patient care perspectives

Precision Therapies for Non–Small Cell Lung Cancer: Side Effects and Patient Education

by Jeffrey Crawford, MD

Overview

Given the large number of targeted therapies that are now available for non–small cell lung cancer (NSCLC), it is essential for patients to receive tailored counseling that is specific to their treatment regimen.

Expert Commentary

Jeffrey Crawford, MD

George Barth Geller Professor for Research in Cancer
Duke University Medical Center
Lead PI of NCTN LAPS Grant
Duke Cancer Institute
Durham, NC

All patients receiving targeted therapy should be carefully monitored and provided with counseling that is tailored to the particular agent that they are taking." 

Jeffrey Crawford, MD

It is important for patients to remember that targeted therapy does not mean nontoxic therapy. Patients often associate chemotherapy with intravenous treatment, so when they are told that they can take a pill for their NSCLC, they tend to be very pleased. They may assume that a pill will not have any side effects or, if side effects do occur, that they will be negligible. However, all targeted agents have side effects because the pathways that we target in cancer cells are also found in normal cells. 

The initial precision therapies for NSCLC target either EGFR or ALK. Side effects of EGFR tyrosine kinase inhibitors (TKIs) such as gefitinib, erlotinib, afatinib, and osimertinib are an extension of the pharmacologic blockade of EGFR-regulated pathways and include skin changes and diarrhea, as well as the potential for other issues such as weakness, abnormal liver function tests, and pulmonary toxicity. ALK TKIs (eg, crizotinib, alectinib, ceritinib, and brigatinib) are also associated with a number of side effects that include edema and fatigue, as well as the potential for less common events such as pulmonary, gastrointestinal, neurologic, and cardiovascular issues. Multiple other TKIs directed against other molecular targets in NSCLC are now US Food and Drug Administration approved. These different TKIs have their own side-effect profiles, and some of them are quite unique.

Thus, all patients receiving targeted therapy should be carefully monitored and provided with counseling that is tailored to the particular agent that they are taking. While it is very important for both the patient and the oncologist to be familiar with the specific side effects of each agent, the challenge is that some of these molecular targets occur in only 1% or 2% of NSCLCs. Thus, oncologists who are treating multiple types of cancer may not see any patients in a given year with a specific abnormality. It can therefore be difficult for community oncologists to keep up with all of the potential toxicities associated with targeted treatments. Along with laboratory monitoring, it is helpful to have a pharmacist, nurse, or nurse pharmacist review the profile of the drug so that the patient can be counseled on what to look out for that may be specific to the TKI.

References

Chu C-Y, Choi J, Eaby-Sandy B, Langer CJ, Lacouture ME. Osimertinib: a novel dermatologic adverse event profile in patients with lung cancer. Oncologist. 2018;23(8):891-899. doi:10.1634/theoncologist.2017-0582

Hirsh V. Managing treatment-related adverse events associated with EGFR tyrosine kinase inhibitors in advanced non-small-cell lung cancer. Curr Oncol. 2011;18(3):126-138. doi:10.3747/co.v18i3.877

Hou H, Sun D, Liu K, et al. The safety and serious adverse events of approved ALK inhibitors in malignancies: a meta-analysis. Cancer Manag Res2019;11:4109-4118. doi:10.2147/CMAR.S190098

Reck M, Rabe KF. Precision diagnosis and treatment for advanced non-small-cell lung cancer. N Engl J Med. 2017;377(9):849-861. doi:10.1056/NEJMra1703413

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