Cancer Treatment Reviews

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1 Cancer Treatment Reviews 38 (2012) Contents lists available at SciVerse ScienceDirect Cancer Treatment Reviews journal homepage: Antitumour Treatment EGFR-mutated oncogene-addicted non-small cell lung cancer: Current trends and future prospects Jean-Charles Soria a,, Tony S. Mok b,e, Federico Cappuzzo c,f, Pasi A. Jänne d,g a Service des Innovations Thérapeutiques Précoces, Institut Gustave Roussy, INSERM Unit 981 and Paris University XI, 39 rue Camille Desmoulins, Villejuif, France b State Key Laboratory in Oncology in South China, Sir YK Pao Centre for Cancer, Department of Clinical Oncology, Chinese University of Hong Kong, Hong Kong c Istituto Toscano Tumori, Ospedale Civile di Livorno, viale Alfieri 36, Livorno, Italy d Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215, United States article info abstract Article history: Received 23 August 2011 Received in revised form 6 October 2011 Accepted 22 October 2011 Keywords: Biological markers Carcinoma Non-small cell lung Receptor Epidermal growth factor Erlotinib Gefitinib Mutation Oncogenes Non-small cell lung cancer (NSCLC) tumours with certain mutations in the epidermal growth factor receptor (EGFR) tyrosine kinase have been termed oncogene addicted to reflect their dependence on EGFR-mediated pro-survival signalling and their high susceptibility to apoptosis induced by EGFR tyrosine kinase inhibitors (EGFR TKIs, e.g. gefitinib and erlotinib). The most common mutations (L858R and exon 19 deletions) predict an improved clinical response to first-line oral EGFR TKIs compared with standard platinum-based chemotherapy in patients with advanced NSCLC. Moreover, these mutations are also prognostic of a relatively indolent course of disease, regardless of treatment, as compared with classical NSCLC. Treatment strategies for oncogene-addicted NSCLC are therefore distinct from those for nononcogene addicted NSCLC, and will depend on the specific genetic mutation present. Ó 2011 Published by Elsevier Ltd. Introduction Corresponding author. Tel.: ; fax: addresses: jean-charles.soria@igr.fr (J.-C. Soria), tony@clo.cuhk.edu.hk (T.S. Mok), f.cappuzzo@googl .com (F. Cappuzzo), Pasi_Janne@dfci.harvard.edu (P.A. Jänne). e Tel.: ; fax: f Tel.: ; fax: g Tel.: ; fax: Lung cancer causes a fifth of all cancer-related deaths. 1 Nonsmall cell lung cancer (NSCLC) accounts for most cases of lung cancer and is usually diagnosed in advanced stages. Platinum-based chemotherapy, the recommended standard first-line systemic treatment for advanced NSCLC, 2 has limited efficacy 3 and significant toxicity. The identification of oncogenic mutations that contribute to the pathogenesis of NSCLC has recently led to novel approaches to diagnosis, classification and management of this disease. The epidermal growth factor receptor (EGFR) tyrosine kinase has been a particularly important target for new therapies. EGFR (also known as ErbB1 or human epidermal growth factor receptor [HER]1) belongs to the Erb family of transmembrane receptor tyrosine kinases. 4 Two EGFR tyrosine kinase inhibitors (TKIs), erlotinib (Tarceva Ò ; Roche) 5 and gefitinib (Iressa Ò ; AstraZeneca), 6 are currently approved for the treatment of NSCLC. EGFR TKIs bind reversibly to the EGFR tyrosine kinase, competing with the substrate, adenosine triphosphate (ATP), and thereby blocking the catalytic activity of the enzyme. First-line EGFR TKI therapy when given as monotherapy or in combination with chemotherapy, 7 12 had disappointing efficacy in Phase III trials performed in populations of patients with NSCLC who were not selected according to any molecular analysis of EGFR. It is now known that the efficacy of EGFR TKI is influenced by somatic mutations in EGFR. More fundamentally, there is accumulating evidence that EGFR-mutated NSCLC represents one of several oncogene-addicted forms of NSCLC that differ from classical NSCLC in terms of the patient groups affected, the prognosis, and the optimal diagnostic and therapeutic approaches. Focusing on EGFR, this paper reviews these developments and discusses their important implications for molecular testing and screening, treatment selection and sequencing, and the evaluation of future treatments for NSCLC. EGFR TKI in unselected NSCLC populations Early Phase III trials showed little benefit of EGFR TKI when these agents were used as monotherapy after the failure of standard chemotherapy in patients with advanced NSCLC. In the /$ - see front matter Ó 2011 Published by Elsevier Ltd. doi: /j.ctrv

2 J.-C. Soria et al. / Cancer Treatment Reviews 38 (2012) BR.21 trial, erlotinib monotherapy significantly improved overall survival (OS) and progression-free survival (PFS) after the failure of standard chemotherapy, as compared with placebo. 13 Gefitinib did not improve survival or other outcomes compared with placebo when used as second- or third-line therapy in the Iressa Ò Survival Evaluation in Lung cancer (ISEL) trial; however, eligibility criteria in this trial restricted the study population to one with a very poor prognosis (patients with advanced NSCLC, refractory or intolerant to their first or second line of therapy and not suitable for further chemotherapy), which may have contributed to the outcomes. 14 Subgroup analysis did show a significant survival benefit in never smokers and patients of Asian origin. In two other studies the Iressa Ò NSCLC Trial Evaluating REsponse and Survival versus Taxotere (INTEREST) and the V trial gefitinib had efficacy similar to docetaxel when used in patients previously treated with platinum-based chemotherapy. 15,16 More recently, in the Iressa Ò as Second-line Therapy in Advanced NSCLC KoreA (ISTANA) study, second-line gefitinib significantly prolonged PFS (as compared with docetaxel) in Korean patients. 17 Maintenance therapy with EGFR TKIs has also significantly improved PFS following platinum-based chemotherapy in unselected patients. 18,19 EGFR TKI also had disappointing efficacy when added to firstline combination chemotherapy regimens. Gefitinib did not significantly improve survival or time to progression (TTP) when added to first-line paclitaxel plus carboplatin or gemcitabine plus cisplatin in the Iressa Ò NSCLC Trial Assessing Combination Treatment (INTACT) trials. 7,8 Erlotinib did not confer a significant overall benefit on these outcomes when it was added to first-line chemotherapy with carboplatin paclitaxel 9 in the TRIBUTE study or cisplatin gemcitabine in the TALENT study. 10 In both studies, erlotinib provided significant survival benefits in the subsets of patients who reported having never smoked. 9,10 More recently, the Tarceva Ò or Chemotherapy (TORCH) study was discontinued when an interim analysis revealed that first-line erlotinib followed on progression by second-line cisplatin gemcitabine was inferior in unselected patients to the reverse, standard strategy of first-line cisplatin gemcitabine followed by second-line erlotinib. 11 The Tarceva Ò Or Placebo In Clinically Advanced Lung cancer (TOPICAL) study showed that erlotinib did not significantly improve OS when added to best supportive care (as compared with best supportive care alone) in a population of chemotherapy-naive patients who had a poor performance status (ECOG 2/3) or who were unfit for platinum chemotherapy, although there was a trend for a prolongation of PFS and a significant prolongation of both OS and PFS in the subset of female patients. 12 EGFR abnormalities in NSCLC EGFR is activated by the binding of various ligands of the extracellular growth factor (EGF) family of peptides. 20 Upon ligand binding, the enzyme homo- or hetero-dimerizes with other EGFR units or other Erb receptor subtypes, e.g. ErbB2 (HER2). The intracellular domain undergoes autophosphorylation and increased kinase activity. These changes result in the transduction of oncogenic signals via downstream pathways that mediate cell survival, proliferation and invasion, including the mitogen-activated protein kinase (MAPK) and phosphatidylinositol 3-kinase (PI3K) pathways. 21 Abnormalities in EGFR in NSCLC tumours include over-expression, amplification and mutation. Although wild-type EGFR is commonly over-expressed in NSCLC tumours (30 75% of samples), 9,10,15,22 24 this does not reliably correlate with a poor prognosis or predict response to EGFR TKIs. 9,10,15,22,23,29,30 EGFR over-expression correlates with a high EGFR gene copy number, as measured by fluorescence in situ hybridization (FISH). 31 According to criteria developed by the University of Colorado Cancer Center (UCCC), EGFR FISH-positivity is defined as either P4 copies of EGFR in >40% of cells or the presence of gene amplification (an EGFR gene to centromere 7 ratio of P2 or >10% of tumour cells demonstrating either >15 copies of EGFR, the presence of small EGFR gene cluster [4 10 copies], or an EGFR signal larger and brighter than centromere 7). 32 Approximately 30 45% of tested NSCLC tumours are FISH-positive. 9,15,23,24,33,34 High EGFR gene copy number (including amplification of the gene) has also shown conflicting results as a predictor of survival after EGFR TKIs, 15,22 24,33,35,36 although it was the only predictor of survival in trials without the confounding effect of chemotherapy and without crossover between arms. Interpretation of studies that have attempted to correlate prognosis or response with the overexpression of wild-type EGFR is hindered by differences in the methods and definitions used, and the lack of differentiation between wild-type and mutated EGFR. 37 Activating EGFR mutations Analysis of trial data revealed that EGFR TKIs were most effective in patients with somatic mutations in the EGFR gene Larger studies recently confirmed that EGFR TKIs significantly improve PFS in patients with these mutations. 22,41 43 EGFR mutations are known as activating mutations because (in most cases) they induce a ligand-independent activation of the tyrosine kinase, 44 resulting in upregulation of oncogenic cell signalling. 37 Activating mutations in the EGFR gene are found in around 10 20% of all patients with advanced NSCLC 45 and in more than 50% of adenocarcinomas and tumours from East Asians, never smokers and women. 37,45 48 These mutations occur in exons of EGFR and result in mutations within the active site of the EGFR kinase domain (Fig. 1). 49 The substitution of arginine for leucine at codon 858 (L858R) accounts for approximately 40% of mutations, with inframe deletions at exon 19 (del E746_A750 being the most common) accounting for another 40 45%. 37,45 Less common mutations (65%) include insertions of residues in exon 20 and substitutions at the glycine residue at position 719 in exon 18 (e.g. G719S). All of these mutations occur close to the shared binding site of ATP and EGFR TKI. 49 L858R and exon 19 deletions render EGFR highly sensitive to gefitinib and erlotinib. 44 Kinetic analysis of the L858R mutation has revealed that it reduces the affinity of the tyrosine kinase for ATP while increasing its affinity for EGFR TKI. In contrast, the G719S point mutation decreases the affinity of EGFR for both ATP and gefitinib. 49 Thus, G719 mutants are sensitive to erlotinib (and the newer Erb family TKIs, e.g. afatinib (BIBW 2992) 50 and neratinib 51 ) but may be less sensitive in vitro to gefitinib (50% inhibitory concentration: 68 mmol/l for gefitinib compared with 16 mmol/l for erlotinib). 44 Other mutations, most notably the T790M mutation in exon 20, are associated with resistance to EGFR TKIs, as discussed below. Importantly, EGFR-mutated NSCLC tumours have been termed oncogene addicted to reflect their dependence on EGFR-mediated pro-survival signalling and their high susceptibility to EGFR TKIinduced apoptosis. 52 The acute inactivation of EGFR is thought to shift the balance of cell signalling, with a rapid deterioration of pro-survival signals resulting in the predominance of more sustained pro-apoptotic signals. 37,52 Testing for EGFR mutations EGFR mutations are usually detected in DNA from tumour samples using gene sequencing (Sanger sequencing) of exon sequences amplified by polymerase chain reaction (PCR). 53 While this method has been regarded as the gold standard, it is associated with various disadvantages, including limited sensitivity, a dependence on

3 418 J.-C. Soria et al. / Cancer Treatment Reviews 38 (2012) mutations have been detected with high specificity but somewhat lower sensitivity by employing mutation-specific antibodies within immune histochemistry analyses. 60,61 In the future, the development of platforms that can simultaneously screen for multiple mutations in various genes, including EGFR, 62 should further facilitate gene-directed therapy. However, these measures will only detect known mutations and will not identify novel mutations. 54 Biomarkers for other genomic mutations in NSCLC Fig. 1. Structure of the epidermal growth factor receptor kinase domain, highlighting the sites of oncogenic mutations. The kinase domain fold consists of a smaller N-terminal lobe and a larger C-terminal lobe. The active site lies in the cleft between the two lobes. The kinase is shown in the active conformation. Locations of activating mutations are indicated in red. The regulatory C-helix is coloured pink, the phosphate coordinating P-loop is shown in magenta, and the activation loop (Aloop) is coloured orange. Reproduced from Eck MJ and Yun CH. Biochim Biophys Acta 2010;1804(3): With permission from Elsevier. 49 For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article. sample preparation methods, and the requirement for a sufficient tumour sample (five to ten 5 lm sections being recommended for molecular diagnosis) The need for direct sequencing has been avoided by the development of rapid, simple and highly sensitive PCR assays for tumour samples 56,57 or blood. 58,59 The Amplification Refractory Mutation System (ARMS ) PCR system 54 has been used advantageously in some recent trials of EGFR TKIs. 36,41 Recently, exon 19 (only del E746_A750) deletions and L858R Various molecular markers and targets are being evaluated as part of efforts to improve NSCLC care (Table 1). The KRAS gene codes for the Kras protein, a membrane-bound guanosine triphosphatase that mediates cell signalling via various pathways. KRAS mutations that trigger over-activity of Kras are an important pathogenic step in NSCLC. 63 According to a recent meta-analysis of 22 studies, KRAS mutations were found in 16% of patients with NSCLC treated with EGFR TKIs in clinical studies, and a quarter of smokers and patients with adenocarcinomas. 64 Some studies have correlated KRAS mutations with lower tumour response rates and progressive disease in patients treated with EGFR TKIs According to the aforementioned meta-analysis, the odds ratio of tumour response in patients with KRAS mutations was 0.29 (p < 0.01) compared with patients with wild-type KRAS. 64 Some retrospective studies have suggested that KRAS mutations also predict survival in patients treated with EGFR TKIs. 36,65,67 However, the predictive value of this marker has not been fully established. 55,64,68,69 Furthermore, different KRAS mutations may vary in their predictive value, as suggested by the recent finding that the glycine-to-aspartate transition mutation at codon 13 of KRAS (p.g13d) predicts survival in patients with chemotherapy-refractory colorectal cancer treated with cetuximab, as compared with patients with other types of KRAS mutations. 70 Additional molecular markers under evaluation in NSCLC include HER2, the echinoderm microtubule-associated protein-like 4 (EML4)-anaplastic lymphoma kinase (ALK) fusion gene (EML4 ALK), PI3K and BRAF, fibroblast growth factor receptor 1 (FGFR1) and insulin-like growth factor receptor 1 (IGF1R). HER2 is over-expressed in up to 35% of patients with NSCLC (especially in adenocarcinomas) and is associated with poor prognosis. 71,72 Increased copy number of the HER2 gene (determined by FISH) is associated with gefitinib sensitivity in patients with EGFR over-expression, gene amplification or mutations. 73 Activating insertion mutations in HER2 are found in around 2% of all patients. They are most common (3%) in women, never smokers and in adenocarcinomas and Table 1 Approximate prevalence rates for selected biomarkers in non-small cell lung cancer tumours. Mutation Frequency Effect on EGFR TKI efficacy All untreated NSCLC Sub-populations EGFR activating 10 20% >50% In adenocarcinomas females, East Asian, " mutation never smokers EGFR T790M Up to 35% a 50% In patients who progress on EGFR TKI ; MET amplification Up to 20%, but rarely high enough to cause 10 20% In patients who progress on EGFR TKI ; resistance (62%) KRAS mutation 16% 25% In adenocarcinomas and smokers ; HER2 mutation 2% 3% In women, never smokers and in adenocarcinomas ; (but potentiate agents active against HER2) BRAF mutation ND 2 3% In adenocarcinomas ; EML4 ALK mutation 5 13% ; PIK3CA mutation 1.5% 5% In patients who progress on EGFR TKI ; See text for references. EFGR, epidermal growth factor receptor; EML4 ALK, echinoderm microtubule-associated protein-like 4-anaplastic lymphoma kinase; HER2, human epidermal growth factor receptor 2; PIK3, phosphatidylinositol 3-kinase. a Rates of 35 38% in recent studies. Prevalence highly dependent on test methods, with some studies reporting rates of <5%.

4 J.-C. Soria et al. / Cancer Treatment Reviews 38 (2012) do not occur in conjunction with EGFR or KRAS mutations. 74,75 As the signalling activity of EGFR and HER2 are interlinked (owing to their heterodimerization during activation), the dual inhibition of both proteins is an attractive target for new treatments for NSCLC. 76 HER2 mutations confer resistance to EGFR TKIs, but sensitivity to novel agents that inhibit both HER2 and EGFR Caused by a small chromosome 2p inversion, EML4 ALK causes the highly oncogenic expression of a chimeric tyrosine kinase in which the N-terminal portion of EML4 is fused to the intracellular portion of ALK. 80 EML4 ALK has been detected in 5 13% of patients with NSCLC and it confers resistance to EGFR TKI therapy, although this may be related to the absence of EGFR mutations in these patients. EML4 ALK-positive patients are younger than those with EGFR-mutations or wild-type EGFR, and are more likely to be male and non-smokers. 81,82 Several ALK inhibitors are in clinical development and have shown promising efficacy so far in EML4 ALK-positive patients, 83 while crizotinib (Xalkori Ò ; Pfizer) 84 has recently been approved in the US for use in patients with ALK-positive, locally advanced or metastatic NSCLC. The ongoing development of immunohistochemical assays should facilitate the routine testing for ALK gene rearrangement and hence the identification of patients who may benefit from these therapies. 85,86 PI3K are lipid kinases that act downstream of tyrosine kinases to promote cell survival and proliferation via signalling mediators, including the serine/threonine kinase Akt and mammalian target of rapamycin (mtor). 87 Amplification and mutation of the PIK3CA gene, which encodes the principal catalytic unit of PI3K, have been implicated in NSCLC in a minority of patients, as have abnormalities in the downstream mediators. Mutations in PIK3CA were found in 1.6% of an international sample of NSCLC tumours. 88 B-RAF is another serine/threonine kinase, coded for by the BRAF gene. Activating mutations in the BRAF gene have been found in 2 5% of NSCLC adenocarcinomas. 89,90 Approximately half of these mutations involve the amino acid substitution V600E, and this is associated with a particularly aggressive phenotype. Inhibitors of PI3K, mtor and BRAF are in clinical development. 83,87,91 95 So far, targeted treatment approaches for NSCLC have been directed at molecular lesions that occur principally in adenocarcinomas and not in squamous cell cancer associated with smoking. Recently, the FGFR1 kinase was identified as a promising therapeutic target for squamous cell lung cancer. Amplification of the FGFR1 gene was found in 22% of squamous lung tumours, compared with only 1% of non-squamous tumours. 96 Furthermore, tumours with FGFR1 amplification were dependent on FGFR1 and were susceptible in vivo to a developmental FGFR inhibitor. 96 Mutations in the gene encoding the discoidin domain receptor (DDR2) kinase have been detected in approximately 3% of squamous cell lung tumours tested, 97 which suggests that such tumours may be susceptible to treatment with multikinase inhibitors in development. IGF1R is a novel marker expressed more commonly in squamous cell NSCLC than in other histologies. 98 Although IGF1R expression does not correlate with survival in patients with resectable NSCLC, 98 a high IGF1R gene copy number (present in 27% of resected NSCLC tumours in one study) appears to be prognostic in this group. 99 The role of EGFR TKI in patients with EGFR mutation Small studies in 2004 first showed that NSCLC tumours with activating EGFR mutations were more likely to respond to EGFR TKIs. 39,40 Subsequent single-arm studies showed that EGFR mutations predicted survival or progression in patients treated with gefitinib. 24,35,45 48,100,101 A pooled analysis of five trials showed that the presence of EGFR mutations predicted these outcomes more accurately than did the clinical predictors of ethnicity, sex, histology and smoking status. 102 Clinical selection of patients Several trials have prospectively compared first-line EGFR TKIs against chemotherapy in patient populations defined clinically according to characteristics associated with activating mutations. The largest trial, the Iressa Ò Pan-Asia Study (IPASS), randomized 1217 East Asian non-smokers (or former light smokers) with previously untreated advanced adenocarcinomas (79% of whom were female) to gefitinib or carboplatin paclitaxel. 41 Overall, gefitinib significantly prolonged the median PFS (Table 2), 41 43,103,104 and increased the objective response rate (ORR), compared with chemotherapy. However, the benefit of gefitinib on PFS was limited to patients with EGFR mutations. EGFR mutation data were available for 437 patients, of whom 261 (59.7%) had mutations (mostly exon 19 deletions and L858R mutations). Gefitinib significantly prolonged PFS (compared with chemotherapy) in patients with EGFR mutations, but was associated with a significantly shorter PFS among patients with wild-type EGFR (Fig. 2). 41 There was no difference in OS between the two treatment arms either in the overall analysis or the analysis according to EGFR status (Table 2). These IPASS data indicate that clinical criteria are not sufficient alone to predict benefit from EGFR TKIs. 55 Similar findings were observed in the smaller First-SIGNAL trial (First-line Single agent Iressa Ò versus Gemcitabine and cisplatin Trial in Never-smokers with Adenocarcinoma of the Lung). This study randomized 313 Korean never-smokers with adenocarcinoma to first-line treatment with gefitinib or cisplatin gemcitabine. 103 Overall, there were no significant differences between the arms in OS or PFS (Table 2). As in IPASS, gefitinib therapy improved PFS versus chemotherapy in mutation-positive patients (although this did not reach statistical significance), but worsened PFS in mutation-negative patients (Table 2). OS did not differ between the groups regardless of EGFR status. 103 In the United States, the Phase II Cancer and Leukaemia Group B (CALGB) study randomized 181 mostly Caucasian never or light smokers with adenocarcinoma to first-line therapy with erlotinib administered either alone or in combination with carboplatin paclitaxel. 104 According to preliminary data (reported in abstract form), these two regimens had similar efficacy and in both arms PFS and OS were significantly prolonged in the subset of patients with EGFR mutations compared with those with wild-type EGFR (Table 2). A similar Phase II study also investigating first-line erlotinib given alone or intercalated with carboplatin paclitaxel chemotherapy in EGFR-positive advanced NSCLC recently reported that patients with EGFR activating mutations did better on erlotinib alone (median PFS 18.2 months vs. 4.9 months for EGFR-mutant patients on erlotinib and chemotherapy). However, in this study the 6-month PFS rates in both treatment arms were significantly less than historical controls. 105 Molecular selection of patients Other trials have specifically selected patients according to the molecular identification of EGFR mutations, rather than by clinical characteristics. The West Japan Thoracic Oncology Group (WJTOG) 3405 trial compared gefitinib against cisplatin docetaxel in 177 Japanese patients with adenocarcinomas and exon 19 or L858R EGFR mutations. 42 In this population, gefitinib therapy significantly prolonged PFS (Table 2) and improved the ORR compared with chemotherapy. There was no significant difference in median OS between the arms, but the reported data are immature and require further follow-up. Similar data were obtained when the North East Japan Study Group compared gefitinib with carboplatin-paclitaxel in patients with EGFR mutations. 43 Two phase III trials have compared first-line erlotinib with platinum-based chemotherapy in patients with NSCLC and activating

5 Table 2 Results of selected randomized Phase III trials comparing first-line EGFR tyrosine kinase inhibitors and chemotherapy in previously untreated patients with advanced non-small cell lung cancer, showing effects on survival measures according to EGFR mutational status. Trial/ref Population Regimens Median OS, m (rate, %) Median PFS, m (rate, %) All EGFR mutation + Wild type All EGFR mutation + Wild-type Clinical selection IPASS 41 FIRST-SIGNAL 103 CALGB East Asian never smokers or former light smokers with adenocarcinoma Korean never smokers with adenocarcinoma Never smokers or former light smokers with adenocarcinoma (>75% Caucasian) Mutational selection WJTOG Japanese patients with adenocarcinoma and EGFR mutations (exon 19 deletions or L858R) NEJSG 43 CTONG 0802 (OPTIMAL) 106 EURTAC 107 Japanese patients with EGFR mutations (and no T790M) Chinese patients with activating EGFR mutations Patients with activating EGFR mutations GEF (n = 609) 18.6 HR vs. chemo: 0.91 (95% CI ) ND HR vs. chemo: 0.78 (95% CI ) ND HR vs. chemo: 1.38 ( ) 5.7 (12 m: 24.9) HR vs. chemo: 0.74 (95% CI ; p < 0.001) ND HR vs. chemo: 0.48 (95% CI ; p < 0.001) PAC + CAR (n = 608) 17.3 ND ND 5.8 (12 m: 6.7) ND ND GEF (n = ND) 20.3 (12 m 73.7) ND ND HR vs. chemo: HR vs. chemo: HR vs. WT: (95% CI ; (95% CI (95% CI, ; p = ) 0.938;p = ) p = ) CIS + GEM 23.1 (12 m: 76.2) ND ND (n = ND) HR vs. WT = (95% CI ; p = ) ERL (n = 82) 24.0 (80% CI ) ERL + CAR + PAC (n = 100) 19.6 (80% CI ) 27.6 (80% CI ) (p= vs. WT) 39.0 (80% CI 39.0 NR) (p = vs. WT) GEF, (n = 88) 30.9 (95% CI 24.1 NR) HR vs. chemo: (95% CI ; p = 0.211) CIS + DOC, (n = 89) GEF, (n = 115) 30.5 (2 y: 61.4%) (p = 0.31 vs. chemo) 15.4 (80% CI ) 13.7 (80% CI ) 6.7 (80% CI ) 16.4 (80% CI ) (p < vs. WT) 6.0 (80% CI ) 17.2 (80% CI ) (p < vs. WT) 9.2 (95% CI ) HR (95% CI ; p < vs. chemo)n NR (15.0 NR) 6.3 (95% CI ) 10.8 (2 y: 8.4%) HR vs. chemo: 0.30 (95% CI ; p < 0.001) CAR + PAC, (n = 115) 23.6 (2 y: 46.7%) 5.4 (2 y: 0%) ERL, n = 82 ND 13.1 HR vs. chemo: 0.16 (95% CI ; p < ) CAR + GEM, ND 4.6 (n = 72) ERL, n = m (95% CI ) HR vs. HR vs. chemo: 0.80; chemo 0.42; p < p = 0.42 Platinum-based (95% CI ) chemotherapy, (n = 76) ND HR vs. chemo: 2.85; 95% CI ; p < 0.001) 2.8 (80% CI ) 4.8 (80% CI ) 420 J.-C. Soria et al. / Cancer Treatment Reviews 38 (2012) CALGB, Cancer and Leukaemia Group B; CAR, carboplatin; CI, confidence interval; CIS, cisplatin; CTONG, Chinese Thoracic Oncology Group; DOC, docetaxel; EGFR, epidermal growth factor receptor; ERL, erlotinib; EURTAC, European Randomised Trial of Tarceva Ò versus Chemotherapy; GEF, gefitinib; GEM, gemcitabine; HR, hazard ratio; INTEREST, Iressa NSCLC Trial Evaluating Response and Survival versus Taxotere; IPASS, Iressa Pan-Asia Study; IV, intravenous; m, month; ND, not disclosed; NEJSG, North East Japan Study Group; n, number of patients randomized; NR, not reached; PAC, paclitaxel; OS, overall survival; PO, orally; PFS, progression-free survival; TTP, time to progression; WJTOC, West Japan Thoracic Oncology Group; WT, wild type; y, year.

6 J.-C. Soria et al. / Cancer Treatment Reviews 38 (2012) A. Overall Probability of progression-free survival Carboplatin plus paclitaxel Hazard ratio, 0.74 (95% Cl, ) p<0.001 Events: Gefitinib, 453 (74.4%) Carboplatin plus paclitaxel, 497 (81.7%) Gefitinib Months since randomization No. at risk Gefitinib Carboplatin plus paclitaxel B. EGFR-mutation-positive Probability of progression-free survival Carboplatin plus paclitaxel Hazard ratio, 0.48 (95% Cl, ) p<0.001 Events: Gefitinib, 97 (73.5%) Carboplatin plus paclitaxel, 111 (86.0%) Gefitinib Months since randomization No. at risk Gefitinib Carboplatin plus paclitaxel Fig. 2. Kaplan Meier curves for progression-free survival in patients with non-small cell lung cancer treated with gefitinib or carboplatin plus paclitaxel in the Iressa Pan-Asia Study. Curves are shown for the overall population (Panel A), patients who were positive for the EGFR mutation (Panel B), patients who were negative for the EGFR mutation (Panel C). Reproduced with permission from Mok TS, et al. Gefitinib or carboplatin-paclitaxel in pulmonary adenocarcinoma. N Engl J Med 2009;361(10): ÓMassachusetts Medical Society EGFR mutations (Table 2). According to preliminary abstract data from the Chinese Thoracic Oncology Group (CTONG) 0802 (OPTI- MAL) trial, erlotinib significantly improved PFS among Chinese patients, as compared with carboplatin gemcitabine. 106 Interim analysis of the European Randomised Trial of Tarceva Ò versus Chemotherapy (EURTAC) also showed a significant benefit of erlotinib versus platinum-based chemotherapy in this setting, 107 and the EMA has recently amended the label for erlotinib to include the first-line treatment of patients with locally advanced or metastatic NSCLC with EGFR activating mutations. EGFR mutations may vary in their prognostic significance. In the IPASS study, gefitinib achieved a higher tumour response rate against tumours with exon 19 mutations as compared with exon 21 deletions (Mok TS, personal communication). There are limited, mostly retrospective, data suggesting that exon 19 deletions may predict a longer OS and/or PFS after EGFR TKI therapy than the L858R point mutation. 47,9,101,102,108 For example, according to a pooled analysis of five trials in the United States, patients with exon 19 deletions had a longer median TTP (14.6 months vs. 9.7 months; p = 0.02) and OS (30.8 months vs months; p < 0.001) than those with L858R mutations. However, the prospective, randomized WJTOG3405 and North East Japan Study Group trials did not find a significant difference in PFS between patients with these mutations, regardless of the treatment arm. 42,43 Suggested explanations

7 422 J.-C. Soria et al. / Cancer Treatment Reviews 38 (2012) C. EGFR-mutation-negative Probability of progression-free survival Gefitinib Hazard ratio, 2.85 (95% Cl, ) p<0.001 Events: Gefitinib, 88 (96.7%) Carboplatin plus paclitaxel, 70 (82.4%) Carboplatin plus paclitaxel Months since randomization No. at risk Gefitinib Carboplatin plus paclitaxel Fig. 2 (continued) for this discrepancy include inter-trial differences in patient ethnicity and use of EGFR TKIs. A potential biological basis for a greater efficacy of EGFR TKI against exon 19-mutated tumours is suggested by evidence that in untreated patients, EGFR amplification occurs invariably in exon 19 mutants (rather than in wild-type or other mutants) and confers an advantage in these cells. 109 This suggests that exon 19 mutants may be particularly dependent on EGFR signalling, and hence especially sensitive to its inhibition by EGFR TKI. 42 In addition, biochemical studies suggest that erlotinib is a much better inhibitor of EGFR in the presence of the exon 19 deletion compared to L858R, which may also contribute to the clinical observations. 110 EGFR mutation as a prognostic biomarker Recent trials have confirmed earlier evidence that EGFR mutations are themselves associated with improved prognosis independently of treatment (Table 2). In the placebo arm of the BR.21 study, the median survival time was 9.1 months among patients with activating EGFR mutations and 3.5 months in those with wild-type EGFR. 111 Combined data from patients treated with carboplatin paclitaxel with or without erlotinib in the TRIBUTE (Tarceva Ò responses in conjunction with carboplatin and paclitaxel) study revealed significant differences between EGFR-mutated and EGFR wild-type in TTP (8 months vs. 5 months; p < 0.001) and OS (not reached vs. 10 months; p < 0.001). 65 Similarly, in the more recent CALGB 3406 trial, PFS and OS were higher in EGFR-mutated patients following treatment with erlotinib with or without carboplatin paclitaxel (Table 2). 105 In the INTEREST trial, OS was significantly longer among patients with EGFR mutations treated with either gefitinib (median 14.2 months) or docetaxel (16.6 months) than it was in the overall populations treated with these two agents (7.6 months vs. 8.0 months, respectively) or in those with wild-type EGFR (6.4 months vs. 6.0 months, respectively). 22 Therefore, EGFR-mutated NSCLC is now thought to represent a distinct form of NSCLC that has a more indolent prognosis than classical NSCLC and which responds readily to EGFR TKIs owing to their oncogene-addicted pathogenesis. 52 However, further prospective data are required to confirm overcome limitations in the existing data. For example, most of the existing trials involved patients with advanced disease and it is possible that some patients in the control had in fact received EGFR TKI as salvage therapy. Pertinently, studies in Japan have shown that EGFR mutations do not independently predict survival among patients who undergo surgical resection of early NSCLC For example, although one univariate analysis of 397 patients found that patients with EGFR mutations survived longer than those without mutations, this association disappeared on multivariate analysis. 114 The predictive value of EGFR mutations in patients treated with chemotherapy alone is unclear. According to a retrospective analysis, EGFR mutation was not associated with improved survival (as compared with wild-type EGFR) among East Asian patients treated with chemotherapy, despite a non-statistically significant trend toward a higher response rate. 115 Among the predominantly white population in the NCIC Clinical Trials Group JBR.10 study, the presence of exon 19 deletions or L858R mutations was associated with a non-significant trend towards a survival benefit following adjuvant chemotherapy with vinorelbine/cisplatin. 116 Clinical trial endpoints: OS versus PFS Conventionally, OS is regarded as the gold-standard measure of oncological efficacy. The assessment of OS is easy, objective, highly accurate and of clear significance to patients. It is not dependent on predetermined clinic visits and can be assessed in all randomized patients using an intention-to-treat approach. Many Phase III trials have failed to show a significant benefit of EGFR TKIs on OS in patients with EGFR-mutated NSCLC, despite their significant prolongation of PFS (Table 2). There are several reasons that might contribute to this finding. Crucially, the indolent prognosis of EGFR-mutated NSCLC, regardless of therapy, is likely to confound the demonstration of a significant difference between treatment arms. Long survival durations necessitate increasingly long follow-up periods, thereby increasing the risk that patients will be lost to follow-up. Furthermore, larger and larger sample sizes are required to provide adequate statistical power to differentiate between increasingly effective comparator regimens. Finally, the assessment of a first-line regimen is confounded by the effects of

8 J.-C. Soria et al. / Cancer Treatment Reviews 38 (2012) second- and third-line therapies administered upon disease progression especially when those therapies are commercially available, as in the case of gefitinib and erlotinib. In many recent trials, patients who show disease progression after first-line chemotherapy are crossed over onto the comparator EGFR TKI, skewing the response in the chemotherapy arm. Thus, the endpoint of OS has important limitations in the evaluation of novel NSCLC treatments. 117 The PFS endpoint avoids many of these problems. 117 PFS events occur before OS events and hence can be assessed using shorter follow-up periods and fewer patients. PFS directly measures drug effects on the tumour burden (while OS incorporates non-cancer causes of death), capturing both tumour shrinkage and stabilization. As PFS is documented at the point of progression, it is not influenced by subsequent lines of therapy. However, PFS also has drawbacks and it remains to be validated as a surrogate endpoint against OS. Measures are also required to minimize confounding effects due to variations and in the timing and nature of assessments, and in the subjective evaluation of progression. 117 Resistance to EGFR TKI The long-term efficacy of current EGFR TKIs in patients with activating EGFR mutations is limited by the invariable development of resistance. Mechanisms of resistance In approximately half of cases, acquired resistance is caused by the selection of the secondary T790M mutation in EGFR, wherein threonine is replaced by methionine at position 790 in exon The T790M mutation is thought to confer resistance to current EGFR TKI therapy by increasing the affinity of EGFR for its substrate, ATP. 119 Rarer secondary point mutations causing EGFR TKI resistance include the replacement of aspartic acid with tyrosine at position 761 (D761Y) 120 and a threonine-to-alanine switch at position 854 (T854A). 121 T790M may also be a rare cause of primary resistance to EGFR TKIs. One prospective study reported one patient with a T790M mutation detected in combination with an L858R mutation using direct sequencing among tumour samples from 98 screened patients (i.e. 1% prevalence). 122 However, direct sequencing might under-estimate the prevalence of T790M. Researchers in Japan analyzed the mutation profiles among samples from 280 patients with NSCLC, 185 of whom (66%) were not treated with EGFR TKIs. Direct sequencing revealed the T790M mutation in 0.4% of patients, while mutant-enriched PCR assay detected the mutation in 3.6%. 123 In the IPASS study, T790M was found in 11 of 437 (2.5%) tested samples using PCR analysis. 41 Using PCR, Maheswaran et al. found low pretreatment levels of T790M, likely to be present only in a small number of cells, in 10 of 26 (38%) patients with EGFR-mutated NSCLC. 124 Moreover, PFS following EGFR TKI therapy was significantly shorter among patients with pretreatment T790M (7.7 months) than in those without it (16.5 months; p < 0.001). More recently, Rosell et al. tested 129 NSCLC tumour samples from EGFR TKI naïve patients using the highly specific TaqMan assay in conjunction with a peptide nucleic acid designed to inhibit amplification of the wildtype allele. 125 The T790M was detected in 35% of patients and, on multivariate analysis, was independently and significantly associated with a shorter PFS (HR 4.35; 95% CI ; p = 0.001). The higher frequencies of T790M mutations detected in these last two analyses (35 38%) may have resulted from the use of PCR assays with enhanced sensitivity. The clinical follow-up data from these studies suggests that in some patients the T790M mutation may exist in a fraction of cells before treatment, and that the selection of cells by EGFR TKI therapy can result in a worse clinical outcome. While the presence of T790M is associated with EGFR TKI treatment failure, there is emerging evidence that patients who fail due to the T790M mutation may have a better prognosis than those who fail without this mutation. Among 93 patients who progressed during EGFR TKI therapy, those with T790M mutation had a significantly longer post-progression survival, were less likely to show subsequent disease progression in a previously uninvolved organ system and had a better performance status at the time of progression, as compared with those without the T790M mutation. Therefore T790M at progression may be a marker for an indolent genotype, despite being associated with EGFR TKI failure. 126 In approximately 20% of patients, EGFR TKI resistance is caused by the amplification of the gene encoding the MET tyrosine kinase MET amplification confers resistance by triggering the alternative oncogenic signalling Erb3 pathway 130 and hence is sometimes referred to as kinase switching. MET amplification can occur independently of T790M mutation, but the two mutations can occasionally occur concurrently. 127,131 An analysis of 15 gefitinib-resistant tumour samples from six patients revealed that T790M was present in 14/15 (93%) tumours without MET amplification, in four out of five (80%) of those with moderate MET amplification (i.e. 64-fold gene copy number gain), and in only one of 13 (8%) of tumours with greater MET amplification (P4-fold). 131 Although primary MET amplification has been reported in 20% of EGFR TKI-naïve patients, 128 recent data suggest that levels of amplification conferring EGFR TKI resistance are rare in untreated patients. As a result, treatment strategies against MET-amplified tumours will be principally relevant to EGFR TKI-resistant patients. 129 MET amplification can be detected by measuring the MET gene copy number using FISH or quantitative DNA analysis. No clear consensus for defining amplification of MET has yet emerged; many studies employ the same criteria used for defining EGFR amplification, 24,32 whereas others define amplification based on the copy number of the MET gene normalised to a control gene. Overexpression of the MET protein can also be evaluated by immunohistochemistry, and the optimum methodology for assessing MET status in clinical specimens has yet to be determined. The relationship between gene copy number and clinical outcome, and hence the threshold for resistance, is not well characterized. 132 Hepatocyte growth factor (HGF), which mediates pro-survival effects through activation of the MET kinase, can induce EGFR TKI resistance by restoring PIK3-Akt signalling. 133 HGF is mainly expressed by tumour-associated stromal cells and predominantly activates MET kinase in a paracrine manner. 134 High levels of HGF expression were found in samples from two patients with EGFR-mutated adenocarcinomas that were intrinsically resistant to EGFR TKI and in one patient with a tumour showing acquired resistance, but without T790M mutation or MET amplification. In contrast, HGF immunoreactivity was low among EGFR TKI responders and patients with T790M-mediated resistance. 133 The developmental anti-met monoclonal antibody, MetMab, blocks HGF-mediated MET activation. According to preliminary Phase II data, MetMab improved PFS and OS when added to erlotinib in the second- or third-line treatment of patients with MET-positive NSCLC (defined as P50% of tumour cells staining moderately or strongly for MET by immunohistochemistry), but worsened these outcomes in those with MET-negative disease. 135 A novel acquired resistance mechanism is the acquisition of mutations in PIK3CA, recently reported for the first time in 2 of 37 tested patients (5%). 136 Interestingly, this study also found that tumours in five patients (14%) underwent a phenotypic change from NSCLC to small cell lung cancer (SCLC) upon the development of EGFR TKI resistance. Whether this represented a fundamental histological change following treatment with EGFR TKIs

9 424 J.-C. Soria et al. / Cancer Treatment Reviews 38 (2012) was unclear. Alternatively, this may reflect the selection of a population of resistant SCLC cells from a histologically heterogeneous original tumour following eradication of the majority NSCLC cells. The EGFR mutations present in the original NSCLC were maintained in each case. A PIK3CA mutation was acquired by one of these SCLC tumours, but none had T790M or MET amplification. This type of histological change was not observed in patients with tumours resistant to chemotherapy and hence may be associated only with EGFR TKI resistance. 136 Further in vitro studies have revealed other mechanisms underlying the intrinsic or acquired resistance to EGFR TKI among EGFRmutated tumours. More recent in vitro data have revealed that the responsiveness of EGFR-mutated NSCLC to EGFR TKI is mediated, at least in part, by the activation of the pro-survival pathway mediated by FAS and NF-jB (nuclear factor kappa-light-chain-enhancer of activated B cells). 137 Resistance to erlotinib can be generated in EGFR-mutant NSCLC cells by inhibiting the IjB, an NF-jB inhibitor, and thereby enhancing NF-jB activity. Conversely, inhibition of NF-jB activity (by inhibiting IjB kinase) restores erlotinib sensitivity. According to preliminary clinical data, high-level NF-jB activity (measured by low levels of IjB) is associated with shorter survival among patients with EGFR-mutant NSCLC treated with EGFR TKI. These data suggest that NF-jB inhibition could be a future therapeutic target for use in combination with EGFR TKI. 137 EGFR TKI resistance in practice Ideally, the mechanism of EGFR TKI resistance should be identified upon disease progression in order to guide subsequent therapy. Criteria for the definition of acquired resistance to EGFR TKIs have recently been proposed to aid investigators and physicians (Table 3). 138 However, there are important challenges to assessment of resistance in clinical practice. 139 First, patients rarely undergo a repeated biopsy upon treatment failure and hence samples for resistance testing are not often available. T790M mutations can be detected non-invasively using PCR-based tests on plasma, 140 but these tests require further validation. A second problem is that tests for T790M need to be highly sensitive, as resistance-conferring alleles may represent only a small fraction of the total number of alleles. High-performance liquid chromatography has been used to improve the sensitivity of resistance mutation testing. 139 Recently, a molecular beacon designed to detect T790M has been used with PCR and in situ fluorescence analysis to provide a rapid, simple and highly sensitive assay. 141 Other challenges include the potential heterogeneity between tumours within the same patient (which may mean that different metastatic sites express different resistance mutations) and the current lack of knowledge concerning the mechanisms of resistance in the fraction of patients who show disease progression without known resistance-conferring point mutations or MET amplification. Clinical cross resistance between EGFR TKIs The T790M and MET amplification mutations confer resistance to both gefitinib and erlotinib. Accordingly, uncontrolled case series have reported that erlotinib provides limited benefit in unselected patients progressed during second-line gefitinib therapy Vasile et al. collected case series data suggesting that almost a third of patients in whom gefitinib failed achieved a partial response or stable disease to erlotinib therapy. 146 These authors pointed out that T790M mutation and MET amplification do not account for all EGFR TKI failures, suggesting that one agent may fail for reasons that do not preclude the effectiveness of another. Some evidence suggests that patients who previously obtained benefit from gefitinib may have a better clinical response to erlotinib. 142,144,146 There are also limited data suggesting that a rebound effect may occur after the cessation of EGFR TKI therapy in patients who develop acquired resistance. A study of 10 patients showed that symptomatic progression and tumour enlargement that occurred after stopping an EGFR TKI may be reversed by the re-initiation of the agent. 147 Overcoming EGFR TKI resistance Several orally administered, small molecule second-generation TKI in late-stage clinical development bind irreversibly to EGFR and hence retain activity against T790M mutants. In addition, these inhibitors are active against multiple receptor types that have interdependent roles in oncogenic signalling. 20 Afatinib (BIBW 2992; Boehringer Ingelheim) is an oral, irreversible inhibitor of the Erb family. Afatinib inhibits wild-type EGFR and variants with the T790M, L854A and other mutations, and shows significantly greater in vitro and in vivo activity than existing EGFR TKIs. 121,148 According to preliminary data from the singlearm LUX-Lung 2 trial, afatinib showed promising efficacy in patients who were chemotherapy naïve or with progressive disease following first-line chemotherapy, and who had EGFR-activating mutations. 149 The placebo-controlled phase IIB/III LUX-Lung 1 trial evaluated afatinib in patients with NSCLC refractory to chemotherapy and at least 12 weeks treatment with gefitinib or erlotinib (n = 585). According to preliminary abstract data, afatinib did not prolong OS in the overall patient population. 150 As previously discussed, this may reflect the confounding effects of the prolonged survival among patients with EGFR oncogene-addicted tumours and the associated lines of subsequent treatment. However, it is also possible that using the current dosing regimen (continuous daily oral) afatinib does not reach concentrations sufficient to inhibit T790M. A post hoc analysis of 391 patients who were most likely to have EGFR mutations (based on their response to, and duration of, prior treatment with EGFR TKIs) showed that afatinib significantly prolonged PFS (4.4 months vs. 1 month for placebo) and showed a trend toward improved OS. 151 The objective response rate in LUX-Lung 1 was 7%. Further trials are investigating the efficacy of afatinib specifically in patients with EGFR-activating mutations. In preclinical models, the combination of afatinib and the EGFR-specific antibody, cetuximab, showed enhanced activity against T790M-mutant NSCLC. 152 Afatinib and cetuximab were evaluated in combination in 26 NSCLC patients with acquired resistance to erlotinib or gefitinib, with confirmed partial responses observed in 8/22 evaluable patients (including 4/13 of patients with T790M+ tumours) and no dose-limiting toxicity. 153 PF299 (PF ; Pfizer) is an oral irreversible EGFR/HER2/ HER4 inhibitor. Preliminary data from a single-arm Phase II study Table 3 Proposed criteria for the definition of patients with acquired resistance to epidermal growth factor receptor tyrosine kinase inhibitors (EGFR TKIs) Previous treatment with a single-agent EGFR TKI (e.g. gefitinib or erlotinib) Presence of a tumour that harbours an EGFR mutation known to be associated with drug sensitivity and/or objective clinical benefit from treatment with an EGFR TKI Systemic progression of disease (RECIST or WHO criteria) while on continuous treatment with gefitinib or erlotinib within the last 30 days No intervening systemic therapy between cessation of gefitinib or erlotinib and initiation of new therapy RECIST, Response Evaluation Criteria in Solid Tumors; WHO, World Health Organization.

10 J.-C. Soria et al. / Cancer Treatment Reviews 38 (2012) Table 4 Summary of developmental Erb family inhibitors for NSCLC. Agent Company Description Phase Refs. Afatinib (BIBW 2992) Boehringer Ingelheim Oral, irreversible EGFR and HER2 inhibitor Phase II/III PF299 (PF ) Pfizer Oral irreversible EGFR/HER2/HER4 inhibitor Phase III Neratinib (HKI 272) Wyeth Oral irreversible EGFR/HER2 inhibitor Phase II Vandetanib (Zactima Ò ) AstraZeneca Oral reversible EGFR/VEGF2 inhibitor Phase II/III BMS Bristol-Myers Squibb Pan-HER and VEGFR inhibitor Phase II XL647 Exelixis Oral reversible EGFR/HER2/VEGFR2 inhibitor Phase II Cetuximab Bristol-Myers Squibb IV monoclonal anti-egfr antibody Phase III , , EGFR, epidermal growth factor receptor; IV, intravenous; VEGF, vascular endothelial growth factor. (n = 39) suggest that PF299 may have promising efficacy as firstline therapy in patients with advanced NSCLC and EGFR mutations based on molecular evidence or clinical characteristics. 154 PF299 has also shown promising efficacy in a single-arm Phase I/II study of Korean patients with KRAS wild-type adenocarcinoma after failure of platinum-based chemotherapy and EGFR TKI therapy. 155 Neratinib (HKI 272; Wyeth) is an irreversible oral EGFR/HER2 inhibitor. 51 In a Phase II study (n = 167), neratinib had little efficacy in EGFR TKI-experienced patients (EGFR-mutated or wild type) or EGFR TKI-naïve patients (ORR 0 3%). No patients with T790M responded. The limited effect of neratinib may have been due to the dose limitation necessitated by a high incidence of diarrhoea. 51 BMS (Bristol Myers-Squibb) is a novel pan-her/vascular endothelial growth factor (VEGF) receptor inhibitor with efficacy against H1975 cells expressing the T790M mutation. 156 A Phase I/II trial demonstrated the activity of BMS in patients with NSCLC, 157 although in a randomized, double-blind trial it showed no significant benefit over erlotinib. 158 The limited survival benefit observed in trials of the secondgeneration TKIs may be a result, in some cases, of limited clinical activity of the drug itself. Alternatively, it could reflect issues with clinical trial design (as discussed above for the Lux-1 trials) or the limitations in our understanding of the biological activity of these multi-kinase inhibitors and of the patient populations most likely to obtain benefit. In addition to these second-generation TKIs, preclinical data have been reported for irreversible, third-generation pyrimidinebased EGFR inhibitors designed with enhanced selectivity against T790M EGFR mutants. 159 Other small molecule agents and monoclonal antibodies targeting EGFR, HER2 and VEGF receptors are also in various stages of clinical development (Table 4). 51, As reviewed elsewhere, 83,87,91 94 an array of other novel therapeutic agents are also under investigation, including those targeting abnormalities in EML4 ALK translocation, the PI3K/Akt/mTOR pathway (e.g. everolimus, 171 ), MET kinase (e.g. ARQ and MetMab 135 ), anti-igf1r (e.g. CP-751, ), Ras and B-RAF kinases and FGFR. Clinical implications: optimizing current and future therapy Molecular testing in practice and in research The optimal therapy for individuals with NSCLC depends on the molecular portrait of their tumour (Fig. 3). Accordingly, biopsy sampling should be performed to give adequate material for genetic testing. 55 Advances in testing methods should soon facilitate the identification of mutations, allowing the simultaneous screening for multiple mutations and the use of less invasive sampling. The key biomarkers used in clinical decision-making or with a role in future trials of molecular targeted agents are EGFR, KRAS, HER2, EML4 ALK, PI3K, Akt, BRAF and FGFR1. At present, the systematic detection of EGFR mutations allows clinicians to identify patients most likely to benefit from available Patient with NSCLC No molecular portrait Molecular portrait Genomic profile Comparative genomic hybridization Sequencing No mutation Specific mutation/amplification Standard platinum-based chemotherapy Histology-driven therapy EGFR HER2 EML4-ALK K-RAS FGFR1 PIK3CA BRAF Gefitinib, erlotinib, Erb-family TKIFR Erb-family TKI ALK inhibitor Sorafenib FGFR1 inhibitor PI3K inhibitor, mtor inhibitor BRAF inhibitor Fig. 3. Potential future treatment pathways defined according to molecular analyses in patients with non-small cell lung cancer (NSCLC). EFGR, epidermal growth factor receptor; EML4 ALK, echinoderm microtubule-associated protein-like 4-anaplastic lymphoma kinase; FGFR1, fibroblast growth factor receptor 1; ER2, human epidermal growth factor receptor 2; mtor, mammalian target of rapamycin; PIK3, phosphatidylinositol 3-kinase; TKI, tyrosine kinase inhibitor.

11 426 J.-C. Soria et al. / Cancer Treatment Reviews 38 (2012) EGFR TKI in a manner analogous to the use of HER-2 testing to direct trastuzumab therapy for breast cancer. 174 Currently, EGFR analysis is recommended for use principally in the subgroups of patients in whom activating mutations are most common, i.e. patients with adenocarcinomas, never smokers, Asians and women. 45,55 Determining and reporting EGFR status as positive or negative may be insufficient given the different effects of known mutations 44 and hence the specific mutation involved should be reported. In principle, the use of both positive and negative predictive markers of EGFR TKI efficacy would help optimize the cost-effectiveness of EGFR TKI use. 53 Thus, in addition to activating mutations, detection of the T790M EGFR mutation and mutations in the MET gene have a role in predicting the response to EGFR TKIs, although further research is required. Although KRAS has shown potential usefulness as a negative predictor, its role in clinical practice is not clear. 55,64,68,69 Tests for HER2 and ALK/EML4 ALK may also be part of routine practice in future, but their role is currently limited to clinical trials of novel agents that target these proteins. 74,83,91 94 In the case of ALK gene rearrangement tests, the positivity rate is likely to be increased by pre-selection according to factors associated with this mutation, i.e. adenocarcinoma histology, EGFR/KRAS-negative status and non-smoking. 175 Similarly, tests for mutations in the PIK3- CA and BRAF, and amplification of FGFR1, are presently employed to select patients for treatment with developmental therapies. 83,87,91 94,96 In the future, DNA dysfunctionality analysis may be used to identify patients who may benefit from sensitizing interventions, such as poly-adp ribose polymerase (PARP) inhibitors. 176 Therapy Histologically driven chemotherapy and radiotherapy remain appropriate for use in patients without genetic mutations associated with response to molecular targeted therapies. Thus, EGFR TKIs should not be used as first-line therapy for patients wild-type EGFR or patients with unknown EGFR genotypes, including those in whom testing cannot be performed for whatever reason. The presence of genetic mutations should direct the selection of the relevant molecular targeted therapies (Fig. 3). At present, patients with activating mutations should receive first-line EGFR TKI therapy, based on evidence that these agents benefit PFS, symptoms and quality of life, 15,41 and because they have the advantage of oral administration. 55 Available data suggest that EGFR TKI monotherapy may be as efficacious as and less toxic than combination therapy with EGFR TKIs and chemotherapy in this setting. 104 There are no head-to-head data comparing EGFR TKIs. However, in Europe, gefitinib is currently approved for use in all lines of therapy in patients with activating EGFR mutations, 6 while erlotinib is only approved for use (regardless of EGFR mutations) after the failure of at least one chemotherapy regimen. 5 This situation may change based on the results of the OPTIMAL 106 trial and EURTAC trials. 107 The optimum treatment regimen for use in patients who progress during EGFR TKI therapy is unclear. Furthermore, asymptomatic, slow progression is frequently seen in patients with EGFR-mutated NSCLC during EGFR TKI therapy and the optimal time to switch these patients to an alternative therapy is unknown. Generally, progressing patients should be exposed to platinumbased chemotherapy. EGFR TKIs are sometimes continued in order to maintain an EGFR inhibitory pressure and to avoid a rebound effect associated with discontinuation. 147 In the near future, a potential strategy in EGFR-addicted NSCLC might be to use an existing EGFR TKI for first-line therapy, followed by platinum-based chemotherapy when resistance occurs (to reduce selection pressure), followed by a novel Erb-family inhibitor (Fig. 3). It has been suggested that tumours that possess the T790M mutation at progression might be particularly susceptible to ongoing EGFR-targeted therapy owing to dependence on EGFR signalling. 126 Recent evidence that EGFR TKI resistance is associated in some cases with histological conversion to SCLC suggests that repeat biopsy may be warranted upon treatment failure, allowing SCLCspecific treatment to be chosen where appropriate. 136 Conclusions Cancer management is moving away from organ-based disease definitions to molecular-based classifications. Treatment strategies for oncogene-addicted NSCLC are distinct from those for non-oncogene addicted NSCLC, and will depend on the specific genetic mutation (e.g. in EGFR, HER-2, EML4 ALK, PIK3CA/Akt and FGFR1). EGFR mutations are now known to be both prognostic (i.e. associated with indolent course) and predictive of survival benefit from EGFR TKI therapy. In the near future the routine care for NSCLC patients is likely to involve a molecular portrait that will inform diagnosis, prognosis and where oncogenic molecular abnormalities are found the selection of targeted therapy directed at the specific mutation or amplification. Crucially, EGFR-mutated NSCLC is likely to be treated increasingly as a chronic illness owing to its relatively good prognosis. This will require a paradigm shift whereby the former use of palliative chemotherapy is replaced by longterm treatment and monitoring, in a manner akin to current strategies used in HER2-positive breast cancer. A second generation of molecular targeted agents in development for NSCLC is likely to offer important benefits over current EGFR TKIs, especially in the management of resistant tumours. Conflict of interest statement J.C.S. has acted as a consultant for Abbott, Amgen, AstraZeneca, Bristol-Myers Squibb, Boehringer-Ingelheim, glaxosmithkiline, Lilly, Merck-Serono, Merck Sharp & Dohme, Pfizer, Roche-Genentech, Servier and sanofi-aventis. T.S.M. has acted as a consultant for AstraZeneca, Roche, Eli Lilly, Pfizer, Taiho, BMS, Merck Serono and Boellinger Ingelheim, has received honoraria from AstraZeneca, Roche, Eli Lilly, Pfizer, Merck Serono, Boehringer-Ingelheim, and has received research funding from Astrazeneca. F.C. has acted as a consultant for Roche and holds a patent for EGFR FISH testing. P.A.J. has acted as a consultant for Boehringer-Ingelheim, Roche, Genentech, Abbott, AstraZeneca and Pfizer. He owns stocks in Gatekeeper Pharmaceuticals and has received royalties from intellectual property related to EGFR mutation tests owned by the Dana-Farber Cancer Institute and licensed to Genzyme. Acknowledgement Editorial assistance in the development of this paper, furnished by Prism Ideas Ltd. (Nantwich, Cheshire, UK) was supported by an unrestricted grant from Boehringer-Ingelheim. References 1. Ferlay J, Autier P, Boniol M, Heanue M, Colombet M, Boyle P. Estimates of the cancer incidence and mortality in Europe in Ann Oncol 2007;18(3): D Addario G, Fruh M, Reck M, Baumann P, Klepetko W, Felip E. Metastatic nonsmall-cell lung cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol 2010;21(Suppl. 5):v Hotta K, Fujiwara Y, Matsuo K, Suzuki T, Kiura K, Tabata M, et al. Recent improvement in the survival of patients with advanced nonsmall cell lung cancer enrolled in phase III trials of first-line, systemic chemotherapy. Cancer 2007;109(5):

12 J.-C. Soria et al. / Cancer Treatment Reviews 38 (2012) Krause DS, Van Etten RA. Tyrosine kinases as targets for cancer therapy. N Engl J Med 2005;353(2): Tarceva Ò Summary of Product Characteristics. Welwyn Garden City, UK: Roche Registration Ltd.; Iressa Ò Summary of Product Characteristics. AstraZeneca, Macclesfield, UK; Giaccone G, Herbst RS, Manegold C, Scagliotti G, Rosell R, Miller V, et al. Gefitinib in combination with gemcitabine and cisplatin in advanced nonsmall-cell lung cancer: a phase III trial INTACT 1. J Clin Oncol 2004;22(5): Herbst RS, Giaccone G, Schiller JH, Natale RB, Miller V, Manegold C, et al. Gefitinib in combination with paclitaxel and carboplatin in advanced nonsmall-cell lung cancer: a phase III trial INTACT 2. J Clin Oncol 2004;22(5): Herbst RS, Prager D, Hermann R, Fehrenbacher L, Johnson BE, Sandler A, et al. TRIBUTE: a phase III trial of erlotinib hydrochloride (OSI-774) combined with carboplatin and paclitaxel chemotherapy in advanced non-small-cell lung cancer. J Clin Oncol 2005;23(25): Gatzemeier U, Pluzanska A, Szczesna A, Kaukel E, Roubec J, De Rosa F, et al. Phase III study of erlotinib in combination with cisplatin and gemcitabine in advanced non-small-cell lung cancer: the Tarceva Lung Cancer Investigation Trial. J Clin Oncol 2007;25(12): Gridelli C, Ciardiello F, Feld R, Butts CA, Gebbia V, Genestreti G, et al. International multicenter randomized phase III study of first-line erlotinib (E) followed by second-line cisplatin plus gemcitabine (CG) versus first-line CG followed by second-line E in advanced non-small cell lung cancer (ansclc): the TORCH trial. J Clin Oncol 2010;28(15 Suppl. 1). 12. Lee S, Rudd R, Khan I, Upadhyay S, Lewanski CR, Falk S, et al. TOPICAL: Randomized phase III trial of erlotinib compared with placebo in chemotherapy-naive patients with advanced non-small cell lung cancer (NSCLC) and unsuitable for first-line chemotherapy. J Clin Oncol 2010;28(15 Suppl. 1). 13. Shepherd FA, Rodrigues PJ, Ciuleanu T, Tan EH, Hirsh V, Thongprasert S, et al. Erlotinib in previously treated non-small-cell lung cancer. N Engl J Med 2005;353(2): Thatcher N, Chang A, Parikh P, Rodrigues PJ, Ciuleanu T, Von PJ, et al. Gefitinib plus best supportive care in previously treated patients with refractory advanced non-small-cell lung cancer: results from a randomised, placebocontrolled, multicentre study (Iressa Survival Evaluation in Lung Cancer). Lancet 2005;366(9496): Kim ES, Hirsh V, Mok T, Socinski MA, Gervais R, Wu YL, et al. Gefitinib versus docetaxel in previously treated non-small-cell lung cancer (INTEREST): a randomised phase III trial. Lancet 2008;22;372(9652): Maruyama R, Nishiwaki Y, Tamura T, Yamamoto N, Tsuboi M, Nakagawa K, et al. Phase III study, V-15 32, of gefitinib versus docetaxel in previously treated Japanese patients with non-small-cell lung cancer. J Clin Oncol 2008;26(26): Lee DH, Park K, Kim JH, Lee JS, Shin SW, Kang JH, et al. Randomized Phase III trial of gefitinib versus docetaxel in non-small cell lung cancer patients who have previously received platinum-based chemotherapy. Clin Cancer Res 2010;16(4): Cappuzzo F, Ciuleanu T, Stelmakh L, Cicenas S, Szczesna A, Juhasz E, et al. Erlotinib as maintenance treatment in advanced non-small-cell lung cancer: a multicentre, randomised, placebo-controlled phase 3 study. Lancet Oncol 2010;11(6): Takeda K, Hida T, Sato T, Ando M, Seto T, Satouchi M, et al. Randomized phase III trial of platinum-doublet chemotherapy followed by gefitinib compared with continued platinum-doublet chemotherapy in Japanese patients with advanced non-small-cell lung cancer: results of a west Japan thoracic oncology group trial (WJTOG0203). J Clin Oncol 2010;28(5): Wilson KJ, Gilmore JL, Foley J, Lemmon MA, Riese DJ. Functional selectivity of EGF family peptide growth factors: implications for cancer. Pharmacol Ther 2009;122(1): Laurent-Puig P, Lievre A, Blons H. Mutations and response to epidermal growth factor receptor inhibitors. Clin Cancer Res 2009;15(4): Douillard JY, Shepherd FA, Hirsh V, Mok T, Socinski MA, Gervais R, et al. Molecular predictors of outcome with gefitinib and docetaxel in previously treated non-small-cell lung cancer: data from the randomized phase III INTEREST trial. J Clin Oncol 2010;28(5): Tsao MS, Sakurada A, Cutz JC, Zhu CQ, Kamel-Reid S, Squire J, et al. Erlotinib in lung cancer molecular and clinical predictors of outcome. N Engl J Med 2005;353(2): Cappuzzo F, Hirsch FR, Rossi E, Bartolini S, Ceresoli GL, Bemis L, et al. Epidermal growth factor receptor gene and protein and gefitinib sensitivity in non-small-cell lung cancer. J Natl Cancer Inst 2005;97(9): Ohsaki Y, Tanno S, Fujita Y, Toyoshima E, Fujiuchi S, Nishigaki Y, et al. Epidermal growth factor receptor expression correlates with poor prognosis in non-small cell lung cancer patients with p53 overexpression. Oncol Rep 2000;7(3): Nicholson RI, Gee JM, Harper ME. EGFR and cancer prognosis. Eur J Cancer 2001;37(Suppl 4):S Meert AP, Martin B, Delmotte P, Berghmans T, Lafitte JJ, Mascaux C, et al. The role of EGF-R expression on patient survival in lung cancer: a systematic review with meta-analysis. Eur Respir J 2002;20(4): Jeon YK, Sung SW, Chung JH, Park WS, Seo JW, Kim CW, et al. Clinicopathologic features and prognostic implications of epidermal growth factor receptor (EGFR) gene copy number and protein expression in non-small cell lung cancer. Lung Cancer 2006;54(3): Clark GM, Zborowski DM, Culbertson JL, Whitehead M, Savoie M, Seymour L, et al. Clinical utility of epidermal growth factor receptor expression for selecting patients with advanced non-small cell lung cancer for treatment with erlotinib. J Thorac Oncol 2006;1(8): Clark GM, Zborowski DM, Santabarbara P, Ding K, Whitehead M, Seymour L, et al. Smoking history and epidermal growth factor receptor expression as predictors of survival benefit from erlotinib for patients with non-small-cell lung cancer in the National Cancer Institute of Canada Clinical Trials Group study BR. 21. Clin Lung Cancer 2006;7(6): Hirsch FR, Varella-Garcia M, Bunn Jr PA, Di Maria MV, Veve R, Bremmes RM, et al. Epidermal growth factor receptor in non-small-cell lung carcinomas: correlation between gene copy number and protein expression and impact on prognosis. J Clin Oncol 2003;21(20): Varella-Garcia M. Stratification of non-small cell lung cancer patients for therapy with epidermal growth factor receptor inhibitors: the EGFR fluorescence in situ hybridization aassay. Diagn Pathol 2006;1: Hirsch FR, Varella-Garcia M, Bunn Jr PA, Franklin WA, Dziadziuszko R, Thatcher N, et al. Molecular predictors of outcome with gefitinib in a phase III placebo-controlled study in advanced non-small-cell lung cancer. J Clin Oncol 2006;24(31): Hirsch FR, Varella-Garcia M, Dziadziuszko R, Xiao Y, Gajapathy S, Skokan M, et al. Fluorescence in situ hybridization subgroup analysis of TRIBUTE, a phase III trial of erlotinib plus carboplatin and paclitaxel in non-small cell lung cancer. Clin Cancer Res 2008;14(19): Schneider CP, Heigener D, Schott-von-Romer K, Gutz S, Laack E, Digel W, et al. Epidermal growth factor receptor-related tumor markers and clinical outcomes with erlotinib in non-small cell lung cancer: an analysis of patients from german centers in the TRUST study. J Thorac Oncol 2008;3(12): Zhu CQ, da Cunha SG, Ding K, Sakurada A, Cutz JC, Liu N, et al. Role of KRAS and EGFR as biomarkers of response to erlotinib in National Cancer Institute of Canada Clinical Trials Group Study BR.21. J Clin Oncol 2008;26(26): Sharma SV, Bell DW, Settleman J, Haber DA. Epidermal growth factor receptor mutations in lung cancer. Nat Rev Cancer 2007;7(3): Pao W, Miller V, Zakowski M, Doherty J, Politi K, Sarkaria I, 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 USA 2004;101(36): Paez JG, Janne PA, Lee JC, Tracy S, Greulich H, Gabriel S, et al. EGFR mutations in lung cancer: correlation with clinical response to gefitinib therapy. Science 2004;304(5676): Lynch TJ, Bell DW, Sordella R, Gurubhagavatula S, Okimoto RA, Brannigan BW, 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(21): Mok TS, Wu YL, Thongprasert S, Yang CH, Chu DT, Saijo N, et al. Gefitinib or carboplatin paclitaxel in pulmonary adenocarcinoma. N Engl J Med 2009;361(10): Mitsudomi T, Morita S, Yatabe Y, Negoro S, Okamoto I, Tsurutani J, et al. Gefitinib versus cisplatin plus docetaxel in patients with non-small-cell lung cancer harbouring mutations of the epidermal growth factor receptor (WJTOG3405): an open label, randomised phase 3 trial. Lancet Oncol 2010;11(2): Maemondo M, Inoue A, Kobayashi K, Sugawara S, Oizumi S, Isobe H, et al. Gefitinib or chemotherapy for non-small-cell lung cancer with mutated EGFR. N Engl J Med 2010;362(25): Kancha RK, on Bubnoff N, Peschel C, Duyster J. Functional analysis of epidermal growth factor receptor (EGFR) mutations and potential implications for EGFR targeted therapy. Clin Cancer Res 2009;15(2): Rosell R, Moran T, Queralt C, Porta R, Cardenal F, Camps C, et al. Screening for epidermal growth factor receptor mutations in lung cancer. N Engl J Med 2009;361(10): Cortes-Funes H, Gomez C, Rosell R, Valero P, Garcia-Giron C, Velasco A, et al. Epidermal growth factor receptor activating mutations in Spanish gefitinib-treated non-small-cell lung cancer patients. Ann Oncol 2005;16(7): Mitsudomi T, Kosaka T, Endoh H, Horio Y, Hida T, Mori S, et al. Mutations of the epidermal growth factor receptor gene predict prolonged survival after gefitinib treatment in patients with non-small-cell lung cancer with postoperative recurrence. J Clin Oncol 2005;23(11): Han SW, Kim TY, Jeon YK, Hwang PG, Im SA, Lee KH, et al. Optimization of patient selection for gefitinib in non-small cell lung cancer by combined analysis of epidermal growth factor receptor mutation, K-ras mutation, and Akt phosphorylation. Clin Cancer Res 2006;12(8): Eck MJ, Yun CH. Structural and mechanistic underpinnings of the differential drug sensitivity of EGFR mutations in non-small cell lung cancer. Biochim Biophys Acta 2010;1804(3): Yang C, Shih J, Chao T, Tsai T, Yu C, Yang P, et al. Use of BIBW 2992, a novel irreversible EGFR/HER2 TKI, to induce regression in patients with adenocarcinoma of the lung and activating EGFR mutations: Preliminary results of a single-arm phase II clinical trial. J Clin Oncol 2008;26(Suppl). abstr Sequist LV, Besse B, Lynch TJ, Miller VA, Wong KK, Gitlitz B, et al. Neratinib, an irreversible pan-erbb receptor tyrosine kinase inhibitor: results of a phase II

13 428 J.-C. Soria et al. / Cancer Treatment Reviews 38 (2012) trial in patients with advanced non-small-cell lung cancer. J Clin Oncol 2010;28(18): Sharma SV, Gajowniczek P, Way IP, Lee DY, Jiang J, Yuza Y, et al. A common signaling cascade may underlie addiction to the Src, BCR-ABL, and EGF receptor oncogenes. Cancer Cell 2006;10(5): John T, Liu G, Tsao MS. Overview of molecular testing in non-small-cell lung cancer: mutational analysis, gene copy number, protein expression and other biomarkers of EGFR for the prediction of response to tyrosine kinase inhibitors. Oncogene 2009;28(Suppl 1):S Ellison G, Donald E, McWalter G, Knight L, Fletcher L, Sherwood J, et al. A comparison of ARMS and DNA sequencing for mutation analysis in clinical biopsy samples. J Exp Clin Cancer Res 2010;29: Gridelli C, De Marinis F, Di Maio M, Cortinovis D, Cappuzzo F, Mok T. Gefitinib as first-line treatment for patients with advanced non-small-cell lung cancer with activating Epidermal Growth Factor Receptor mutation: Implications for clinical practice and open issues. Lung Cancer 2011;72(1): Pan Q, Pao W, Ladanyi M. Rapid polymerase chain reaction-based detection of epidermal growth factor receptor gene mutations in lung adenocarcinomas. J Mol Diagn 2005;7(3): Ohnishi H, Ohtsuka K, Ooide A, Matsushima S, Goya T, Watanabe T. A simple and sensitive method for detecting major mutations within the tyrosine kinase domain of the epidermal growth factor receptor gene in non-small-cell lung carcinoma. Diagn Mol Pathol 2006;15(2): He C, Liu M, Zhou C, Zhang J, Ouyang M, Zhong N, et al. Detection of epidermal growth factor receptor mutations in plasma by mutant-enriched PCR assay for prediction of the response to gefitinib in patients with non-small-cell lung cancer. Int J Cancer 2009;125(10): Mack PC, Holland WS, Burich RA, Sangha R, Solis LJ, Li Y, et al. EGFR mutations detected in plasma are associated with patient outcomes in erlotinib plus docetaxel-treated non-small cell lung cancer. J Thorac Oncol 2009;4(12): Yu J, Kane S, Wu J, Benedettini E, Li D, Reeves C, et al. Mutation-specific antibodies for the detection of EGFR mutations in non-small-cell lung cancer. Clin Cancer Res 2009;15(9): Kawahara A, Yamamoto C, Nakashima K, Azuma K, Hattori S, Kashihara M, et al. Molecular diagnosis of activating EGFR mutations in non-small cell lung cancer using mutation-specific antibodies for immunohistochemical analysis. Clin Cancer Res 2010;16(12): Su Z, as-santagata D, Duke M, Hutchinson K, Lin YL, Borger DR, et al. A platform for rapid detection of multiple oncogenic mutations with relevance to targeted therapy in non-small-cell lung cancer. J Mol Diagn 2011;13(1): Okudela K, Woo T, Kitamura H. KRAS gene mutations in lung cancer: particulars established and issues unresolved. Pathol Int 2010;60(10): Mao C, Qiu LX, Liao RY, Du FB, Ding H, Yang WC, et al. KRAS mutations and resistance to EGFR-TKIs treatment in patients with non-small cell lung cancer: a meta-analysis of 22 studies. Lung Cancer 2010;69(3): Eberhard DA, Johnson BE, Amler LC, Goddard AD, Heldens SL, Herbst RS, et al. Mutations in the epidermal growth factor receptor and in KRAS are predictive and prognostic indicators in patients with non-small-cell lung cancer treated with chemotherapy alone and in combination with erlotinib. J Clin Oncol 2005;23(25): Massarelli E, Varella-Garcia M, Tang X, Xavier AC, Ozburn NC, Liu DD, et al. KRAS mutation is an important predictor of resistance to therapy with epidermal growth factor receptor tyrosine kinase inhibitors in non-small-cell lung cancer. Clin Cancer Res 2007;13(10): Marchetti A, Milella M, Felicioni L, Cappuzzo F, Irtelli L, Del Grammastro M, et al. Clinical implications of KRAS mutations in lung cancer patients treated with tyrosine kinase inhibitors: an important role for mutations in minor clones. Neoplasia 2009;11(10): Loriot Y, Mordant P, Deutsch E, Olaussen KA, Soria JC. Are RAS mutations predictive markers of resistance to standard chemotherapy? Nat Rev Clin Oncol 2009;6(9): Roberts PJ, Stinchcombe TE, Der CJ, Socinski MA. Personalized medicine in non-small-cell lung cancer: is KRAS a useful marker in selecting patients for epidermal growth factor receptor-targeted therapy? J Clin Oncol 2010;28(31): De Roock W, Jonker DJ, Di Nicolantonic F, Sartore-Bianchi A, Tu D, Siena S, et al. Association of KRAS p. G13D mutation with outcome in patients with chemotherapy-refractory metastatic colorectal cancer treated with cetuximab. JAMA 2010;304(16): Pellegrini C, Falleni M, Marchetti A, Cassani B, Miozzo M, Buttitta F, et al. HER- 2/Neu alterations in non-small cell lung cancer: a comprehensive evaluation by real time reverse transcription-pcr, fluorescence in situ hybridization, and immunohistochemistry. Clin Cancer Res 2003;9(10 Pt 1): Nakamura H, Kawasaki N, Taguchi M, Kabasawa K. Association of HER-2 overexpression with prognosis in nonsmall cell lung carcinoma: a metaanalysis. Cancer 2005;103(9): Cappuzzo F, Varella-Garcia M, Shigematsu H, Domenichini I, Bartolini S, Ceresoli GL, et al. Increased HER2 gene copy number is associated with response to gefitinib therapy in epidermal growth factor receptor-positive non-small-cell lung cancer patients. J Clin Oncol 2005;23(22): Shigematsu H, Takahashi T, Nomura M, Majmudar K, Suzuki M, Lee H, et al. Somatic mutations of the HER2 kinase domain in lung adenocarcinomas. Cancer Res 2005;65(5): Buttitta F, Barassi F, Fresu G, Felicioni L, Chella A, Paolizzi D, et al. Mutational analysis of the HER2 gene in lung tumors from Caucasian patients: mutations are mainly present in adenocarcinomas with bronchioloalveolar features. Int J Cancer 2006;119(11): Doebele RC, Oton AB, Peled N, Camidge DR, Bunn Jr PA. New strategies to overcome limitations of reversible EGFR tyrosine kinase inhibitor therapy in non-small cell lung cancer. Lung Cancer 2010;69(1): Wang SE, Narasanna A, Perez-Torres M, Xiang B, Wu FY, Yang S, et al. HER2 kinase domain mutation results in constitutive phosphorylation and activation of HER2 and EGFR and resistance to EGFR tyrosine kinase inhibitors. Cancer Cell 2006;10(1): Perera SA, Li D, Shimamura T, Raso MG, Ji H, Chen L, et al. HER2YVMA drives rapid development of adenosquamous lung tumors in mice that are sensitive to BIBW2992 and rapamycin combination therapy. Proc Natl Acad Sci USA 2009;106(2): Kelly RJ, Carter C, Giaccone G. Personalizing therapy in an epidermal growth factor receptor-tyrosine kinase inhibitor-resistant non-small-cell lung cancer using PF and trastuzumab. J Clin Oncol 2010;28(28):e Soda M, Choi YL, Enomoto M, Takada S, Yamashita Y, Ishikawa S, et al. Identification of the transforming EML4 ALK fusion gene in non-small-cell lung cancer. Nature 2007;448(7153): Shaw AT, Yeap BY, Mino-Kenudson M, Digumarthy SR, Costa DB, Heist RS, et al. Clinical features and outcome of patients with non-small-cell lung cancer who harbor EML4 ALK. J Clin Oncol 2009;27(26): Wong DW, Leung EL, So KK, Tam IY, Sihoe AD, Cheng LC, et al. The EML4 ALK fusion gene is involved in various histologic types of lung cancers from nonsmokers with wild-type EGFR and KRAS. Cancer 2009;115(8): Sasaki T, Rodig SJ, Chirieac LR, Janne PA. The biology and treatment of EML4 ALK non-small cell lung cancer. Eur J Cancer 2010;46(10): Xalkori Ò package insert. New York, NY: Pfizer; Paik JH, Choe G, Kim H, Choe JY, Lee HJ, Lee CT, et al. Screening of anaplastic lymphoma kinase rearrangement by immunohistochemistry in non-small cell lung cancer: correlation with fluorescence in situ hybridization. J Thorac Oncol 2011;6(3): Yi ES, Boland JM, Maleszewski JJ, Roden AC, Oliveira AM, Aubry MC, et al. Correlation of IHC and FISH for ALK gene rearrangement in non-small cell lung carcinoma: IHC score algorithm for FISH. J Thorac Oncol 2011;6(3): Wojtalla A, Arcaro A. Targeting phosphoinositide 3-kinase signalling in lung cancer. Crit Rev Oncol Hematol 2011;80(2): Yamamoto H, Shigematsu H, Nomura M, Lockwood WW, Sato M, Okumura N, et al. PIK3CA mutations and copy number gains in human lung cancers. Cancer Res 2008;68(17): Schmid K, Oehl N, Wrba F, Pirker R, Pirker C, Filipits M. EGFR/KRAS/BRAF mutations in primary lung adenocarcinomas and corresponding locoregional lymph node metastases. Clin Cancer Res 2009;15(14): Marchetti A, Felicioni L, Malatesta S, Grazia SM, Guetti L, Chella A, et al. Clinical features and outcome of patients with non-small-cell lung cancer harboring BRAF mutations. J Clin Oncol 2011;29(26): Korc M, Friesel RE. The role of fibroblast growth factors in tumor growth. Curr Cancer Drug Targets 2009;9(5): Albert S, Serova M, Dreyer C, Sablin MP, Faivre S, Raymond E. New inhibitors of the mammalian target of rapamycin signaling pathway for cancer. Expert Opin Investig Drugs 2010;19(8): Janku F, Stewart DJ, Kurzrock R. Targeted therapy in non-small-cell lung cancer is it becoming a reality? Nat Rev Clin Oncol 2010;7(7): Pal SK, Figlin RA, Reckamp K. Targeted therapies for non-small cell lung cancer: an evolving landscape. Mol Cancer Ther 2010;9(7): Paik PK, Arcila ME, Fara M, Sima CS, Miller VA, Kris MG, et al. Clinical characteristics of patients with lung adenocarcinomas harboring BRAF mutations. J Clin Oncol 2011;29(15): Weiss J, Sos ML, Seidel D, Peifer M, Zander T, Heuckmann JM, et al. Frequent and focal FGFR1 amplification associates with therapeutically tractable FGFR1 dependency in squamous cell lung cancer. Sci Transl Med 2010;2(62):62ra Hammerman PS, Sos ML, Ramos AH, Xu C, Dutt A, Xhou W, et al. Mutations in the DDR2 kinase gene identify a novel therapeutic target in squamous cell lung cancer. Cancer Discov 2011;1:OF Cappuzzo F, Tallini G, Finocchiaro G, Wilson RS, Ligorio C, Giordano L, et al. Insulin-like growth factor receptor 1 (IGF1R) expression and survival in surgically resected non-small-cell lung cancer (NSCLC) patients. Ann Oncol 2010;21(3): Dziadziuszko R, Merrick DT, Witta SE, Mendoza AD, Szostakiewicz B, Szymanowska A, et al. Insulin-like growth factor receptor 1 (IGF1R) gene copy number is associated with survival in operable non-small-cell lung cancer: a comparison between IGF1R fluorescent in situ hybridization, protein expression, and mrna expression. J Clin Oncol 2010;28(13): Taron M, Ichinose Y, Rosell R, Mok T, Massuti B, Zamora L, et al. Activating mutations in the tyrosine kinase domain of the epidermal growth factor receptor are associated with improved survival in gefitinib-treated chemorefractory lung adenocarcinomas. Clin Cancer Res 2005;11(16): Riely GJ, Pao W, Pham D, Li AR, Rizvi N, Venkatraman ES, et al. Clinical course of patients with non-small cell lung cancer and epidermal growth factor receptor exon 19 and exon 21 mutations treated with gefitinib or erlotinib. Clin Cancer Res 2006;12(3 Pt 1):

14 J.-C. Soria et al. / Cancer Treatment Reviews 38 (2012) Jackman DM, Miller VA, Cioffredi LA, Yeap BY, Janne PA, Riely GJ, et al. Impact of epidermal growth factor receptor and KRAS mutations on clinical outcomes in previously untreated non-small cell lung cancer patients: results of an online tumor registry of clinical trials. Clin Cancer Res 2009;15(16): Lee JS, Park K, Kim SW, et al. A randomized phase III study of gefitinib versus standard chemotherapy (gemcitabine plus cisplatin) as a first-line treatment for never-smokers with advanced or metastatic adenocarcinoma of the lung. Presented at 13th World Conference on Lung Cancer, San Francisco. J Thorac Oncol 2009 abstr PRS Jänne PA, Wang XF, Socinski MA, Crawford J, Capelletti M, Edelman MJ, et al. Randomized phase II trial of erlotinib (E) alone or in combination with carboplatin/paclitaxel (CP) in never or light former smokers with advanced lung adenocarcinoma: CALGB J Clin Oncol 2010;28(15 Suppl.) abstr Hirsch FR, Kabbinavar F, Eisen T, Martins R, Schnell FM, Dziadziuszko R, et al. A randomized, Phase II, biomarker-selected study comparing erlotinib to erlotinib intercalated with chemotherapy in first-line therapy for advanced non-small-cell lung cancer. J Clin Oncol 2011;29(26): Zhou C, Wu Y-L, Chen G, Feng J, Liu X, Wang C, et al. Efficacy results from the randomised phase iii optimal (CTONG 0802) study comparing first-line erlotinib versus carboplatin (CBDCA) plus gemcitabine (GEM), in chinese advanced nonsmall-cell lung cancer (NSCLC) patients (PTS) with egfr activating mutations. Ann Oncol 2010;21(Suppl. 8):viii Rosell R, Gervais R, Vergnenegre A, Massuti B, Felip E, Cardenal F, et al. Erlotinib versus chemotherapy (CT) in advanced non-small cell lung cancer (NSCLC) patients (p) with epidermal growth factor receptor (EGFR) mutations: Interim results of the European Erlotinib Versus Chemotherapy (EURTAC) phase III randomized trial. J Clin Oncol 2011;29(Suppl.) abstr Jackman DM, Yeap BY, Sequist LV, Lindeman N, Holmes AJ, Joshi VA, et al. Exon 19 deletion mutations of epidermal growth factor receptor are associated with prolonged survival in non-small cell lung cancer patients treated with gefitinib or erlotinib. Clin Cancer Res 2006;12(13): Sholl LM, Yeap BY, Iafrate AJ, Holmes-Tisch AJ, Chou YP, Wu MT, et al. Lung adenocarcinoma with EGFR amplification has distinct clinicopathologic and molecular features in never-smokers. Cancer Res 2009;69(21): Carey KD, Garton AJ, Romero MS, Kahler J, Thomson S, Ross S, et al. Kinetic analysis of epidermal growth factor receptor somatic mutant proteins shows increased sensitivity to the epidermal growth factor receptor tyrosine kinase inhibitor, erlotinib. Cancer Res 2006;66(16): Shepherd FA, Tsao MS. Unraveling the mystery of prognostic and predictive factors in epidermal growth factor receptor therapy. J Clin Oncol 2006;24(7): Shigematsu H, Lin L, Takahashi T, Nomura M, Suzuki M, Wistuba II, et al. Clinical and biological features associated with epidermal growth factor receptor gene mutations in lung cancers. J Natl Cancer Inst 2005;97(5): Kim YT, Kim TY, Lee DS, Park SJ, Park JY, Seo SJ, et al. Molecular changes of epidermal growth factor receptor (EGFR) and KRAS and their impact on the clinical outcomes in surgically resected adenocarcinoma of the lung. Lung Cancer 2008;59(1): Kosaka T, Yatabe Y, Onozato R, Kuwano H, Mitsudomi T. Prognostic implication of EGFR, KRAS, and TP53 gene mutations in a large cohort of Japanese patients with surgically treated lung adenocarcinoma. J Thorac Oncol 2009;4(1): Lin CC, Hsu HH, Sun CT, Shih JY, Lin ZZ, Yu CJ, et al. Chemotherapy response in East Asian non-small cell lung cancer patients harboring wild-type or activating mutation of epidermal growth factor receptors. J Thorac Oncol 2010;5(9): Tsao MS, Sakurada A, Ding K, viel-ronen S, Ludkovski O, Liu N, et al. Prognostic and predictive value of epidermal growth factor receptor tyrosine kinase domain mutation status and gene copy number for adjuvant chemotherapy in non-small cell lung cancer. J Thorac Oncol 2011;6(1): Soria JC, Massard C, Le CT. Should progression-free survival be the primary measure of efficacy for advanced NSCLC therapy? Ann Oncol 2010;21(12): Pao W, Miller VA, Politi KA, Riely GJ, Somwar R, Zakowski MF, et al. Acquired resistance of lung adenocarcinomas to gefitinib or erlotinib is associated with a second mutation in the EGFR kinase domain. PLoS Med 2005;2(3):e Yun CH, Mengwasser KE, Toms AV, Woo MS, Greulich H, Wong KK, et al. The T790M mutation in EGFR kinase causes drug resistance by increasing the affinity for ATP. Proc Natl Acad Sci USA 2008;105(6): Balak MN, Gong Y, Riely GJ, Somwar R, Li AR, Zakowski MF, et al. Novel D761Y and common secondary T790M mutations in epidermal growth factor receptor-mutant lung adenocarcinomas with acquired resistance to kinase inhibitors. Clin Cancer Res 2006;12(21): Bean J, Riely GJ, Balak M, Marks JL, Ladanyi M, Miller VA, et al. Acquired resistance to epidermal growth factor receptor kinase inhibitors associated with a novel T854A mutation in a patient with EGFR-mutant lung adenocarcinoma. Clin Cancer Res 2008;14(22): Sequist LV, Martins RG, Spigel D, Grunberg SM, Spira A, Janne PA, et al. Firstline gefitinib in patients with advanced non-small-cell lung cancer harboring somatic EGFR mutations. J Clin Oncol 2008;26(15): Inukai M, Toyooka S, Ito S, Asano H, Ichihara S, Soh J, et al. Presence of epidermal growth factor receptor gene T790M mutation as a minor clone in non-small cell lung cancer. Cancer Res 2006;66(16): Maheswaran S, Sequist LV, Nagrath S, Ulkus L, Brannigan B, Collura CV, et al. Detection of mutations in EGFR in circulating lung-cancer cells. N Engl J Med 2008;359(4): Rosell R, Molina MA, Costa C, Simonetti S, Gimenez-Capitan A, Bertran- Alamillo J, et al. Pretreatment EGFR T790M mutation and BRCA1 mrna expression in erlotinib-treated advanced non-small-cell lung cancer patients with EGFR mutations. Clin Cancer Res 2011;17(5): Oxnard GR, Arcila ME, Sima CS, Riely GJ, Chmielecki J, Kris MG, et al. Acquired resistance to EGFR tyrosine kinase inhibitors in EGFR-mutant lung cancer: distinct natural history of patients with tumors harboring the T790M mutation. Clin Cancer Res 2011;17(6): Bean J, Brennan C, Shih JY, Riely G, Viale A, Wang L, 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 USA 2007;104(52): Beau-Faller M, Ruppert AM, Voegeli AC, Neuville A, Meyer N, Guerin E, et al. MET gene copy number in non-small cell lung cancer: molecular analysis in a targeted tyrosine kinase inhibitor naive cohort. J Thorac Oncol 2008;3(4): Cappuzzo F, Janne PA, Skokan M, Finocchiaro G, Rossi E, Ligorio C, et al. MET increased gene copy number and primary resistance to gefitinib therapy in non-small-cell lung cancer patients. Ann Oncol 2009;20(2): Engelman JA, Zejnullahu K, Mitsudomi T, Song Y, Hyland C, Park JO, et al. MET amplification leads to gefitinib resistance in lung cancer by activating ERBB3 signaling. Science 2007;316(5827): Suda K, Murakami I, Katayama T, Tomizawa K, Osada H, Sekido Y, et al. Reciprocal and complementary role of MET amplification and EGFR T790M mutation in acquired resistance to kinase inhibitors in lung cancer. Clin Cancer Res 2010;16(22): 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(10): Yano S, Wang W, Li Q, Matsumoto K, Sakurama H, Nakamura T, et al. Hepatocyte growth factor induces gefitinib resistance of lung adenocarcinoma with epidermal growth factor receptor-activating mutations. Cancer Res 2008;68(22): Matsumoto K, Nakamura T. Hepatocyte growth factor and the met system as a mediator of tumor stromal interactions. Int J Cancer 2006;119(3): Spigel D, Ervin T, Ramlau R, Daniel D, Goldschmidt J, Krzakowski M, et al. Randomized multicenter double-blind placebocontrolled phase ii study evaluating metmab, an antibody to met receptor, in combination with erlotinib, in patients with advanced non-smallcell lung cancer. Ann Oncol 2010;21(Suppl. 8):viii7 LBA Sequist LV, Waltman BA, as-santagata D, Digumarthy S, Turke AB, Fidias P, et al. Genotypic and histological evolution of lung cancers acquiring resistance to EGFR inhibitors. Sci Transl Med 2011;3(75):75ra Bivona TG, Hieronymus H, Parker J, Chang K, Taron M, Rosell R, et al. FAS and NF-kappaB signalling modulate dependence of lung cancers on mutant EGFR. Nature 2011;471(7339): Jackman D, Pao W, Riely GJ, Engelman JA, Kris MG, Janne PA, et al. Clinical definition of acquired resistance to epidermal growth factor receptor tyrosine kinase inhibitors in non-small-cell lung cancer. J Clin Oncol 2010;28(2): Jänne PA. Challenges of detecting EGFR T790M in gefitinib/erlotinib-resistant tumours. Lung Cancer 2008;60(Suppl. 2):S Kuang Y, Rogers A, Yeap BY, Wang L, Makrigiorgos M, Vetrand K, et al. Noninvasive detection of EGFR T790M in gefitinib or erlotinib resistant nonsmall cell lung cancer. Clin Cancer Res 2009;15(8): Oh YH, Kim Y, Kim YP, Seo SW, Mitsudomi T, Ahn MJ, et al. Rapid detection of the epidermal growth factor receptor mutation in non-small-cell lung cancer for analysis of acquired resistance using molecular beacons. J Mol Diagn 2010;12(5): Cho BC, Im CK, Park MS, Kim SK, Chang J, Park JP, et al. Phase II study of erlotinib in advanced non-small-cell lung cancer after failure of gefitinib. J Clin Oncol 2007;25(18): Costa DB, Nguyen KS, Cho BC, Sequist LV, Jackman DM, Riely GJ, et al. Effects of erlotinib in EGFR mutated non-small cell lung cancers with resistance to gefitinib. Clin Cancer Res 2008;14(21): Lee DH, Kim SW, Suh C, Yoon DH, Yi EJ, Lee JS. Phase II study of erlotinib as a salvage treatment for non-small-cell lung cancer patients after failure of gefitinib treatment. Ann Oncol 2008;19(12): Vasile E, Tibaldi C, Chella A, Falcone A. Erlotinib after failure of gefitinib in patients with advanced non-small cell lung cancer previously responding to gefitinib. J Thorac Oncol 2008;3(8): Vasile E, Tibaldi C, Falcone A. Is erlotinib really active after failure of gefitinib in advanced non-small-cell lung cancer patients? Ann Oncol 2009;20(4): Riely GJ, Kris MG, Zhao B, Akhurst T, Milton DT, Moore E, et al. Prospective assessment of discontinuation and reinitiation of erlotinib or gefitinib in patients with acquired resistance to erlotinib or gefitinib followed by the addition of everolimus. Clin Cancer Res 2007;13(17): Li D, Ambrogio L, Shimamura T, Kubo S, Takahashi M, Chirieac LR, et al. BIBW2992, an irreversible EGFR/HER2 inhibitor highly effective in preclinical lung cancer models. Oncogene 2008;27(34):

15 430 J.-C. Soria et al. / Cancer Treatment Reviews 38 (2012) Yang C, Shih J, Su W, Hsia T, Sequist LV, Chang G, et al. A phase II study of BIBW 2992 in patients with adenocarcinoma of the lung and activating EGFR/HER1 mutations (lux-lung 2). Ann Oncol 2010;21(Suppl. 8):viii Miller VA, Hirsh V, Cadranel J, Chen Y-M, Park K, Kim S-W, et al. Phase IIB/III double-blind randomized trial of afatinib (BIBW 2992, an irreversible inhibitor of EGFR/HER1 and HER2) 1 best supportive care (BSC) versus placebo 1 BSC in patients with nsclc failing 1-2 lines of chemotherapy and erlotinib or gefitinib (LUX-lung 1). Ann Oncol 2010;21(Suppl 8):viii Miller VA, Hirsh V, Cadranel J, Chen Y-M, Park K, Kim S-W, et al. Subgroup analysis of LUX-Lung 1: a randomized Phase III trial of afatinib (BIBW 2992) + best supportive care (BSC) versus placebo + BSC in patients with NSCLC failing 1-2 lines of chemotherapy and erlotinib or gefitinib. Oral presentation at Chicago Multidisciplinary Symposium in Thoracic Oncology, Chicago, USA. Available from: UpcomingMeetings/Thoracic/ScientificProgram/pres/documents/ ThorPlenaryMiller.pdf Regales L, Gong Y, Shen R, De Stanchina E, Vivanco I, Goel A, et al. Dual targeting of EGFR can overcome a major drug resistance mutation in mouse models of EGFR mutant lung cancer. J Clin Invest 2009;119(10): Janjigian YY, Groen HJ, Horn L, Smit EF, Fu Y, Wang F, et al. Activity and tolerability of afatinib (BIBW 2992) and cetuximab in NSCLC patients with acquired resistance to erlotinib or gefitinib. J Clin Oncol 2011;29(Suppl.) abstr Mok T, Spigel DR, Park K, Socinski MA, Tung SY, Kim D, et al. Efficacy and safety of PF (PF299), an oral, irreversible, pan-human epidermal growth factor receptor (pan-her) tyrosine kinase inhibitor (TKI), as first-line treatment (tx) of selected patients (pts) with advanced (adv) non-small cell lung cancer (NSCLC). J Clin Oncol 2010;28(15 Suppl.) Abstr Park K, Heo DS, Cho B, Kim D, Ahn M, Lee S, et al. PF (PF299) in Asian patients (pts) with non-small cell lung cancer (NSCLC) refractory to chemotherapy (CT) and erlotinib (E) or gefitinib (G): A phase (P) I/II study. J Clin Oncol 2010;28(15 Suppl.) abstr de La Motte RT, Galluzzi L, Olaussen KA, Zermati Y, Tasdemir E, Robert T, et al. A novel epidermal growth factor receptor inhibitor promotes apoptosis in non-small cell lung cancer cells resistant to erlotinib. Cancer Res 2007;67(13): Bahleda R, Felip E, Herbst RS, Hanna NH, Laurie SA, Shepherd FA, et al. Phase I multicenter trial of BMS : safety, pharmacokinetic profile, biological effects, and early clinical evaluation in patients with advanced solid tumors and non-small cell lung cancer. J Clin Oncol 2008;26(15 Suppl.). Abstr Sbar E, Besse B, Felip E, Shaw A, Ahn M-J, Salvati M, et al. A double-blind, randomized, parallel, two-arm phase II trial of BMS versus erlotinib in previous chemotherapy-treated non-small cell lung cancer (NSCLC) patients: a safety review. J Thorac Oncol 2010;5(12 Suppl. 5):S Zhou W, Ercan D, Chen L, Yun CH, Li D, Capelletti M, et al. Novel mutantselective EGFR kinase inhibitors against EGFR T790M. Nature 2009;462(7276): de Boer RH, Arrieta O, Yang CH, Gottfried M, Chan V, Raats J, et al. Vandetanib plus pemetrexed for the second-line treatment of advanced non-small-cell lung cancer: a randomized, double-blind phase III trial. J Clin Oncol 2011;29(8): Natale RB, Bodkin D, Govindan R, Sleckman BG, Rizvi NA, Capo A, et al. Vandetanib versus gefitinib in patients with advanced non-small-cell lung cancer: results from a two-part, double-blind, randomized phase ii study. J Clin Oncol 2009;27(15): Herbst RS, Sun Y, Eberhardt WE, Germonpre P, Saijo N, Zhou C, et al. Vandetanib plus docetaxel versus docetaxel as second-line treatment for patients with advanced non-small-cell lung cancer (ZODIAC): a double-blind, randomised, phase 3 trial. Lancet Oncol 2010;11(7): Lee J, Hirsh V, Park K, Qin S, Blajman CR, Perng R, et al. Vandetanib versus placebo in patients with advanced non-small cell lung cancer (NSCLC) after prior therapy with an EGFR tyrosine kinase inhibitor (TKI): A randomized, double-blind phase III trial (ZEPHYR). J Clin Oncol 2010;28(15 Suppl.) abstr Miller VA, Wakelee HA, Lara PN, et al. Activity and tolerance of XL647 in NSCLC patients with acquired resistance to EGFR TKIs: Preliminary results of a phase II trial. J Clin Oncol 2008;26(Suppl.) abstr Rizvi NA, Kris MG, Miller VA, et al. Activity of XL647 in clinically selected NSCLC patients (pts) enriched for the presence of EGFR mutations: results from Phase 2. J Clin Oncol 2008;26(Suppl.) abstr Pirker R, Pereira JR, Szczesna A, Von PJ, Krzakowski M, Ramlau R, et al. Cetuximab plus chemotherapy in patients with advanced non-small-cell lung cancer (FLEX): an open-label randomised phase III trial. Lancet 2009;373(9674): Lynch TJ, Patel T, Dreisbach L, McCleod M, Heim WJ, Hermann RC, et al. Cetuximab and first-line taxane/carboplatin chemotherapy in advanced nonsmall-cell lung cancer: results of the randomized multicenter phase III trial BMS099. J Clin Oncol 2010;28(6): Khambata-Ford S, Harbison CT, Hart LL, Awad M, Xu LA, Horak CE, et al. Analysis of potential predictive markers of cetuximab benefit in BMS099, a phase III study of cetuximab and first-line taxane/carboplatin in advanced non-small-cell lung cancer. J Clin Oncol 2010;28(6): Neal JW, Heist RS, Fidias P, Temel JS, Huberman M, Marcoux JP, et al. Cetuximab monotherapy in patients with advanced non-small cell lung cancer after prior epidermal growth factor receptor tyrosine kinase inhibitor therapy. J Thorac Oncol 2010;5(11): Riely GJ, Janjigian YY, Azzoli CG, Pietanza M, Krug LM, Rizvi NA, et al. Phase II trial of cetuximab and erlotinib in patients with lung adenocarcinoma and acquired resistance to erlotinib. J Clin Oncol 2010;28(15 Suppl.) abstr Price KA, Azzoli CG, Krug LM, Pietanza MC, Rizvi NA, Pao W, et al. Phase II trial of gefitinib and everolimus in advanced non-small cell lung cancer. J Thorac Oncol 2010;5(10): Yap TA, Olmos D, Brunetto AT, Tunariu N, Barriuso J, Riisnaes R, et al. Phase I trial of a selective c-met inhibitor ARQ 197 incorporating proof of mechanism pharmacodynamic studies. J Clin Oncol 2011;29(10): Karp DD, Paz-Ares LG, Novello S, Haluska P, Garland L, Cardenal F, et al. Phase II study of the anti-insulin-like growth factor type 1 receptor antibody CP- 751,871 in combination with paclitaxel and carboplatin in previously untreated, locally advanced, or metastatic non-small-cell lung cancer. J Clin Oncol 2009;27(15): Cardoso F, Senkus-Konefka E, Fallowfield L, Costa A, Castiglione M. Locally recurrent or metastatic breast cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2010;21(Suppl. 5):v Camidge DR, Kono SA, Flacco A, Tan AC, Doebele RC, Zhou Q, et al. Optimizing the detection of lung cancer patients harboring anaplastic lymphoma kinase (ALK) gene rearrangements potentially suitable for ALK inhibitor treatment. Clin Cancer Res 2010;16(22): Underhill C, Toulmonde M, Bonnefoi H. A review of PARP inhibitors: from bench to bedside. Ann Oncol 2011;22(2):