 1 (8)
6 (16) 28 (76) 3 (8)
14 (20) 49 (70) 7 (10)
2.1 0.6–5.1
4.3 0.9–29.3
3.1 0.6–29.3
2.8 0.5–29.3
22 (88) 1 (4) 1 (4) 0 0 1 (4)
10 (83) 1 (8) 0 0 0 1 (8)
32 (86) 2 (5) 1 (3) 0 0 2 (5)
58 (83) 4 (6) 2 (3) 1 (1) 1 (1) 4 (6)
9 (36) 11 (44) 5 (20)
4 (33) 3 (25) 5 (42)
13 (35) 14 (38) 10 (27)
22 (31) 20 (29) 28 (40)
25 (100) 0 0 2 (8) 1 (4)
12 (100) 0 1 (8) 1 (8) 0
37 (100) 0 1 (3) 3 (9) 1 (3)
63 (90) 2 (3) 1 (1) 4 (6) 8 (11)
a
Neither patient treated with prior gefitinib received treatment with erlotinib. Other HER TKIs included in the dose escalation cohorts: MM-121 (monoclonal antibody directed against HER3; n ¼ 1); in the expansion cohorts: cetuximab (cohort 1, n ¼ 2), afatinib (cohort 1, n ¼ 2 [the same patients who received cetuximab]), and pertuzumab (cohort 2, n ¼ 1). Note that all of these patients also received prior erlotinib. ECOG, Eastern Cooperative Oncology Group; EGFR, epidermal growth factor receptor; HER, human epidermal growth factor receptor; TKI, tyrosine kinase inhibitor. b
and eight during the expansion phase. In addition, one patient died 25 days after discontinuing single-agent crizotinib. In 15 cases, death was considered disease related; in one case, the cause was unknown. None were considered treatment related.
Antitumor Activity During the escalation phase, there were no ORs; 20 patients (61%) had a best overall response of SD. Among 34 evaluable patients in the expansion phase, one patient (expansion cohort 1) had a PR lasting 6.3 weeks and 11
patients (32%) had SD. The OR rate (95% exact CI) was 2.9% (0.115.3) for the expansion phase and 1.5% (0.08.0) across both phases of the study. Most cases of SD (19 of 31 [61%]) persisted for 3 to 6 months, and tumor shrinkage was observed in some patients in the expansion phase (Fig. 1). Median PFS was 3.0 months (95% CI: 2.84.3) in the escalation phase and 2.1 months (95% CI: 1.43.5) in the expansion phase (Supplementary Table 2). The probability of being progression free at months 2, 4, and 6 is shown in Supplementary Table 2.
742 Jänne et al
Journal of Thoracic Oncology
Vol. 11 No. 5
Table 2. Treatment-Related Adverse Events Occurring in at Least 10% of Patients (Safety Analysis Population, n ¼ 70) n (%) Adverse Event
Any Gradea
Grade 3
Any treatment-related adverse event Diarrhea Nausea Vomiting Decreased appetite Fatigue Paronychia Rash Peripheral edema Dry skin Acneiform dermatitis Mucosal inflammation Visual impairment Stomatitis Dyspepsia Skin fissures Increased ALT Anemia Increased AST Dysgeusia Pruritus
66 52 40 29 27 26 23 23 22 20 19 13 13 10 8 8 7 7 7 7 7
27 (39) 11 (16) 2 (3) 0 1 (1) 4 (6) 3 (4) 5 (7) 0 0 1 (1) 1 (1) 0 1 (1) 0 0 1 (1) 2 (3) 0 0 0
(94) (74) (57) (41) (39) (37) (33) (33) (31) (29) (27) (19) (19) (14) (11) (11) (10) (10) (10) (10) (10)
a
Three grade 4 treatment-related adverse events were reported: acute respiratory distress syndrome, hyperuricemia, and pulmonary embolism; there were no grade 5 treatment-related adverse events. ALT, alanine aminotransferase; AST, aspartate aminotransferase.
PK The effect of dacomitinib on plasma steady-state exposure of crizotinib was assessed in expansion cohort 1, and that of crizotinib on plasma steady-state exposure of dacomitinib was assessed in expansion cohort 2. Because of the limited number of patients evaluable for analysis of PK drug interaction, formal statistical analysis of these data would not have been meaningful. However, a trend toward decreased crizotinib exposure was observed when crizotinib was coadministered with dacomitinib compared with when it was administered alone (Table 3). A slight trend toward increased dacomitinib exposure was also observed during coadministration with crizotinib compared with administration of dacomitinib alone.
Biomarker Studies Tumor samples for biomarker analysis were available for 35 of 37 patients enrolled in the expansion phase (95%; cohort 1, n ¼ 23; cohort 2, n ¼ 12 [Supplementary Table 3]). Of the 20 samples suitable for EGFR mutational analysis (15 samples either had no tumor in the tissue or were of insufficient quantity for analysis), most (n ¼ 18) had activating EGFR mutations. Eleven of these samples showed a concurrent resistance mutation in exon 20
Figure 1. Best percentage change from baseline in target lesion size by patient in expansion cohort 1 (A) and expansion cohort 2 (B). On the basis of the response-evaluable population, excluding patients with early death, indeterminate response, or nonmeasurable disease.
(T790M alone [n ¼ 9], S768I alone [n ¼ 1], or T790M and S7681 [n ¼ 1]). Thirty, 26, and 22 tumor samples, respectively, were suitable for evaluation of MET, HER2, and EGFR amplification by FISH; 30 samples were also evaluable for ALK rearrangement. Only one sample showed low-level MET amplification (a ratio of the MET-specific signal to the centromere-specific signal of 2.12, with the cutoff for amplification defined as 2.1), and none showed HER2 amplification, whereas five of 22 samples displayed some level of EGFR amplification. No samples tested positive for ALK rearrangement. Thirty baseline tumor samples were suitable for IHC analysis of HGF and MET, whereas 22 samples were suitable for EGFR analysis. Expression of EGFR and MET varied widely, with the median percentage positive typically being 90% or higher but ranging from 2% to 100% for EGFR and from 0% to 100% for MET (Table 4). As assessed by H-scores, levels of expression of EGFR and MET were moderately high or moderate, respectively, with a few tumors displaying very strong expression. In the expansion cohort overall, mean and median H-scores, respectively, were 176 and 193 for EGFR (range 2–300) and 161 and 138 for MET (range 0– 300). However, no association was found between EGFR or MET protein expression and best percentage change in tumor volume, PFS, or treatment duration. EGFR and
May 2016
Pan-HER and ALK/ROS1/MET Inhibition in NSCLC
Table 3. Steady-State Plasma Crizotinib and Dacomitinib PK Parameter Summary in the Expansion Cohorts after Administration of Dacomitinib (30 mg Once Daily) and Crizotinib (200 mg Twice Daily) Alone or in Combination
Parameter (Units) Expansion cohort 1: crizotinib PK Total no. in treatment group No. contributing to summary statisticsa AUClast (ng∙h/mL) AUC10 (ng∙h/mL)b Cmin (ng/mL) Cmax (ng/mL) Tlast (h) Tmax (h) Expansion cohort 2: dacomitinib PK Total no. in treatment group No. contributing to summary statisticsc AUClast (ng∙h/mL) AUC24 (ng∙h/mL) Cmin (ng/mL) Cmax (ng/mL) CL/F (L/h) Tlast (h) Tmax (h)
Crizotinib or Dacomitinib Alone (Day 1)
Dacomitinib þ Crizotinib (Cycle 2, Day 1)
19
19
16
19
2223 (53) 2167 (56) 181.8 (64) 306.0 (57) 9.65 (7.63–10.1) 2.04 (0–4.00)
1365 (47) 1489 (44) 102.8 (51) 191.5 (43) 9.00 (7.67–10.0) 3.20 (2.02–9.00)
10
10
6
5
1016 (45) 995.7 (45) 33.11 (58) 47.15 (44) 32.24 (34) 24.40 (24.0–26.2) 16.0 (5.90–24.6)
1148 (44) 1148 (44) 39.92 (47) 59.58 (49) 26.09 (44) 23.80 (22.6–24.0) 5.92 (3.83–9.80)
Note: All values are geometric mean (geometric %CV) except median (range) for Tmax and Tlast. a Patients with 10 days of continuous crizotinib dosing. b Crizotinib, n ¼ 11; crizotinib þ dacomitinib, n ¼ 13. c Patients with 14 days of continuous dacomitinib dosing. AUC10, area under the plasma concentration-time curve for 10-hour samples; AUC24, area under the plasma concentration-time curve for 24-hour samples; AUClast, area under the plasma concentration-time curve from time zero to the last quantifiable concentration; CL/F, oral clearance; Cmax, maximum plasma concentration; Cmin, minimum plasma concentration; CV, coefficient of variation; PK, pharmacokinetic(s); Tlast, time of last quantifiable concentration; Tmax, time to maximum plasma concentration.
MET protein expression in each patient, along with best overall response and mutational data, are provided in Supplementary Table 3. The patient who achieved a PR (Supplementary Table 3, patient 6) had high tumor EGFR expression (IHC staining result 3þ, H-score 284) and moderate or low MET expression (H-score 140). This patient’s tumor harbored an EGFR exon 19 deletion and a T790M mutation and displayed low-level EGFR amplification (2.11fold), but no amplification of MET. The patient had received only one previous systemic regimen comprising single-agent erlotinib, which was stopped 26 days before starting the study treatment. Expression of HGF at the tumor level was less prevalent than that of EGFR and MET, with an overall median percentage positive of 45%. Where present, HGF
743
expression generally was relatively low, with a median H-score of 45 across all samples (range 0–280). Plasma s-MET was detected in 17 patients in expansion cohort 1 and six patients in expansion cohort 2 at baseline. Plasma s-MET concentrations showed a trend toward slightly increased expression over baseline with time (Fig. 2). There was no association between treatment duration and s-MET concentration.
Discussion Development of acquired resistance to EGFR TKIs during therapy for NSCLC is the main barrier to longterm clinical benefit of EGFR-targeted therapies, and there is an urgent need to develop novel agents or new treatment regimens.35 Dacomitinib and crizotinib are active against tumors bearing mutated EGFR and amplified MET, respectively.21,25,26,36,37 Hypothesizing that the combination of these two agents would be beneficial to patients after failure of targeted therapy or development of acquired resistance to EGFR TKIs, we evaluated the combination in this phase I study. The study was biomarker rich, as we hoped to increase our understanding of the drivers of EGFR TKI resistance and evaluate the link between these mechanisms and the response to dacomitinib plus crizotinib. The combination of dacomitinib with crizotinib proved insufficiently effective and was associated with greater toxicity than that seen with the individual agents. The MTD of dacomitinib combined with crizotinib was determined to be dacomitinib, 30 mg once daily, and crizotinib, 200 mg twice daily, which was the lowest dose level tested and is lower than the phase III dose of dacomitinib (45 mg once daily) and the approved starting dose of crizotinib (250 mg twice daily) when used as single agents. The most frequently reported treatment-related toxicities were diarrhea, nausea, vomiting, decreased appetite, and fatigue. Although the safety profile was consistent with that of either drug alone,25,27,28,37–41 there appeared to be additive toxicity, leading to increased frequency and severity of some common treatment-related AEs compared with those reported with each single agent. The relatively high incidence of diarrhea (any grade, 74%; grade 3, 16%) in particular was of concern. In addition, 26% of patients permanently discontinued study therapy owing to AEs of any cause. There were no treatment-related deaths, but the overall high rate of deaths during the study (21%) and short duration of treatment (median, approximately 50 days) suggested that these patients had significantly advanced disease, which may also have influenced the toxicity profile observed. We saw minimal antitumor activity in this study: only one patient had a PR, whereas 46% of patients had SD. One major reason for the limited activity observed may
744 Jänne et al
Table 4. Expression of Biomarkers EGFR, MET, and HGF at Baseline, as Assessed by IHC Analysis in Patients in the Expansion Cohorts Expansion Cohort 1 (n ¼ 23)a EGFR
a
Expansion Total (n ¼ 35)
MET
HGF
EGFR
MET
HGF
EGFR
MET
HGF
19
19
8
11
11b
22
30
30c
67 ± 37 90 (0–100) 56
48 ± 37 40 (0–100) 78
70 ± 37 85 (5–100) 53
85 ± 26 97 (15–100) 30
50 ± 46 67 (0–100) 93
75 ± 35 92 (2–100) 46
73 ± 34 93 (0–100) 47
48 ± 40 45 (0–100) 82
150 ± 115 125 (0–300) 77
63 ± 70 40 (0–280) 111
167 ± 126 170 (7–300) 75
179 ± 102 165 (20–299) 57
52 ± 48 67 (0–104) 93
176 ± 107 193 (2–300) 61
161 ± 109 138 (0–300) 68
59 ±62 45 (0–280) 105
1 (5) 1 (5) 4 (21) 13 (68)
1 (5) 12 (63) 4 (21) 2 (11)
0 0 4 (50) 4 (50)
0 0 5 (45) 6 (55)
1 (9) 6 (55) 4 (36) 0
0 1 (5) 5 (23) 16 (73)
1 (3) 1 (3) 9 (30) 19 (63)
2 (7) 18 (60) 8 (27) 2 (7)
7 (37) 11 (58) 1 (5) 0 49 ± 43 40 (0–100) 89
11 ± 26 0 (0–95) 235
8 (80) 0 1 (10) 1 (10) 52 ± 47 58 (2–100) 89
58 ± 43 75 (2–100) 75
2±5 0 (0–15) 200
15 (52) 11 (38) 2 (7) 1 (3) 58 ± 40 69 (0–100) 69
52 ± 43 44 (0–100) 82
8 ± 21 0 (0–95) 268
Tumor samples were not available for two patients enrolled in expansion cohort 1. Samples analyzable for maximum staining intensity in the stromal compartment: n ¼ 10. c Samples analyzable for maximum staining intensity in the stromal compartment: n ¼ 29. CV, coefficient of variation; EGFR, epidermal growth factor receptor; HGF, hepatocyte growth factor; IHC, immunohistochemical; MET, mesenchymal-epithelial transition factor; SD, standard deviation. b
Journal of Thoracic Oncology
Samples analyzable, n 14 Percent positive Mean ± SD 77 ± 34 Median (range) 94 (2–100) % CV 44 H-score (neoplastic compartment) Mean ± SD 181 ± 99 Median (range) 193 (2–300) % CV 55 Maximum staining intensity, n (%) Neoplastic compartment 0 0 þ1 1 (7) þ2 1 (7) þ3 12 (86) Stromal compartment 0 þ1 þ2 þ3 Staining intensity, 2þ or 3þ, % Mean ± SD 61 ± 38 Median (range) 69 (0–100) % CV 61
Expansion Cohort 2 (n ¼ 12)
Vol. 11 No. 5
May 2016
Figure 2. Plasma concentrations of soluble mesenchymalepithelial transition factor in individual patients over time in expansion cohort 1 (A) and expansion cohort 2 (B). C, cycle; D, day.
have been that dacomitinib at 30 mg once daily is unlikely to reach concentrations required to inhibit T790M. An earlier phase I study suggested that systemic exposure to dacomitinib at doses of 30 or higher mg once daily exceeded the threshold concentration for efficacy against wild-type EGFR or EGFR with common activating mutations, as predicted in preclinical studies.19,42 However, the same preclinical studies suggested that higher concentrations were needed to fully inhibit EGFR harboring the T790M mutation.19 Because this mutation is the dominant mechanism of resistance to firstgeneration EGFR TKIs11 (T790M was present in 50% of mutation-evaluable patients in our study), suboptimal concentrations of dacomitinib could have had an impact on the outcome of the entire population. The second strand to the hypothesis tested in the present study relied on the activity of crizotinib in tumors bearing MET amplifications, as has been previously reported.21,25 According to previously published series, MET amplification is present in as many as 22% of lung cancers with acquired resistance to EGFR inhibitors.12 In our study, however, only one of 30 patients (3%) tested for MET amplification by FISH analysis showed any gene amplification, and this was at a low level, indicating that MET amplification may be less frequent than initially
Pan-HER and ALK/ROS1/MET Inhibition in NSCLC
745
reported in this population, although consistent with more recent reports.16,17 Despite displaying high levels of MET expression, the patient with low-level MET amplification showed progressive disease—possibly because MET was not the true pathogenic driver in this case. Two recent studies have suggested that response to MET inhibitors is associated with MET gene copy number. In a study of crizotinib in MET-amplified NSCLC, clinical activity appeared to correlate with the extent of MET amplification relative to the centromere on chromosome 7.25 In a second study of the MET inhibitor INC280 combined with gefitinib in patients with EGFR-mutated NSCLC and progression after EGFR TKI treatment with confirmed MET dysregulation, all responders had high MET status (an IHC staining result of 3þ and/or gene copy number 5).43 The level of MET gene copy number, measured as either the ratio to the centromere of chromosome 7 (true amplification) or mean MET gene copies per cell (which could include both true amplification and high polysomy), is likely to influence the chances of MET acting as either a true driver or codriver in an individual tumor and, by extension, the ability of the biomarker to predict benefit from MET inhibition either alone or in combination with an EGFR inhibitor. However, the study by Wu et al. also suggested that high levels of MET protein (an IHC staining result of 3þ in 50% of tumor cells) were predictive of response to MET inhibition.43 In our study, tumors from 20 of 30 patients evaluated had at least some cells that stained 3þ by IHC staining for MET, 10 of which met Wu et al.’s definition of being positive for high levels of MET expression, and MET expression based on H-score for those tumors was high (range 280300). In tumors from the 20 patients who did not meet the definition of Wu et al., tumor MET expression was generally low or moderate. Thus, both the lack of MET amplification and moderate levels of MET expression may have contributed to the poor response rates that we observed. There was no association between MET expression and any measure of antitumor activity tested. The efficacy of single-agent EGFR TKIs will ultimately be limited by acquired resistance. Combination therapies offer the possibility of overcoming multiple drugresistance mechanisms simultaneously and hence may lead to more durable and sustained tumor responses. However, such treatments must also be tolerable for potentially extended periods of time. In the present study, the combination of dacomitinib and crizotinib was neither effective nor well tolerated in patients in whom resistance to prior EGFR inhibitors had developed, and no further evaluation of this combination is planned. However, given that MET amplification and EGFR T790M mutations can occur together (in the same tumor or in
746 Jänne et al
different tumors in the same patient), there continues to be a biological rationale for combining agents that target these two resistance mechanisms. Next-generation EGFR inhibitors, including osimertinib (AZD9291) and rocelitinib (CO-1686), which are selective for mutant EGFR (with both the EGFR-activating and the T790M mutations) over wild-type EGFR, have demonstrated response rates of >50% in phase I or II clinical trials of patients harboring EGFR T790M.44,45 Given the improved toxicity profile of this new class of EGFR inhibitors, they may be more amenable to combination treatment strategies, including those involving MET inhibitors.
Journal of Thoracic Oncology
9.
10.
11.
12.
Acknowledgments This study was sponsored by Pfizer Inc. We would like to thank all of the participating patients and their families, as well as the investigators, research nurses, study coordinators, and operations staff. Medical writing support was provided by Wendy Sacks and Jo Chapman at ACUMED (New York, NY, and Tytherington, United Kingdom) and was funded by Pfizer, Inc.
13.
14.
Supplementary Data Note: To access the supplementary material accompanying this article, visit the online version of the Journal of Thoracic Oncology at www.jto.org and at http://dx.doi. org/10.1016/j.jtho.2016.01.022.
15.
16.
References 1. Shigematsu H, Lin L, Takahashi T, et al. Clinical and biological features associated with epidermal growth factor receptor gene mutations in lung cancers. J Natl Cancer Inst. 2005;97:339–346. 2. Lynch TJ, Bell DW, Sordella R, et al. Activating mutations in the epidermal growth factor receptor underlying responsiveness of non-small-cell lung cancer to gefitinib. N Engl J Med. 2004;350:2129–2139. 3. Pao W, Miller V, Zakowski M, et al. EGF receptor gene mutations are common in lung cancers from “never smokers” and are associated with sensitivity of tumors to gefitinib and erlotinib. Proc Natl Acad Sci U S A. 2004;101:13306–13311. 4. Paez JG, Jänne PA, Lee JC, et al. EGFR mutations in lung cancer: correlation with clinical response to gefitinib therapy. Science. 2004;304:1497–1500. 5. Yun CH, Boggon TJ, Li Y, et al. Structures of lung cancerderived EGFR mutants and inhibitor complexes: mechanism of activation and insights into differential inhibitor sensitivity. Cancer Cell. 2007;11:217–227. 6. Rosell R, Moran T, Queralt C, et al. Screening for epidermal growth factor receptor mutations in lung cancer. N Engl J Med. 2009;361:958–967. 7. Cancer Genome Atlas Research Network. Comprehensive molecular profiling of lung adenocarcinoma. Nature. 2014;511:543–550. 8. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: non-small cell lung cancer.
17.
18.
19.
20.
21.
22.
Vol. 11 No. 5
Version 7.2015. http://www.nccn.org/professionals/ physician_gls/pdf/nscl.pdf. Accessed July 13, 2015. Lee CK, Brown C, Gralla RJ, et al. Impact of EGFR inhibitor in non-small cell lung cancer on progression-free and overall survival: a meta-analysis. J Natl Cancer Inst. 2013;105:595–605. Engelman JA, Janne PA. Mechanisms of acquired resistance to epidermal growth factor receptor tyrosine kinase inhibitors in non-small cell lung cancer. Clin Cancer Res. 2008;14:2895–2899. Ma C, Wei S, Song Y. T790M and acquired resistance of EGFR TKI: a literature review of clinical reports. J Thorac Dis. 2011;3:10–18. Engelman JA, Zejnullahu K, Mitsudomi T, et al. MET amplification leads to gefitinib resistance in lung cancer by activating ERBB3 signaling. Science. 2007;316: 1039–1043. Bean J, Brennan C, Shih JY, et al. MET amplification occurs with or without T790M mutations in EGFR mutant lung tumors with acquired resistance to gefitinib or erlotinib. Proc Natl Acad Sci U S A. 2007;104:20932– 20937. Chen HJ, Mok TS, Chen ZH, et al. Clinicopathologic and molecular features of epidermal growth factor receptor T790M mutation and c-MET amplification in tyrosine kinase inhibitor-resistant Chinese non-small cell lung cancer. Pathol Oncol Res. 2009;15:651–658. Turke AB, Zejnullahu K, Wu YL, et al. Preexistence and clonal selection of MET amplification in EGFR mutant NSCLC. Cancer Cell. 2010;17:77–88. Sequist LV, Waltman BA, Dias-Santagata D, et al. Genotypic and histological evolution of lung cancers acquiring resistance to EGFR inhibitors. Sci Transl Med. 2011;3, 75ra26. Yu HA, Arcila ME, Rekhtman N, et al. Analysis of tumor specimens at the time of acquired resistance to EGFRTKI therapy in 155 patients with EGFR-mutant lung cancers. Clin Cancer Res. 2013;19:2240–2247. Arcila ME, Oxnard GR, Nafa K, et al. Rebiopsy of lung cancer patients with acquired resistance to EGFR inhibitors and enhanced detection of the T790M mutation using a locked nucleic acid-based assay. Clin Cancer Res. 2011;17:1169–1180. Engelman JA, Zejnullahu K, Gale CM, et al. PF00299804, an irreversible pan-ERBB inhibitor, is effective in lung cancer models with EGFR and ERBB2 mutations that are resistant to gefitinib. Cancer Res. 2007;67:11924–11932. Gonzales AJ, Hook KE, Althaus IW, et al. Antitumor activity and pharmacokinetic properties of PF-00299804, a second-generation irreversible pan-erbB receptor tyrosine kinase inhibitor. Mol Cancer Ther. 2008;7:1880–1889. Ou SH, Kwak EL, Siwak-Tapp C, et al. Activity of crizotinib (PF02341066), a dual mesenchymal-epithelial transition (MET) and anaplastic lymphoma kinase (ALK) inhibitor, in a non-small cell lung cancer patient with de novo MET amplification. J Thorac Oncol. 2011;6:942–946. Schwab R, Petak I, Kollar M, et al. Major partial response to crizotinib, a dual MET/ALK inhibitor, in a squamous cell lung (SCC) carcinoma patient with de novo c-MET amplification in the absence of ALK rearrangement. Lung Cancer. 2014;83:109–111.
May 2016 23. Mendenhall MA, Goldman JW. MET-mutated NSCLC with major response to crizotinib. J Thorac Oncol. 2015;10: e33–e34. 24. Waqar SN, Morgensztern D, Sehn J. MET mutation associated with responsiveness to crizotinib. J Thorac Oncol. 2015;10:e29–e31. 25. Camidge DR, Ou S-HI, Shapiro G, et al. Efficacy and safety of crizotinib in patients with advanced c-METamplified non-small cell lung cancer (NSCLC). Presented at: 2014 ASCO Annual Meeting. May 30–June 3, 2014; Chicago, IL. 26. Janne PA, Ou SH, Kim DW, et al. Dacomitinib as first-line treatment in patients with clinically or molecularly selected advanced non-small-cell lung cancer: a multicentre, open-label, phase 2 trial. Lancet Oncol. 2014;15:1433–1441. 27. Ellis PM, Shepherd FA, Millward M, et al. Dacomitinib compared with placebo in pretreated patients with advanced or metastatic non-small-cell lung cancer (NCIC CTG BR.26): a double-blind, randomised, phase 3 trial. Lancet Oncol. 2014;15:1379–1388. 28. Ramalingam SS, Janne PA, Mok T, et al. Dacomitinib versus erlotinib in patients with advanced-stage, previously treated non-small-cell lung cancer (ARCHER 1009): a randomised, double-blind, phase 3 trial. Lancet Oncol. 2014;15:1369–1378. 29. Kazandjian D, Blumenthal GM, Chen HY, et al. FDA approval summary: crizotinib for the treatment of metastatic non-small cell lung cancer with anaplastic lymphoma kinase rearrangements. Oncologist. 2014;19:e5–e11. 30. Paik PK, Drilon A, Fan PD, et al. Response to MET inhibitors in patients with stage IV lung adenocarcinomas harboring MET mutations causing exon 14 skipping. Cancer Discov. 2015;5:842–849. 31. Agarwal S, Zerillo C, Kolmakova J, et al. Association of constitutively activated hepatocyte growth factor receptor (Met) with resistance to a dual EGFR/Her2 inhibitor in non-small-cell lung cancer cells. Br J Cancer. 2009;100:941–949. 32. Tang Z, Du R, Jiang S, et al. Dual MET-EGFR combinatorial inhibition against T790M-EGFR-mediated erlotinibresistant lung cancer. Br J Cancer. 2008;99:911–922. 33. Xu L, Kikuchi E, Xu C, et al. Combined EGFR/MET or EGFR/HSP90 inhibition is effective in the treatment of lung cancers codriven by mutant EGFR containing T790M and MET. Cancer Res. 2012;72:3302–3311.
Pan-HER and ALK/ROS1/MET Inhibition in NSCLC
747
34. Nanjo S, Yamada T, Nishihara H, et al. Ability of the Met kinase inhibitor crizotinib and new generation EGFR inhibitors to overcome resistance to EGFR inhibitors. PLoS One. 2013;8:e84700. 35. Stinchcombe TE. Novel agents in development for advanced non-small cell lung cancer. Ther Adv Med Oncol. 2014;6:240–253. 36. Park K, Cho BC, Kim DW, et al. Safety and efficacy of dacomitinib in Korean patients with KRAS wild-type advanced non-small-cell lung cancer refractory to chemotherapy and erlotinib or gefitinib: a phase I/II trial. J Thorac Oncol. 2014;9:1523–1531. 37. Ramalingam SS, Blackhall F, Krzakowski M, et al. Randomized phase II study of dacomitinib (PF-00299804), an irreversible pan-human epidermal growth factor receptor inhibitor, versus erlotinib in patients with advanced nonsmall-cell lung cancer. J Clin Oncol. 2012;30:3337–3344. 38. Camidge DR, Bang YJ, Kwak EL, et al. Activity and safety of crizotinib in patients with ALK-positive non-small-cell lung cancer: updated results from a phase 1 study. Lancet Oncol. 2012;13:1011–1019. 39. Shaw AT, Kim DW, Nakagawa K, et al. Crizotinib versus chemotherapy in advanced ALK-positive lung cancer. N Engl J Med. 2013;368:2385–2394. 40. Shaw AT, Ou SH, Bang YJ, et al. Crizotinib in ROS1rearranged non-small-cell lung cancer. N Engl J Med. 2014;371:1963–1971. 41. Solomon BJ, Mok T, Kim DW, et al. First-line crizotinib versus chemotherapy in ALK-positive lung cancer. N Engl J Med. 2014;371:2167–2177. 42. Jänne PA, Boss DS, Camidge DR, et al. Phase I doseescalation study of the pan-HER inhibitor, PF299804, in patients with advanced malignant solid tumors. Clin Cancer Res. 2011;17:1131–1139. 43. Wu Y-L, Yang J C-H, Kim D-W, et al. Safety and efficacy of INC280 in combination with gefitinib (gef) in patients with EGFR-mutated (mut), MET-positive NSCLC: a singlearm phase lb/ll study [abstract]. J Clin Oncol. 2014;32(suppl 5s):8017. 44. Janne PA, Ramalingam SS, Yang JC, et al. Clinical activity of the mutant-selective EGFR inhibitor AZD9291 in patients (pts) with EGFR inhibitor–resistant non-small cell lung cancer [abstract]. J Clin Oncol. 2014;32(suppl 5s):8009. 45. Sequist LV, Soria JC, Goldman JW, et al. Rociletinib in EGFR-mutated non-small-cell lung cancer. N Engl J Med. 2015;372:1700–1709.
Combined Pan-HER and ALK/ROS1/MET Inhibition with Dacomitinib and Crizotinib in Advanced Non–Small Cell Lung Cancer: Results of a Phase I Study Pasi A. Jänne, MD, PhD,a,b,* Alice T. Shaw, MD, PhD,c D. Ross Camidge, MD, PhD,d Giuseppe Giaccone, MD, PhD,e S. Martin Shreeve, MD, PhD,f Yiyun Tang, PhD,f Zelanna Goldberg, MD,f Jean-François Martini, PhD,f Huiping Xu, PhD,f Leonard P. James, MD, PhD,g Benjamin J. Solomon, M.B.B.S., PhDh a
Lowe Center for Thoracic Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts Belfer Center for Applied Cancer Science, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts c Massachusetts General Hospital, Boston, Massachusetts d University of Colorado Denver, Colorado e Georgetown University, Washington, District of Columbia f Pfizer Oncology, La Jolla, California g Pfizer Oncology, New York, New York h Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia b
Received 22 December 2015; accepted 26 January 2016 Available online - 17 February 2016
ABSTRACT Introduction: This phase I study investigated the activity of the irreversible pan-human epidermal growth factor receptor inhibitor dacomitinib in combination with the mesenchymal-epithelial transition factor/anaplastic lymphoma kinase/ROS proto-oncogene 1, receptor tyrosine kinase inhibitor crizotinib in advanced non–small cell lung cancer. Methods: Patients with progression after at least one line of chemotherapy or targeted therapy received dacomitinib once daily and crizotinib once daily or twice daily, with doses escalated until intolerable toxicity; the expansion cohorts received the maximum tolerated dose of the combination. The primary objective was to define the recommended phase II dose; secondary objectives included assessment of safety and activity of the combination in epidermal growth factor receptor inhibitor-resistant patients and correlation with tumor biomarkers. Results: Seventy patients were treated in the doseescalation (n ¼ 33) and expansion phases (n ¼ 37), with the maximum tolerated dose defined as dacomitinib, 30 mg once daily, plus crizotinib, 200 mg twice daily. Grade 3 or 4 treatment-related adverse events were reported in 43% of patients: the most common were diarrhea (16%), rash (7%), and fatigue (6%). There were 16 deaths; none were considered treatment related. One patient (1%) had a partial response; 46% had stable disease. Most of the tumor samples analyzed had activating
epidermal growth factor receptor gene (EGFR) mutations (18 of 20 [90%]); 50% (10 of 20) had a concurrent resistance mutation. Only one sample showed MMNG HOS Transforming gene (MET) amplification (the patient had progressive disease), whereas 59% (13 of 22) and 47% (14 of 30) had high levels of expression of epidermal growth factor receptor and mesenchymal-epithelial transition factor on the basis of H-scores, respectively. There was no apparent association between biomarker expression and antitumor activity.
*Corresponding author. Disclosure: Dr. Jänne reports receiving grants and research support from Astellas and AstraZeneca; receiving consulting fees from Astra Zeneca, Roche, Genentech, Merrimack, Chugai, and Clovis Oncology; and holding stock in Gatekeeper. Dr. Shaw reports receiving grants and personal fees from Pfizer, Novartis, Ariad, Chugai, Genentech, DaiichiSankyo, and Ignyta. Dr. Camidge reports receiving consulting fees from Pfizer. Drs. Shreeve, Tang, Goldberg, Martini, Xu, and James were employees of Pfizer at the time this work was conducted and held Pfizer stock. Dr. Solomon reports receiving consulting fees from Pfizer, Novartis, Roche, Merck Sharpe & Dohme, AstraZeneca, and BMS; receiving research funding from Pfizer; holding patent/ intellectual property with Biodesix; and receiving travel, accommodation, and other expenses from Roche and AstraZeneca. The remaining author declares no conflict of interest. Address for correspondence: Pasi A. Jänne, MD, PhD, Lowe Center for Thoracic Oncology, Dana-Farber Cancer Institute, 450 Brookline Ave., LC4114, Boston, MA 02215. E-mail: [email protected] ª 2016 International Association for the Study of Lung Cancer. Published by Elsevier Inc. All rights reserved. ISSN: 1556-0864 http://dx.doi.org/10.1016/j.jtho.2016.01.022
Journal of Thoracic Oncology
Vol. 11 No. 5: 737-747
738 Jänne et al
Conclusion: The combination of dacomitinib and crizotinib showed limited antitumor activity in patients with advanced non–small cell lung cancer and was associated with substantial toxicity. 2016 International Association for the Study of Lung Cancer. Published by Elsevier Inc. All rights reserved. Keywords: Non–small cell; Dacomitinib; Crizotinib; EGFR TKI resistance; Biomarkers
Introduction In non–small cell lung cancer (NSCLC), the presence of specific activating mutations in the epidermal growth factor receptor gene (EGFR) is predictive of benefit from treatment with epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs).1–5 Sensitizing mutations have been reported to occur in 8% to 17% of nonAsian patients,1,6,7 with frequencies of 30% reported in Asian patients.1 For patients with advanced EGFRmutant lung cancer, EGFR TKIs are the standard of care,8 offering marked improvements in clinical outcomes compared with standard chemotherapy.9 Development of resistance to EGFR TKIs, however, is inevitable,10 most frequently through the acquisition of a T790M mutation in EGFR (responsible for an estimated 50% to 60% of cases11). Upregulation or activation of other receptor tyrosine kinases (RTKs) such as mesenchymalepithelial transition factor (MET) through gene amplification has also been observed, with earlier reports putting the frequency of MMNG HOS Transforming gene (MET) amplification at 15% to 22%12–15 and more recent analyses reporting frequencies of 5%.16,17 Both EGFR mutations and MET amplification have been detected in the same tumor and individually in independent tumors from the same individual,12,13,18 suggesting that heterogeneity may play an important role in resistance. Dacomitinib and crizotinib are active against EGFRmutated and MET-activated tumors, respectively.19–25 Dacomitinib is a highly selective irreversible secondgeneration inhibitor of the human epidermal growth factor receptor (HER) family of RTKs—including EGFR (HER1)—and was effective in preclinical models that showed resistance to the first-generation EGFR TKIs gefitinib or erlotinib, including those expressing the T790M resistance mutation.19,20 In the clinic, dacomitinib has demonstrated efficacy in a phase II trial in EGFR TKI–naive patients with advanced NSCLC who were selected on the basis of clinical or molecular criteria.26 In phase III trials, dacomitinib has not demonstrated superiority over placebo or erlotinib in unselected patients who were previously treated with chemotherapy.27,28 Crizotinib, an inhibitor of MET, anaplastic lymphoma
Journal of Thoracic Oncology
Vol. 11 No. 5
kinase, and ROS proto-oncogene 1 (ROS1), was first approved by the U.S. Food and Drug Administration in 2011 for the treatment of advanced anaplastic lymphoma kinase gene (ALK)-positive NSCLC.29 A fast and durable response with crizotinib was achieved in a patient with MET amplification but negative for ALK.21 Several other case reports have also shown a response to crizotinib in patients with tumors bearing MET amplification and/or MET mutations.22–24,30 In a cohort of 14 patients with NSCLC and MET amplification treated with crizotinib, five were shown to have objective responses (ORs).25 In vitro studies and an in vivo study using a transgenic mouse lung tumor model expressing EGFR-mutant Del19-T790M or L858R-T790M, each with concurrent MET overexpression, have shown synergistic effects between MET and EGFR inhibition when combined.31–33 A second study also demonstrated synergy of crizotinib and newer-generation EGFR TKIs in mouse tumor models, although toxicity was an issue when crizotinib was combined with afatinib at higher doses.34 These data suggested that patients in whom resistance to EGFR TKIs has developed through MET amplification or upregulation may benefit from combined inhibition of MET and EGFR. This report describes the results of a phase I study of the combination of dacomitinib and crizotinib in patients with NSCLC after failure of at least one prior chemotherapy regimen or EGFR TKI (ClinicalTrials.gov identifier: NCT01121575). The study consisted of two phases: a dose-escalation phase and an expansion phase.
Patients and Methods Patient Population The study enrolled adults aged 18 years or older with histologically proven locally advanced or metastatic NSCLC after failure of prior chemotherapy or targeted therapy (dose-escalation phase) or acquired resistance to erlotinib or gefitinib (expansion phase). Acquired resistance was defined as progression after an initial response (complete or partial response [PR]) or stable disease (SD) for at least 6 months while receiving single-agent erlotinib or gefitinib. Other key eligibility criteria were an Eastern Cooperative Oncology Group performance status of 0 to 2, adequate organ function, and at least one measurable or evaluable lesion. Exclusion criteria included participation in other studies or lung cancer treatment within 2 weeks of the study’s start, interstitial fibrosis or lung disease, brain metastases unless neurologically stable, cardiac abnormalities or uncontrolled hypertension, and prior malignancy (other than NSCLC) within the past 3 years. Each patient gave written informed consent to their participation in the study.
May 2016
Study Design and Treatment This was a multicenter, open-label, nonrandomized, dose-escalation phase I study with an expansion phase (Supplementary Fig. 1). Patients enrolled in the doseescalation phase were initially dosed at 30 mg of dacomitinib once daily and 200 mg of crizotinib twice daily (twice daily, dose level 1). The first cycle was defined as 28 days, with subsequent cycles defined as 21 days. The dose was escalated or reduced until the maximum tolerated dose (MTD) was determined as described in Supplementary Methods; other planned dose levels are shown in Supplementary Table 1. The MTD was defined as the dose level of combined dacomitinib and crizotinib at which none or one of six patients presented with a dose-limiting toxicity (DLT) during cycle 1 of treatment, with the next highest dose being the maximally administered dose at which two or more patients experienced DLTs. The expansion phase comprised two cohorts that ran concurrently. A new tumor biopsy was required for enrollment, with further samples optional. In expansion cohort 1, patients received combined dacomitinib and crizotinib orally on a continuous daily schedule. To evaluate the effect of dacomitinib on crizotinib pharmacokinetics (PK), patients received single-agent crizotinib on a continuous daily schedule for a 10- to 14-day lead-in period before introduction of dacomitinib. In expansion cohort 2, patients were initially treated with dacomitinib only until progression and then received combined dacomitinib and crizotinib; the effect of crizotinib on dacomitinib PK was assessed in this cohort. The primary objective of the study was to define the recommended phase II dose of combined dacomitinib and crizotinib in patients with advanced NSCLC. Secondary objectives were to assess the overall safety and tolerability of the combination, the antitumor activity of combined treatment, and the PK of the single agents and the combination; to analyze baseline biomarkers in tumors and blood in patients with acquired resistance to erlotinib or gefitinib and the effect of combined dacomitinib and crizotinib on biomarkers in these patients; and to explore mechanisms of resistance to EGFRtargeted therapy. The study was conducted according to the principles of the Declaration of Helsinki and complied with International Conference on Harmonisation Good Clinical Practice Guidelines. The protocol was approved by the relevant institutional review boards or independent ethics committees.
Assessments Adverse events (AEs) were graded using National Cancer Institute Common Terminology Criteria for Adverse Events (version 4.02) and were monitored until
Pan-HER and ALK/ROS1/MET Inhibition in NSCLC
739
at least 28 days after the last dose of the study drug. Other safety assessments included determination of laboratory parameters, physical examination, measurement of vital signs, electrocardiograms, and ophthalmology examinations. Disease was assessed at baseline and every other cycle, beginning on day 1 of cycle 3. Computed tomography or magnetic resonance imaging was performed whenever disease progression was suspected or to confirm an OR lasting at least 4 weeks after first documentation. Antitumor activity was assessed by investigators according to Response Evaluation Criteria in Solid Tumors v1.1. Brain and bone scans were performed regularly if brain or bone metastases were detected at screening or if clinically indicated.
PK PK-evaluable patients are described in Supplementary Methods. Blood samples were collected on day 1 (the day before day 1 of cycle 1 of combination treatment) and day 1 of cycle 2 in the expansion cohorts to evaluate the possible effects of crizotinib and dacomitinib on each other. Plasma crizotinib and dacomitinib concentrations were determined separately using validated, sensitive, and specific high-performance liquid chromatography tandem mass spectrometry methods. PK parameters were estimated using noncompartmental analysis.
Biomarker Studies Tumor tissue biopsies from the expansion cohorts were evaluated for genetic and/or protein markers, including EGFR, erb-b2 receptor tyrosine kinase 2 gene (HER2), and Kirsten rat sarcoma viral oncogene homolog gene (KRAS) mutations. MET, EGFR, and HER2 amplification was assessed by fluorescence in situ hybridization (FISH); hepatocyte growth factor ([HGF] the ligand for MET), EGFR, and MET expression were measured by immunohistochemical (IHC) analysis; and ALK gene fusions were identified by FISH. Blood samples were taken for determination of soluble MET (s-MET) protein levels, which were measured by enzyme-linked immunosorbant assay. Staining intensity for EGFR, HGF, and MET were evaluated using IHC assays on a semiquantitative scale, and the percentage of neoplastic cells staining at each of the following four levels was recorded: 0 (unstained), 1þ (weak staining), 2þ (moderate staining), and 3þ (strong staining). An H-score was calculated using the following formula: (3 % cells staining at 3þ) þ (2 % cells staining at 2þ) þ (1 % cells staining at 1þ), yielding a possible range of 0 to 300. For the purposes of stratification, low and high expression were defined as H-scores of less than 150 or 150 or higher, respectively.
740 Jänne et al
The total percentage of positive cells (i.e., cells scoring 1þ), H-score, and percentage of cells staining 2þ and/ or 3þ were used for further statistical analyses. In the FISH assay, a standard cutoff of 2.1 for the ratio of target gene-specific signal to the centromere-specific signal was used to identify amplification events. ALK rearrangement was defined as positive in samples displaying more than 15% cells with rearrangements.
Statistical Analyses The safety analysis population included all patients who received at least one dose of study drug, of whom response-evaluable patients were those with an adequate baseline tumor assessment. OR rates (the proportion of response-evaulable patients with confirmed complete responses or PRs) were summarized with the corresponding two-sided 95% confidence interval (CI) calculated using the exact method based on the F distribution. If patients’ tumor remained stable for 6 weeks or longer after the first dose in the absence of an OR, their best overall response was classified as SD. Progression-free survival (PFS) was summarized using the Kaplan Meier method; the Brookmeyer-Crowley method was used to provide 95% CIs for estimates of the medians. The 95% CI for PFS at specific time points was calculated using the normal approximation to the log-transformed cumulative hazard rate on the basis of Greenwood’s estimate of the variance of PFS. All other data were summarized using descriptive statistics.
Results Patients Between August 2010 and February 2014, three centers in the United States and one in Australia enrolled 70 patients, including 33 patients in the dose-escalation phase and 37 patients in the expansion phase (cohort 1, n ¼ 25; cohort 2, n ¼ 12). All 70 patients received at least one dose of either or both study drugs and were therefore included in the safety analysis population; three patients in the expansion phase did not receive the combination. The response-evaluable population included 67 patients (96%): 33 in the dose-escalation phase and 34 in the expansion phase. Approximately half the patient population were never-smokers (51% [Table 1]). Nearly all patients (99%) had metastatic disease, most (90%) had an Eastern Cooperative Oncology Group performance status of 0 of 1, and 40% had received three or more prior lines of systemic therapy. Overall, 93% of patients had been previously treated with either erlotinib (90%) or gefitinib (3%); only five patients in the dose-escalation phase had received no prior EGFR TKI. Eight patients (11%) had received prior crizotinib, including seven in the
Journal of Thoracic Oncology
Vol. 11 No. 5
dose-escalation phase. Median treatment duration (range) was 52.5 days (2–287) for dacomitinib and 51.0 days (2–295) for crizotinib.
Safety In the dose-escalation phase (Supplementary Fig. 1), the dosing cohorts studied comprised patients receiving dacomitinib, 30 mg once daily, and crizotinib, 200 mg twice daily (n ¼ 14); dacomitinib, 30 mg once daily, and crizotinib, 250 mg twice daily (n ¼ 7); dacomitinib, 45 mg once daily, and crizotinib, 200 mg twice daily (n ¼ 6); and dacomitinib, 45 mg once daily, and crizotinib, 250 mg once daily (n ¼ 6). Three patients had DLTs: grade 3 increased alanine aminotransferase level (at dacomitinib, 45 mg once daily, and crizotinib, 200 mg twice daily, n ¼ 1), grade 3 diarrhea (at dacomitinib, 45 mg once daily, and crizotinib, 200 mg twice daily, n ¼ 1), and grade 3 mucosal inflammation (at dacomitinib, 30 mg once daily, and crizotinib, 250 mg twice daily, n ¼ 1). All three DLTs resolved. The MTD for the combination was therefore identified as dacomitinib, 30 mg once daily, and crizotinib, 200 mg twice daily, (dose level 1) and used in the expansion phase. In the study overall, 66 patients (94%) had at least one treatment-related AE (Table 2). The most common events were diarrhea (74%), nausea (57%), vomiting (41%), decreased appetite (39%), and fatigue (37%). Twenty-seven (39%) and three (4%) patients had grade 3 or 4 treatment-related AEs, respectively, of which diarrhea (16%), rash (7%), and fatigue (6%) were the most frequent (all grade 3). Across both study phases, 46 (66%) and 43 (61%) patients had at least one interruption in dacomitinib or crizotinib dosing, respectively. Six patients had a dose reduction: four in the dose-escalation phase (three reductions in dacomitinib and one in crizotinib) and two in expansion cohort 1 (one reduction in crizotinib and one in both dacomitinib and crizotinib). Eighteen patients (26%) permanently discontinued treatment (either dacomitinib or crizotinib or both) during the combination treatment period because of AEs of any cause, which were considered treatment-related in eight patients (11%). Ten patients (14%) had treatment-related serious AEs, which consisted of diarrhea (n ¼ 4); nausea, dehydration, and hyperuricemia (n ¼ 2 each); and hypersensitivity, increased blood creatinine level, acute respiratory distress syndrome, pulmonary embolism, and hypotension (n ¼ 1 each). Overall, 29 patients (41%) had serious AEs of any cause, with diarrhea (6%), disease progression (6%), and hypoxia (4%) the only events to occur in 4% of patients or more. During the combination treatment period, 15 patients (21%) died: seven during the dose-escalation phase
May 2016
Pan-HER and ALK/ROS1/MET Inhibition in NSCLC
741
Table 1. Patient Demographics and Baseline Disease Characteristics (Safety Analysis Population) Escalation Cohort Expansion Cohort 1 Expansion Cohort 2 Expansion Total Overall Total (n ¼ 33) (n ¼ 25) (n ¼ 12) (n ¼ 37) (N ¼ 70) Age, y Median 59.0 Range 38–78 Sex, n (%) Male 15 (45) Female 18 (55) Race, n (%) White 27 (82) Black 0 Asian 6 (18) Other 0 Smoking classification, n (%) Never smoked 12 (36) Current smoker 1 (3) Former smoker 20 (61) ECOG performance status, n (%) 0 8 (24) 1 21 (64) 2 4 (12) Time since diagnosis, y Median 2.1 Range 0.5–10.3 Histology, n (%) Adenocarcinoma 26 (79) Bronchioloalaveolar carcinoma 2 (6) Adenosquamous carcinoma 1 (3) Squamous cell carcinoma 1 (3) Large cell carcinoma 1 (3) Other 2 (6) No. prior systemic therapy regimens, n (%) 1 9 (27) 2 6 (18) 3 18 (55) Prior EGFR/HER TKI, n (%) Erlotinib 26 (79) 2 (6) Gefitiniba Dacomitinib 0 1 (3) Otherb Prior crizotinib 7 (21)
60.0 42–82
57.5 39–76
60.0 39–82
59.5 38–82
9 (36) 16 (64)
3 (25) 9 (75)
12 (32) 25 (68)
27 (39) 43 (61)
21 (84) 0 4 (16) 0
9 1 1 1
(75) (8) (8) (8)
30 (81) 1 (3) 5 (14) 1 (3)
57 (81) 1 (1) 11 (16) 1 (1)
18 (72) 2 (8) 5 (20)
6 (50) 0 6 (50)
24 (65) 2 (5) 11 (30)
36 (51) 3 (4) 31 (44)
4 (16) 19 (76) 2 (8)
2 (17) 9 (75) 1 (8)
6 (16) 28 (76) 3 (8)
14 (20) 49 (70) 7 (10)
2.1 0.6–5.1
4.3 0.9–29.3
3.1 0.6–29.3
2.8 0.5–29.3
22 (88) 1 (4) 1 (4) 0 0 1 (4)
10 (83) 1 (8) 0 0 0 1 (8)
32 (86) 2 (5) 1 (3) 0 0 2 (5)
58 (83) 4 (6) 2 (3) 1 (1) 1 (1) 4 (6)
9 (36) 11 (44) 5 (20)
4 (33) 3 (25) 5 (42)
13 (35) 14 (38) 10 (27)
22 (31) 20 (29) 28 (40)
25 (100) 0 0 2 (8) 1 (4)
12 (100) 0 1 (8) 1 (8) 0
37 (100) 0 1 (3) 3 (9) 1 (3)
63 (90) 2 (3) 1 (1) 4 (6) 8 (11)
a
Neither patient treated with prior gefitinib received treatment with erlotinib. Other HER TKIs included in the dose escalation cohorts: MM-121 (monoclonal antibody directed against HER3; n ¼ 1); in the expansion cohorts: cetuximab (cohort 1, n ¼ 2), afatinib (cohort 1, n ¼ 2 [the same patients who received cetuximab]), and pertuzumab (cohort 2, n ¼ 1). Note that all of these patients also received prior erlotinib. ECOG, Eastern Cooperative Oncology Group; EGFR, epidermal growth factor receptor; HER, human epidermal growth factor receptor; TKI, tyrosine kinase inhibitor. b
and eight during the expansion phase. In addition, one patient died 25 days after discontinuing single-agent crizotinib. In 15 cases, death was considered disease related; in one case, the cause was unknown. None were considered treatment related.
Antitumor Activity During the escalation phase, there were no ORs; 20 patients (61%) had a best overall response of SD. Among 34 evaluable patients in the expansion phase, one patient (expansion cohort 1) had a PR lasting 6.3 weeks and 11
patients (32%) had SD. The OR rate (95% exact CI) was 2.9% (0.115.3) for the expansion phase and 1.5% (0.08.0) across both phases of the study. Most cases of SD (19 of 31 [61%]) persisted for 3 to 6 months, and tumor shrinkage was observed in some patients in the expansion phase (Fig. 1). Median PFS was 3.0 months (95% CI: 2.84.3) in the escalation phase and 2.1 months (95% CI: 1.43.5) in the expansion phase (Supplementary Table 2). The probability of being progression free at months 2, 4, and 6 is shown in Supplementary Table 2.
742 Jänne et al
Journal of Thoracic Oncology
Vol. 11 No. 5
Table 2. Treatment-Related Adverse Events Occurring in at Least 10% of Patients (Safety Analysis Population, n ¼ 70) n (%) Adverse Event
Any Gradea
Grade 3
Any treatment-related adverse event Diarrhea Nausea Vomiting Decreased appetite Fatigue Paronychia Rash Peripheral edema Dry skin Acneiform dermatitis Mucosal inflammation Visual impairment Stomatitis Dyspepsia Skin fissures Increased ALT Anemia Increased AST Dysgeusia Pruritus
66 52 40 29 27 26 23 23 22 20 19 13 13 10 8 8 7 7 7 7 7
27 (39) 11 (16) 2 (3) 0 1 (1) 4 (6) 3 (4) 5 (7) 0 0 1 (1) 1 (1) 0 1 (1) 0 0 1 (1) 2 (3) 0 0 0
(94) (74) (57) (41) (39) (37) (33) (33) (31) (29) (27) (19) (19) (14) (11) (11) (10) (10) (10) (10) (10)
a
Three grade 4 treatment-related adverse events were reported: acute respiratory distress syndrome, hyperuricemia, and pulmonary embolism; there were no grade 5 treatment-related adverse events. ALT, alanine aminotransferase; AST, aspartate aminotransferase.
PK The effect of dacomitinib on plasma steady-state exposure of crizotinib was assessed in expansion cohort 1, and that of crizotinib on plasma steady-state exposure of dacomitinib was assessed in expansion cohort 2. Because of the limited number of patients evaluable for analysis of PK drug interaction, formal statistical analysis of these data would not have been meaningful. However, a trend toward decreased crizotinib exposure was observed when crizotinib was coadministered with dacomitinib compared with when it was administered alone (Table 3). A slight trend toward increased dacomitinib exposure was also observed during coadministration with crizotinib compared with administration of dacomitinib alone.
Biomarker Studies Tumor samples for biomarker analysis were available for 35 of 37 patients enrolled in the expansion phase (95%; cohort 1, n ¼ 23; cohort 2, n ¼ 12 [Supplementary Table 3]). Of the 20 samples suitable for EGFR mutational analysis (15 samples either had no tumor in the tissue or were of insufficient quantity for analysis), most (n ¼ 18) had activating EGFR mutations. Eleven of these samples showed a concurrent resistance mutation in exon 20
Figure 1. Best percentage change from baseline in target lesion size by patient in expansion cohort 1 (A) and expansion cohort 2 (B). On the basis of the response-evaluable population, excluding patients with early death, indeterminate response, or nonmeasurable disease.
(T790M alone [n ¼ 9], S768I alone [n ¼ 1], or T790M and S7681 [n ¼ 1]). Thirty, 26, and 22 tumor samples, respectively, were suitable for evaluation of MET, HER2, and EGFR amplification by FISH; 30 samples were also evaluable for ALK rearrangement. Only one sample showed low-level MET amplification (a ratio of the MET-specific signal to the centromere-specific signal of 2.12, with the cutoff for amplification defined as 2.1), and none showed HER2 amplification, whereas five of 22 samples displayed some level of EGFR amplification. No samples tested positive for ALK rearrangement. Thirty baseline tumor samples were suitable for IHC analysis of HGF and MET, whereas 22 samples were suitable for EGFR analysis. Expression of EGFR and MET varied widely, with the median percentage positive typically being 90% or higher but ranging from 2% to 100% for EGFR and from 0% to 100% for MET (Table 4). As assessed by H-scores, levels of expression of EGFR and MET were moderately high or moderate, respectively, with a few tumors displaying very strong expression. In the expansion cohort overall, mean and median H-scores, respectively, were 176 and 193 for EGFR (range 2–300) and 161 and 138 for MET (range 0– 300). However, no association was found between EGFR or MET protein expression and best percentage change in tumor volume, PFS, or treatment duration. EGFR and
May 2016
Pan-HER and ALK/ROS1/MET Inhibition in NSCLC
Table 3. Steady-State Plasma Crizotinib and Dacomitinib PK Parameter Summary in the Expansion Cohorts after Administration of Dacomitinib (30 mg Once Daily) and Crizotinib (200 mg Twice Daily) Alone or in Combination
Parameter (Units) Expansion cohort 1: crizotinib PK Total no. in treatment group No. contributing to summary statisticsa AUClast (ng∙h/mL) AUC10 (ng∙h/mL)b Cmin (ng/mL) Cmax (ng/mL) Tlast (h) Tmax (h) Expansion cohort 2: dacomitinib PK Total no. in treatment group No. contributing to summary statisticsc AUClast (ng∙h/mL) AUC24 (ng∙h/mL) Cmin (ng/mL) Cmax (ng/mL) CL/F (L/h) Tlast (h) Tmax (h)
Crizotinib or Dacomitinib Alone (Day 1)
Dacomitinib þ Crizotinib (Cycle 2, Day 1)
19
19
16
19
2223 (53) 2167 (56) 181.8 (64) 306.0 (57) 9.65 (7.63–10.1) 2.04 (0–4.00)
1365 (47) 1489 (44) 102.8 (51) 191.5 (43) 9.00 (7.67–10.0) 3.20 (2.02–9.00)
10
10
6
5
1016 (45) 995.7 (45) 33.11 (58) 47.15 (44) 32.24 (34) 24.40 (24.0–26.2) 16.0 (5.90–24.6)
1148 (44) 1148 (44) 39.92 (47) 59.58 (49) 26.09 (44) 23.80 (22.6–24.0) 5.92 (3.83–9.80)
Note: All values are geometric mean (geometric %CV) except median (range) for Tmax and Tlast. a Patients with 10 days of continuous crizotinib dosing. b Crizotinib, n ¼ 11; crizotinib þ dacomitinib, n ¼ 13. c Patients with 14 days of continuous dacomitinib dosing. AUC10, area under the plasma concentration-time curve for 10-hour samples; AUC24, area under the plasma concentration-time curve for 24-hour samples; AUClast, area under the plasma concentration-time curve from time zero to the last quantifiable concentration; CL/F, oral clearance; Cmax, maximum plasma concentration; Cmin, minimum plasma concentration; CV, coefficient of variation; PK, pharmacokinetic(s); Tlast, time of last quantifiable concentration; Tmax, time to maximum plasma concentration.
MET protein expression in each patient, along with best overall response and mutational data, are provided in Supplementary Table 3. The patient who achieved a PR (Supplementary Table 3, patient 6) had high tumor EGFR expression (IHC staining result 3þ, H-score 284) and moderate or low MET expression (H-score 140). This patient’s tumor harbored an EGFR exon 19 deletion and a T790M mutation and displayed low-level EGFR amplification (2.11fold), but no amplification of MET. The patient had received only one previous systemic regimen comprising single-agent erlotinib, which was stopped 26 days before starting the study treatment. Expression of HGF at the tumor level was less prevalent than that of EGFR and MET, with an overall median percentage positive of 45%. Where present, HGF
743
expression generally was relatively low, with a median H-score of 45 across all samples (range 0–280). Plasma s-MET was detected in 17 patients in expansion cohort 1 and six patients in expansion cohort 2 at baseline. Plasma s-MET concentrations showed a trend toward slightly increased expression over baseline with time (Fig. 2). There was no association between treatment duration and s-MET concentration.
Discussion Development of acquired resistance to EGFR TKIs during therapy for NSCLC is the main barrier to longterm clinical benefit of EGFR-targeted therapies, and there is an urgent need to develop novel agents or new treatment regimens.35 Dacomitinib and crizotinib are active against tumors bearing mutated EGFR and amplified MET, respectively.21,25,26,36,37 Hypothesizing that the combination of these two agents would be beneficial to patients after failure of targeted therapy or development of acquired resistance to EGFR TKIs, we evaluated the combination in this phase I study. The study was biomarker rich, as we hoped to increase our understanding of the drivers of EGFR TKI resistance and evaluate the link between these mechanisms and the response to dacomitinib plus crizotinib. The combination of dacomitinib with crizotinib proved insufficiently effective and was associated with greater toxicity than that seen with the individual agents. The MTD of dacomitinib combined with crizotinib was determined to be dacomitinib, 30 mg once daily, and crizotinib, 200 mg twice daily, which was the lowest dose level tested and is lower than the phase III dose of dacomitinib (45 mg once daily) and the approved starting dose of crizotinib (250 mg twice daily) when used as single agents. The most frequently reported treatment-related toxicities were diarrhea, nausea, vomiting, decreased appetite, and fatigue. Although the safety profile was consistent with that of either drug alone,25,27,28,37–41 there appeared to be additive toxicity, leading to increased frequency and severity of some common treatment-related AEs compared with those reported with each single agent. The relatively high incidence of diarrhea (any grade, 74%; grade 3, 16%) in particular was of concern. In addition, 26% of patients permanently discontinued study therapy owing to AEs of any cause. There were no treatment-related deaths, but the overall high rate of deaths during the study (21%) and short duration of treatment (median, approximately 50 days) suggested that these patients had significantly advanced disease, which may also have influenced the toxicity profile observed. We saw minimal antitumor activity in this study: only one patient had a PR, whereas 46% of patients had SD. One major reason for the limited activity observed may
744 Jänne et al
Table 4. Expression of Biomarkers EGFR, MET, and HGF at Baseline, as Assessed by IHC Analysis in Patients in the Expansion Cohorts Expansion Cohort 1 (n ¼ 23)a EGFR
a
Expansion Total (n ¼ 35)
MET
HGF
EGFR
MET
HGF
EGFR
MET
HGF
19
19
8
11
11b
22
30
30c
67 ± 37 90 (0–100) 56
48 ± 37 40 (0–100) 78
70 ± 37 85 (5–100) 53
85 ± 26 97 (15–100) 30
50 ± 46 67 (0–100) 93
75 ± 35 92 (2–100) 46
73 ± 34 93 (0–100) 47
48 ± 40 45 (0–100) 82
150 ± 115 125 (0–300) 77
63 ± 70 40 (0–280) 111
167 ± 126 170 (7–300) 75
179 ± 102 165 (20–299) 57
52 ± 48 67 (0–104) 93
176 ± 107 193 (2–300) 61
161 ± 109 138 (0–300) 68
59 ±62 45 (0–280) 105
1 (5) 1 (5) 4 (21) 13 (68)
1 (5) 12 (63) 4 (21) 2 (11)
0 0 4 (50) 4 (50)
0 0 5 (45) 6 (55)
1 (9) 6 (55) 4 (36) 0
0 1 (5) 5 (23) 16 (73)
1 (3) 1 (3) 9 (30) 19 (63)
2 (7) 18 (60) 8 (27) 2 (7)
7 (37) 11 (58) 1 (5) 0 49 ± 43 40 (0–100) 89
11 ± 26 0 (0–95) 235
8 (80) 0 1 (10) 1 (10) 52 ± 47 58 (2–100) 89
58 ± 43 75 (2–100) 75
2±5 0 (0–15) 200
15 (52) 11 (38) 2 (7) 1 (3) 58 ± 40 69 (0–100) 69
52 ± 43 44 (0–100) 82
8 ± 21 0 (0–95) 268
Tumor samples were not available for two patients enrolled in expansion cohort 1. Samples analyzable for maximum staining intensity in the stromal compartment: n ¼ 10. c Samples analyzable for maximum staining intensity in the stromal compartment: n ¼ 29. CV, coefficient of variation; EGFR, epidermal growth factor receptor; HGF, hepatocyte growth factor; IHC, immunohistochemical; MET, mesenchymal-epithelial transition factor; SD, standard deviation. b
Journal of Thoracic Oncology
Samples analyzable, n 14 Percent positive Mean ± SD 77 ± 34 Median (range) 94 (2–100) % CV 44 H-score (neoplastic compartment) Mean ± SD 181 ± 99 Median (range) 193 (2–300) % CV 55 Maximum staining intensity, n (%) Neoplastic compartment 0 0 þ1 1 (7) þ2 1 (7) þ3 12 (86) Stromal compartment 0 þ1 þ2 þ3 Staining intensity, 2þ or 3þ, % Mean ± SD 61 ± 38 Median (range) 69 (0–100) % CV 61
Expansion Cohort 2 (n ¼ 12)
Vol. 11 No. 5
May 2016
Figure 2. Plasma concentrations of soluble mesenchymalepithelial transition factor in individual patients over time in expansion cohort 1 (A) and expansion cohort 2 (B). C, cycle; D, day.
have been that dacomitinib at 30 mg once daily is unlikely to reach concentrations required to inhibit T790M. An earlier phase I study suggested that systemic exposure to dacomitinib at doses of 30 or higher mg once daily exceeded the threshold concentration for efficacy against wild-type EGFR or EGFR with common activating mutations, as predicted in preclinical studies.19,42 However, the same preclinical studies suggested that higher concentrations were needed to fully inhibit EGFR harboring the T790M mutation.19 Because this mutation is the dominant mechanism of resistance to firstgeneration EGFR TKIs11 (T790M was present in 50% of mutation-evaluable patients in our study), suboptimal concentrations of dacomitinib could have had an impact on the outcome of the entire population. The second strand to the hypothesis tested in the present study relied on the activity of crizotinib in tumors bearing MET amplifications, as has been previously reported.21,25 According to previously published series, MET amplification is present in as many as 22% of lung cancers with acquired resistance to EGFR inhibitors.12 In our study, however, only one of 30 patients (3%) tested for MET amplification by FISH analysis showed any gene amplification, and this was at a low level, indicating that MET amplification may be less frequent than initially
Pan-HER and ALK/ROS1/MET Inhibition in NSCLC
745
reported in this population, although consistent with more recent reports.16,17 Despite displaying high levels of MET expression, the patient with low-level MET amplification showed progressive disease—possibly because MET was not the true pathogenic driver in this case. Two recent studies have suggested that response to MET inhibitors is associated with MET gene copy number. In a study of crizotinib in MET-amplified NSCLC, clinical activity appeared to correlate with the extent of MET amplification relative to the centromere on chromosome 7.25 In a second study of the MET inhibitor INC280 combined with gefitinib in patients with EGFR-mutated NSCLC and progression after EGFR TKI treatment with confirmed MET dysregulation, all responders had high MET status (an IHC staining result of 3þ and/or gene copy number 5).43 The level of MET gene copy number, measured as either the ratio to the centromere of chromosome 7 (true amplification) or mean MET gene copies per cell (which could include both true amplification and high polysomy), is likely to influence the chances of MET acting as either a true driver or codriver in an individual tumor and, by extension, the ability of the biomarker to predict benefit from MET inhibition either alone or in combination with an EGFR inhibitor. However, the study by Wu et al. also suggested that high levels of MET protein (an IHC staining result of 3þ in 50% of tumor cells) were predictive of response to MET inhibition.43 In our study, tumors from 20 of 30 patients evaluated had at least some cells that stained 3þ by IHC staining for MET, 10 of which met Wu et al.’s definition of being positive for high levels of MET expression, and MET expression based on H-score for those tumors was high (range 280300). In tumors from the 20 patients who did not meet the definition of Wu et al., tumor MET expression was generally low or moderate. Thus, both the lack of MET amplification and moderate levels of MET expression may have contributed to the poor response rates that we observed. There was no association between MET expression and any measure of antitumor activity tested. The efficacy of single-agent EGFR TKIs will ultimately be limited by acquired resistance. Combination therapies offer the possibility of overcoming multiple drugresistance mechanisms simultaneously and hence may lead to more durable and sustained tumor responses. However, such treatments must also be tolerable for potentially extended periods of time. In the present study, the combination of dacomitinib and crizotinib was neither effective nor well tolerated in patients in whom resistance to prior EGFR inhibitors had developed, and no further evaluation of this combination is planned. However, given that MET amplification and EGFR T790M mutations can occur together (in the same tumor or in
746 Jänne et al
different tumors in the same patient), there continues to be a biological rationale for combining agents that target these two resistance mechanisms. Next-generation EGFR inhibitors, including osimertinib (AZD9291) and rocelitinib (CO-1686), which are selective for mutant EGFR (with both the EGFR-activating and the T790M mutations) over wild-type EGFR, have demonstrated response rates of >50% in phase I or II clinical trials of patients harboring EGFR T790M.44,45 Given the improved toxicity profile of this new class of EGFR inhibitors, they may be more amenable to combination treatment strategies, including those involving MET inhibitors.
Journal of Thoracic Oncology
9.
10.
11.
12.
Acknowledgments This study was sponsored by Pfizer Inc. We would like to thank all of the participating patients and their families, as well as the investigators, research nurses, study coordinators, and operations staff. Medical writing support was provided by Wendy Sacks and Jo Chapman at ACUMED (New York, NY, and Tytherington, United Kingdom) and was funded by Pfizer, Inc.
13.
14.
Supplementary Data Note: To access the supplementary material accompanying this article, visit the online version of the Journal of Thoracic Oncology at www.jto.org and at http://dx.doi. org/10.1016/j.jtho.2016.01.022.
15.
16.
References 1. Shigematsu H, Lin L, Takahashi T, et al. Clinical and biological features associated with epidermal growth factor receptor gene mutations in lung cancers. J Natl Cancer Inst. 2005;97:339–346. 2. Lynch TJ, Bell DW, Sordella R, et al. Activating mutations in the epidermal growth factor receptor underlying responsiveness of non-small-cell lung cancer to gefitinib. N Engl J Med. 2004;350:2129–2139. 3. Pao W, Miller V, Zakowski M, et al. EGF receptor gene mutations are common in lung cancers from “never smokers” and are associated with sensitivity of tumors to gefitinib and erlotinib. Proc Natl Acad Sci U S A. 2004;101:13306–13311. 4. Paez JG, Jänne PA, Lee JC, et al. EGFR mutations in lung cancer: correlation with clinical response to gefitinib therapy. Science. 2004;304:1497–1500. 5. Yun CH, Boggon TJ, Li Y, et al. Structures of lung cancerderived EGFR mutants and inhibitor complexes: mechanism of activation and insights into differential inhibitor sensitivity. Cancer Cell. 2007;11:217–227. 6. Rosell R, Moran T, Queralt C, et al. Screening for epidermal growth factor receptor mutations in lung cancer. N Engl J Med. 2009;361:958–967. 7. Cancer Genome Atlas Research Network. Comprehensive molecular profiling of lung adenocarcinoma. Nature. 2014;511:543–550. 8. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: non-small cell lung cancer.
17.
18.
19.
20.
21.
22.
Vol. 11 No. 5
Version 7.2015. http://www.nccn.org/professionals/ physician_gls/pdf/nscl.pdf. Accessed July 13, 2015. Lee CK, Brown C, Gralla RJ, et al. Impact of EGFR inhibitor in non-small cell lung cancer on progression-free and overall survival: a meta-analysis. J Natl Cancer Inst. 2013;105:595–605. Engelman JA, Janne PA. Mechanisms of acquired resistance to epidermal growth factor receptor tyrosine kinase inhibitors in non-small cell lung cancer. Clin Cancer Res. 2008;14:2895–2899. Ma C, Wei S, Song Y. T790M and acquired resistance of EGFR TKI: a literature review of clinical reports. J Thorac Dis. 2011;3:10–18. Engelman JA, Zejnullahu K, Mitsudomi T, et al. MET amplification leads to gefitinib resistance in lung cancer by activating ERBB3 signaling. Science. 2007;316: 1039–1043. Bean J, Brennan C, Shih JY, et al. MET amplification occurs with or without T790M mutations in EGFR mutant lung tumors with acquired resistance to gefitinib or erlotinib. Proc Natl Acad Sci U S A. 2007;104:20932– 20937. Chen HJ, Mok TS, Chen ZH, et al. Clinicopathologic and molecular features of epidermal growth factor receptor T790M mutation and c-MET amplification in tyrosine kinase inhibitor-resistant Chinese non-small cell lung cancer. Pathol Oncol Res. 2009;15:651–658. Turke AB, Zejnullahu K, Wu YL, et al. Preexistence and clonal selection of MET amplification in EGFR mutant NSCLC. Cancer Cell. 2010;17:77–88. Sequist LV, Waltman BA, Dias-Santagata D, et al. Genotypic and histological evolution of lung cancers acquiring resistance to EGFR inhibitors. Sci Transl Med. 2011;3, 75ra26. Yu HA, Arcila ME, Rekhtman N, et al. Analysis of tumor specimens at the time of acquired resistance to EGFRTKI therapy in 155 patients with EGFR-mutant lung cancers. Clin Cancer Res. 2013;19:2240–2247. Arcila ME, Oxnard GR, Nafa K, et al. Rebiopsy of lung cancer patients with acquired resistance to EGFR inhibitors and enhanced detection of the T790M mutation using a locked nucleic acid-based assay. Clin Cancer Res. 2011;17:1169–1180. Engelman JA, Zejnullahu K, Gale CM, et al. PF00299804, an irreversible pan-ERBB inhibitor, is effective in lung cancer models with EGFR and ERBB2 mutations that are resistant to gefitinib. Cancer Res. 2007;67:11924–11932. Gonzales AJ, Hook KE, Althaus IW, et al. Antitumor activity and pharmacokinetic properties of PF-00299804, a second-generation irreversible pan-erbB receptor tyrosine kinase inhibitor. Mol Cancer Ther. 2008;7:1880–1889. Ou SH, Kwak EL, Siwak-Tapp C, et al. Activity of crizotinib (PF02341066), a dual mesenchymal-epithelial transition (MET) and anaplastic lymphoma kinase (ALK) inhibitor, in a non-small cell lung cancer patient with de novo MET amplification. J Thorac Oncol. 2011;6:942–946. Schwab R, Petak I, Kollar M, et al. Major partial response to crizotinib, a dual MET/ALK inhibitor, in a squamous cell lung (SCC) carcinoma patient with de novo c-MET amplification in the absence of ALK rearrangement. Lung Cancer. 2014;83:109–111.
May 2016 23. Mendenhall MA, Goldman JW. MET-mutated NSCLC with major response to crizotinib. J Thorac Oncol. 2015;10: e33–e34. 24. Waqar SN, Morgensztern D, Sehn J. MET mutation associated with responsiveness to crizotinib. J Thorac Oncol. 2015;10:e29–e31. 25. Camidge DR, Ou S-HI, Shapiro G, et al. Efficacy and safety of crizotinib in patients with advanced c-METamplified non-small cell lung cancer (NSCLC). Presented at: 2014 ASCO Annual Meeting. May 30–June 3, 2014; Chicago, IL. 26. Janne PA, Ou SH, Kim DW, et al. Dacomitinib as first-line treatment in patients with clinically or molecularly selected advanced non-small-cell lung cancer: a multicentre, open-label, phase 2 trial. Lancet Oncol. 2014;15:1433–1441. 27. Ellis PM, Shepherd FA, Millward M, et al. Dacomitinib compared with placebo in pretreated patients with advanced or metastatic non-small-cell lung cancer (NCIC CTG BR.26): a double-blind, randomised, phase 3 trial. Lancet Oncol. 2014;15:1379–1388. 28. Ramalingam SS, Janne PA, Mok T, et al. Dacomitinib versus erlotinib in patients with advanced-stage, previously treated non-small-cell lung cancer (ARCHER 1009): a randomised, double-blind, phase 3 trial. Lancet Oncol. 2014;15:1369–1378. 29. Kazandjian D, Blumenthal GM, Chen HY, et al. FDA approval summary: crizotinib for the treatment of metastatic non-small cell lung cancer with anaplastic lymphoma kinase rearrangements. Oncologist. 2014;19:e5–e11. 30. Paik PK, Drilon A, Fan PD, et al. Response to MET inhibitors in patients with stage IV lung adenocarcinomas harboring MET mutations causing exon 14 skipping. Cancer Discov. 2015;5:842–849. 31. Agarwal S, Zerillo C, Kolmakova J, et al. Association of constitutively activated hepatocyte growth factor receptor (Met) with resistance to a dual EGFR/Her2 inhibitor in non-small-cell lung cancer cells. Br J Cancer. 2009;100:941–949. 32. Tang Z, Du R, Jiang S, et al. Dual MET-EGFR combinatorial inhibition against T790M-EGFR-mediated erlotinibresistant lung cancer. Br J Cancer. 2008;99:911–922. 33. Xu L, Kikuchi E, Xu C, et al. Combined EGFR/MET or EGFR/HSP90 inhibition is effective in the treatment of lung cancers codriven by mutant EGFR containing T790M and MET. Cancer Res. 2012;72:3302–3311.
Pan-HER and ALK/ROS1/MET Inhibition in NSCLC
747
34. Nanjo S, Yamada T, Nishihara H, et al. Ability of the Met kinase inhibitor crizotinib and new generation EGFR inhibitors to overcome resistance to EGFR inhibitors. PLoS One. 2013;8:e84700. 35. Stinchcombe TE. Novel agents in development for advanced non-small cell lung cancer. Ther Adv Med Oncol. 2014;6:240–253. 36. Park K, Cho BC, Kim DW, et al. Safety and efficacy of dacomitinib in Korean patients with KRAS wild-type advanced non-small-cell lung cancer refractory to chemotherapy and erlotinib or gefitinib: a phase I/II trial. J Thorac Oncol. 2014;9:1523–1531. 37. Ramalingam SS, Blackhall F, Krzakowski M, et al. Randomized phase II study of dacomitinib (PF-00299804), an irreversible pan-human epidermal growth factor receptor inhibitor, versus erlotinib in patients with advanced nonsmall-cell lung cancer. J Clin Oncol. 2012;30:3337–3344. 38. Camidge DR, Bang YJ, Kwak EL, et al. Activity and safety of crizotinib in patients with ALK-positive non-small-cell lung cancer: updated results from a phase 1 study. Lancet Oncol. 2012;13:1011–1019. 39. Shaw AT, Kim DW, Nakagawa K, et al. Crizotinib versus chemotherapy in advanced ALK-positive lung cancer. N Engl J Med. 2013;368:2385–2394. 40. Shaw AT, Ou SH, Bang YJ, et al. Crizotinib in ROS1rearranged non-small-cell lung cancer. N Engl J Med. 2014;371:1963–1971. 41. Solomon BJ, Mok T, Kim DW, et al. First-line crizotinib versus chemotherapy in ALK-positive lung cancer. N Engl J Med. 2014;371:2167–2177. 42. Jänne PA, Boss DS, Camidge DR, et al. Phase I doseescalation study of the pan-HER inhibitor, PF299804, in patients with advanced malignant solid tumors. Clin Cancer Res. 2011;17:1131–1139. 43. Wu Y-L, Yang J C-H, Kim D-W, et al. Safety and efficacy of INC280 in combination with gefitinib (gef) in patients with EGFR-mutated (mut), MET-positive NSCLC: a singlearm phase lb/ll study [abstract]. J Clin Oncol. 2014;32(suppl 5s):8017. 44. Janne PA, Ramalingam SS, Yang JC, et al. Clinical activity of the mutant-selective EGFR inhibitor AZD9291 in patients (pts) with EGFR inhibitor–resistant non-small cell lung cancer [abstract]. J Clin Oncol. 2014;32(suppl 5s):8009. 45. Sequist LV, Soria JC, Goldman JW, et al. Rociletinib in EGFR-mutated non-small-cell lung cancer. N Engl J Med. 2015;372:1700–1709.