Efficacy and Safety of Afatinib vs Erlotinib and Gefitinib in EGFR+ NSCLC

Transcript:Benjamin P. Levy, MD: In terms of response, there is a very favorable impression of afatinib in the patients that I have used it on. And, not every patient gets afatinib in my practice, but for those that I’ve used it, the drug works quite well. Toxicity is another issue and something that we have to keep in mind when we’re delivering afatinib for our patients. It tends to come with more side effects, and we have to be cognizant and mindful of those side effects as we treat our patients. But, in terms of its effect, I’ve been pleased with the way that afatinib has worked. I’ve been pleased with the way all of these drugs, first-generation or second-generation TKIs, have worked for our patients with EGFR-mutant lung cancer.

The concern I have with afatinib has been the toxicities in the grade 3/4 AEs as they relate to two. One is rash and the other is diarrhea. And, every patient is a little different in the way they experience these AEs to afatinib. Many of my patients do have to get a dose reduction of afatinib, and many of my patients I start at 30 mg rather than 40 mg. But, what we’ve seen is that our experience with afatinib has mirrored the data, and that is that this drug, while effective, does have some toxicities that you have to keep in mind. Those toxicities may be a little bit more than we see with first- or second-generation TKIs.

It’s important that treatment decisions be individualized for patients with EGFR-mutant lung cancer and really weighing the benefits of a drug versus the risks. I think second-generation TKIs potentially, and theoretically, have more effect in terms of response, but come at the cost of toxicity. So, this really factors into my treatment decisions for patients. For a very fit patient who has del19 mutation, I will consider afatinib. I may start them at 40 mg, or even at 30 mg, but I will be ready to dose reduce. For my older patients in which toxicity is more of a concern, for those patients perhaps over the age of 65 or have a waning performance status, I will consider more commonly the first-generation TKIs like erlotinib or gefitinib.

For patients who are elderly, or have comorbidities, who are eligible for targeted therapies, I will generally offer them gefitinib. I’ve had some experience with this and had good results. I think what we know about gefitinib is this drug tends to have the least toxic AE profile. And, for those patients in whom I’m concerned about toxicity, I will use gefitinib or even start on erlotinib at 100 mg. But, generally, for those patients with comorbidities who are elderly where I’m worried about toxicity, I will use gefitinib. I think these are patients where afatinib should probably be avoided.

Transcript Edited for Clarity