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Community Practice Connections™: Working Group to Optimize Outcomes in EGFR-mutated Lung Cancers: Evolving Concepts for Nurses to Facilitate and Improve Patient Care PER Pulse Recap

PER Pulse Recap

PER Pulse™ Recap


1 of 3
PER Pulse™ Recap

Clinical Data With EGFR TKIs in Lung Cancer

The Working Group to Optimize Outcomes in EGFR-Mutated Lung Cancers: Evolving Concepts for Nurses to Facilitate and Improve Patient Care, which was held May 6, 2017, in conjunction with the 2017 Oncology Nursing Society Annual Meeting, updated oncology nurses and other practitioners on key lung cancer data sets, educating them on how this evidence can be interpreted in the context of evolving epidermal growth factor receptor (EGFR)-targeted treatment paradigms. In addition, this program provided expert guidance on how to proactively mitigate and manage treatment-related toxicities, navigate molecular testing concerns, and improve patient compliance. This first of 3 PER Pulse™ Recaps from this program focuses on recent and emerging clinical data with EGFR tyrosine kinase inhibitors (TKIs) in lung cancer.

  • Three EGFR TKIs, erlotinib, afatinib, and gefitinib are approved in the first-line setting for patients with EGFR-mutated non¬–small-cell lung cancer. All 3 of these TKIs have demonstrated improved outcomes (response rates, progression-free survival [PFS], and quality of life) compared with chemotherapy in this patient population.
  • In addition, osimertinib, a third-generation TKI that is currently approved for recurrent T790M-positive disease, is being tested in the frontline setting. Phase I data for frontline osimertinib in patients with EGFR-mutated disease demonstrated a median PFS of 19 months. The ongoing Phase III FLAURA trial is a head-to-head trial of osimertinib vs first-generation EGFR TKIs in this setting, and its results should indicate whether there should be a change in practice.
  • Combination therapies are also under investigation for this patient population. In a Japanese randomized phase II trial, the addition of bevacizumab to erlotinib in the first-line setting produced a 6.3-month improvement in median PFS. This combination, as well as the combination of afatinib + the anti-EGFR monoclonal antibody cetuximab are currently being investigated in phase III trials.
  • For patients whose disease progresses on first-line EGFR TKI therapy, molecular testing for the T790M resistance mutation prior to changing therapy is a standard approach. Liquid-based biopsies, with their procedural ease and rapid turnaround time, have demonstrated utility in this setting. For patients whose disease harbors the T790M mutation, osimertinib is approved. If molecular tests are negative for T790M, this diagnosis should be confirmed, particularly if obtained by a liquid-based biopsy. For these patients, platinum-based chemotherapy is an appropriate approach.

For additional commentary about these topics and others, visit www.gotoper.com for archived video of the Working Group to Optimize Outcomes in EGFR-Mutated Lung Cancers: Evolving Concepts for Nurses to Facilitate and Improve Patient Care, as well as downloadable slides summarizing results from the meeting. 


2 of 3
PER Pulse™ Recap

Toxicities of EGFR TKIs in Lung Cancer

The Working Group to Optimize Outcomes in EGFR-Mutated Lung Cancers: Evolving Concepts for Nurses to Facilitate and Improve Patient Care, which was held May 6, 2017, in conjunction with the 2017 Oncology Nursing Society Annual Meeting, updated oncology nurses and other practitioners on key lung cancer data sets, educating them on how this evidence can be interpreted in the context of evolving epidermal growth factor receptor (EGFR)-targeted treatment paradigms. In addition, this program provided expert guidance on how to proactively mitigate and manage treatment-related toxicities, navigate molecular testing concerns, and improve patient compliance. This second of 3 PER Pulse™ Recaps from this program focuses on the toxicities associated with EGFR tyrosine kinase inhibitors (TKIs) in non¬–small-cell lung cancer.

Ann Culkin, RN, OCN, office practice nurse at Memorial Sloan Kettering Cancer Center and Christine H. Teklehaimanote, MSN, NP, AOCNP from the University of California Davis Medical Center provided a number of management tips for the care of patients who experience mild acneiform rash in multiple locations during EGFR TKI therapy.

  • Acknowledge the emotional distress that some patients feel when they develop rash
  • Warn them prior to treatment initiation that rash is a common toxicity and give them a prescription for clindamycin topical solution upfront, so they can start treatment immediately upon developing the rash
  • Remind them to call the office if they feel the rash is not under control
  • Account for the distribution of rash when grading it
  • Recommend sunscreen for even minimal sun exposure (eg, walking from a car into a building)
  • Discover how patients are currently managing skin care
  • Provide education on several aspects of skin care, including the need to moisturize, which soaps to use, and how to care for fingernails and toenails
  • Consider combination therapy with clindamycin and pimecrolimus 1% cream

For additional commentary about these topics and others, visit www.gotoper.com for archived video of the Working Group to Optimize Outcomes in EGFR-Mutated Lung Cancers: Evolving Concepts for Nurses to Facilitate and Improve Patient Care, as well as downloadable slides summarizing results from the meeting. 


3 of 3
PER Pulse™ Recap

Role of Plasma Biopsies in Lung Cancer in 2017

The Working Group to Optimize Outcomes in EGFR-Mutated Lung Cancers: Evolving Concepts for Nurses to Facilitate and Improve Patient Care, which was held May 6, 2017, in conjunction with the 2017 Oncology Nursing Society Annual Meeting, updated oncology nurses and other practitioners on key lung cancer data sets, educating them on how this evidence can be interpreted in the context of evolving epidermal growth factor receptor (EGFR)-targeted treatment paradigms. In addition, this program provided expert guidance on how to proactively mitigate and manage treatment-related toxicities, navigate molecular testing concerns, and improve patient compliance. This third of 3 PER Pulse™ Recaps from this program focuses on the role of plasma biopsies in lung cancer in 2017.

Benjamin P. Levy, MD, assistant professor and clinical director at Johns Hopkins Sidney Kimmel Cancer Center, and Karen C. Lee, MSN, FNP-BC, clinical nurse practitioner at Memorial Sloan Kettering Cancer Center, discussed the clinical implications of different sources of biopsy from patients with advanced lung cancer.

Treatment-naïve disease
Dr Levy stated that tissue biopsy remains the gold standard for treatment-naïve disease, at the very least for making a histology diagnosis (eg, adenocarcinoma, squamous cell carcinoma). While it is ideal to also use tissue for molecular testing, often the amount of tissue available makes that impossible. In those circumstances, it is reasonable to use a plasma biopsy, also called a liquid biopsy, for molecular testing rather than waiting for a tissue rebiopsy. Plasma biopsies have the advantage of being less invasive, having a quicker turnaround time, and may be more attractive to someone who is reluctant to undergo a rebiopsy.

Ms Lee jumped in to share a patient case illustrating one way plasma biopsies are used at her institution. For a recent asymptomatic newly diagnosed patient, who had a high likelihood of harboring an EGFR sensitizing mutation due to his Asian ethnicity, adenocarcinoma histology, and never smoker status, his tissue biopsy was insufficient to perform molecular testing. In this case, his team sent off his plasma biopsy both for standard molecular testing, which has a turnaround time of 1 week or less, and next-generation sequencing, which is expected to take much longer (4-5 weeks). Therefore, if his standard molecular testing results are positive for a sensitizing EGFR mutation, he can quickly start on an EGFR TKI such as erlotinib. If results are negative and given that he is asymptomatic, they will wait for the sequencing results in order to plan treatment. This use of a plasma biopsy allows Ms Levy’s team to quickly obtain molecular testing without having to schedule a rebiopsy.

Treatment-refractory disease
Dr Levy discussed how the use of biopsies differs in the treatment-refractory setting for patients receiving first-line EGFR TKIs. Research has shown that patients progressing on an EGFR TKI who test positive for the EGFR resistance mutation T790M using a plasma biopsy are just as likely to respond to T790M-targeted therapy (such as osimertinib) as patients testing positive using a tissue biopsy. Therefore, he has no hesitation in using a plasma biopsy to test these patients for T790M. However, because research has shown a weaker correlation between patient outcomes with plasma and tissue biopsies when T790M results are negative, patients with T790M-negative results using a plasma biopsy need to be retested using a new tissue biopsy.

For additional commentary about these topics and others, visit www.gotoper.com for archived video of the Working Group to Optimize Outcomes in EGFR-Mutated Lung Cancers: Evolving Concepts for Nurses to Facilitate and Improve Patient Care, as well as downloadable slides summarizing results from the meeting. 

PER® Practice Pulse
Practice Pattern Questions
How often do you attend society oncology/hematology meetings? (ASCO, ASH, SABCS)
Practice Pattern Questions
What is the most significant barrier to implementing new information in your clinical practice?






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