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EGFR mutated NSCLC: Treatment Advances and Highlights from ASCO 2025 - Episode 6

Monitoring Therapies in Patients with CNS Involvement

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Panelists discuss the critical role of regular brain MRI monitoring in EGFR-mutant lung cancer, balancing timely detection of intracranial progression with the risks of early radiation; they emphasize individualized treatment sequencing guided by progression patterns and resistance profiling through biopsies and liquid biopsies to optimize patient outcomes.

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    Monitoring patients with EGFR-mutant lung cancer, especially regarding intracranial disease, remains a critical challenge. For patients with known brain metastases, three-monthly brain MRIs are standard practice to detect progression early, although insurance approvals and logistical issues can complicate this. For patients without baseline brain metastases, frequent MRI monitoring is less straightforward. Radiation oncologists have increasingly recognized the importance of delaying stereotactic radiosurgery (SRS) to avoid potential toxicities such as brain necrosis, especially given that patients are now living longer with these therapies. Coordination between oncologists and radiation specialists is key to balancing timely local treatment with preserving quality of life.

    When disease progression occurs, treatment decisions depend on the pattern of progression. Indolent or oligoprogressive disease can often be managed with close observation or local therapies such as radiation or surgery, allowing continuation of the current systemic therapy. For systemic progression, re-biopsy or liquid biopsy to identify resistance mechanisms, including small cell transformation, guides next steps. If a patient progresses after receiving combination therapies like one regimen or another, options include re-challenging with chemotherapy or switching to alternative regimens, depending on prior exposure and patient condition. Liquid biopsies are emerging as valuable tools to monitor disease dynamics and inform treatment sequencing, though wider validation and implementation are needed. Overall, sequencing therapies thoughtfully based on individual resistance patterns and disease behavior is essential for optimal care.

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