Examining Treatment Outcomes with Erlotinib in ...

Accepted Manuscript Examining Treatment Outcomes with Erlotinib in Patients with Advanced Non-SmallCell Lung Cancer Whose Tumors Harbor Uncommon Epidermal Growth Factor Receptors Mutations Barbara Klughammer, Wolfram Brugger, Federico Cappuzzo, Tudor Ciuleanu, Tony Mok, Martin Reck, Eng Huat Tan, Paul Delmar, Gaelle Klingelschmitt, Anny-Yue Yin, Olivia Spleiss, Lin Wu, David S. Shames PII:

S1556-0864(16)00283-5

DOI:

10.1016/j.jtho.2015.12.107

Reference:

JTHO 82

To appear in:

Journal of Thoracic Oncology

Received Date: 9 September 2015 Revised Date:

16 December 2015

Accepted Date: 17 December 2015

Please cite this article as: Klughammer B, Brugger W, Cappuzzo F, Ciuleanu T, Mok T, Reck M, Tan EH, Delmar P, Klingelschmitt G, Yin A-Y, Spleiss O, Wu L, Shames DS, Examining Treatment Outcomes with Erlotinib in Patients with Advanced Non-Small-Cell Lung Cancer Whose Tumors Harbor Uncommon Epidermal Growth Factor Receptors Mutations, Journal of Thoracic Oncology (2016), doi: 10.1016/j.jtho.2015.12.107. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT

Examining Treatment Outcomes with Erlotinib in Patients with Advanced Non-Small-Cell Lung Cancer Whose Tumors Harbor

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Uncommon Epidermal Growth Factor Receptors Mutations

Barbara Klughammer,* Wolfram Brugger,† Federico Cappuzzo,‡ Tudor Ciuleanu,§ Tony Mok,ǁ Martin Reck,¶ Eng Huat Tan,# Paul Delmar,* Gaelle Klingelschmitt,*

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Anny-Yue Yin,* Olivia Spleiss,* Lin Wu,* and David S. Shames**

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*F. Hoffmann-La Roche Ltd, Basel, Switzerland; †Schwarzwald-Baar Klinikum, Academic Teaching Hospital, University of Freiburg, Villingen-Schwenningen, Germany; ‡Istituto Toscano Tumori, Ospedale Civile, Livorno, Italy; §Prof Dr Ion Chiricuta Institute of Oncology, Department of Medical Oncology and UMF Iuliu Hatieganu, Cluj-Napoca, Romania; ǁState Key Laboratory of Southern China, Hong Kong Cancer Institute, Department of Clinical

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Oncology, Prince of Wales Hospital, Hong Kong, China; ¶Department of Thoracic Oncology, LungenClinic Grosshansdorf, Airway Research Center North (ARCN), member of the German Research Center for Lung Diseases (DZL), Grosshansdorf, Germany; #Department

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of Medical Oncology, National Cancer Centre, Singapore; and **Oncology Biomarker

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Development, Genentech Inc., San Francisco, CA, USA.

Target journal: J Thorac Oncol (first choice, max. word count is 4,000 with 6 tables/figures); Mol Cancer (second choice)

Current word count: 4,033

Corresponding author: 1

ACCEPTED MANUSCRIPT Barbara Klughammer F. Hoffmann-La Roche Ltd Basel Switzerland

E-mail: [email protected]

Conflicts of Interest and Source of Funding

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Tel: +41 61 68 86386

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P. Delmar, B. Klughmammer, D. Shames and L. Wu are employees of F. Hoffmann-La

Roche and own stocks in F. Hoffmann-La Roche. G. Klingelschmitt, O. Spleiss and A. Yue

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are employees of F. Hoffmann-La Roche. T. Ciuleanu has recieved honorarium from F. Hoffmann-La Roche. T. Mok has consulted for, and recieved honoraria for symposia and advisory boards for F. Hoffmann-La Roche. M. Reck has served as an advisor for F.

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Hoffmann-La Roche.

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This manuscript was funded by F. Hoffmann-La Roche .

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Abstract (250 word limit; word count 240) Introduction: Exon 19 deletions and exon 21 L858R mutation of the epidermal growth factor receptor (EGFR) predict activity of EGFR tyrosine kinase inhibitors (TKIs) including erlotinib; however, the ability of less common EGFR mutations to predict efficacy of erlotinib is

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unclear. Methods: The efficacy of erlotinib in individual patients with rare EGFR mutations from the MERIT, SATURN, TITAN, TRUST, ATLAS, BeTa, and FASTACT-2 trials was analyzed and

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compared with data from the literature.

Results: Of the patients tested for biomarkers, the frequency of rare mutations identified

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here ranged from 1.7% (8/467) in the SATURN study, to 7.4% (27/364) in ATLAS. Some rare mutations were associated with greater clinical benefit with EGFR TKI therapy, or with improved prognosis independent of treatment, while others appeared to have a poorer prognosis. In particular, exon 18 G719 mutations, exon 19 K757R and E746G mutations, the exon 20 S768I mutation, and the exon 21 G836S mutation appeared to confer a good

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outcome with erlotinib treatment while exon 18 S720I showed a particularly poor outcome. However, due to the small number of patients with each mutation, it is difficult to confirm whether these rare mutations do indeed confer sensitivity or resistance to erlotinib.

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Conclusions: Erlotinib can have differential efficacy depending on the specific EGFR mutation. More research is needed to create a central database such as the ‘My Cancer

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Genome’ database of rare mutations to definitively confirm whether these mutations are activating, resistant, or neutral.

Key Words: NSCLC, Erlotinib, EGFR mutations, Uncommon, Rare.

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ACCEPTED MANUSCRIPT INTRODUCTION The epidermal growth factor receptor (EGFR) tyrosine-kinase inhibitor (TKI) erlotinib has been at the forefront of changes in treatment practice for advanced non-small-cell lung cancer (NSCLC) over the last 10 years. Erlotinib was initially approved for use in the second-

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/third-line setting in an unselected population, based on statistically significant improvements in overall survival (OS) versus placebo.1 Erlotinib was subsequently approved for

maintenance treatment of unselected NSCLC based on data from the SATURN trial.2

Finally, erlotinib was also approved for the first-line treatment of patients whose tumors

trials of single-agent erlotinib versus chemotherapy.3–5

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harbor activating mutations of EGFR, based on compelling evidence from several clinical

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The most common activating mutations used to guide treatment decisions in NSCLC are deletions in exon 19 of EGFR and the specific point mutation L858R in exon 21. However, many testing methods are actually able to identify other less common activating mutations, as well as the most frequent resistance mutations (e.g. T790M in exon 20).

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Genetic profiling suggests that some patients with advanced NSCLC whose tumors harbor these less common mutations of EGFR may derive a greater or lesser benefit from treatment with erlotinib or other EGFR TKIs (e.g. afatinib, gefitinib) than those with classical activating

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mutations, but full mutation profiling is still in its infancy. In order to allow for truly personalized treatment, a greater understanding of these

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‘rare’ mutations is required, to allow for individual patient profiling and accurate prediction of response to EGFR TKI therapy. Examining existing data and tumor samples can provide valuable guidance in building these disease profiles for application to clinical practice, particularly in cases where the number of patients with a specific mutation is insufficient to carry out a full clinical trial. De Pas et al. investigated the frequency of rare mutations in 681 cases of NSCLC screened between 2006 and 2010. Out of the 99 cases with EGFR mutations, 18 harbored rare mutations. Of these patients, 10 were treated with erlotinib or gefitinib, with varying responses depending on the specific mutations.6 In an observational, 4

ACCEPTED MANUSCRIPT prospective cohort of 188 NSCLC patients, common and rare mutations were assessed with regards to EGFR TKI response by Arrieta et al. Patients with rare mutations had significantly (p < 0.001) lower response rates to EGFR TKIs than those with common mutations.7Similarly, Chiu et al. examined 639 patients with activating EGFR mutations (478

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with common mutations; 161 with rare mutations). When treated with EFGR TKIs, the response rate was significantly lower for patients with rare mutations compared with

common mutations (41.6 vs 66.5%, p = 0.001) and the median progression-free survival (PFS) was also lower (7.7 vs 11.4 months, p = 0.001).8 A retrospective analysis by Baek et

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al. also reported that patients with rare or complex mutations had inferior response and

survival when treated with EGFR TKIs compared with patients whose tumors had common

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EGFR mutations.9

In a post-hoc analysis from three clinical studies of afatinib (LUX-Lung 2, LUX-Lung 3 and LUX-Lung 6), 75/600 (12%) patients had rare EGFR mutations and, following afatinib treatment the median PFS varied depending on the type of mutation.10 Patients with point

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mutations or duplications had a median PFS of 10.7 months and a median OS of 19.4 months, whereas patients with de-novo T790M mutations had a median PFS of 2.9 months and a median OS of 14.9 months. Patients with an exon 20 insertion had a median PFS of

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2.7 months and median OS of 9.2 months.10

Here we report individual patient data in a case report style, from patients with rare

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mutations as assessed from baseline tumor samples from several well-controlled clinical studies of erlotinib to assess the efficacy outcomes for patients with uncommon mutations.

METHODS

Clinical Studies Included in This Analysis Data from the SATURN (NCT00556712), TITAN (NCT00556322), TRUST (NCT00949910), ATLAS (NCT00257608), BeTa (NCT00130728), FASTACT-2 (NCT00883779), and MERIT (BO18279) studies were assessed in this analysis. MERIT was 5

ACCEPTED MANUSCRIPT a single-arm, open-label, phase II gene expression profiling study that aimed to identify candidate genes to predict outcomes in patients receiving erlotinib.11 The TRUST study was a phase IV expanded access study, which assessed efficacy and safety outcomes with erlotinib (regardless of line of therapy) in a large patient population reflective of real-life

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clinical practice (>7000 patients).12 Biomarker samples were obtained where possible and several prior analyses were carried out, including EGFR mutations.13,14 SATURN and TITAN were twin phase III studies conducted in the post-first-line setting. Patients were initially

enrolled into a chemotherapy run-in phase, following which they could be enrolled into either

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SATURN (if their disease had not yet progressed) or TITAN (if their disease had progressed during the initial cycles of first-line chemotherapy). Patients in SATURN were randomized to

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receive either erlotinib maintenance therapy or placebo,2 while those in TITAN were randomized to receive either second-line erlotinib or chemotherapy (docetaxel or pemetrexed, at the investigators’ discretion).15 Tumor sampling was mandatory in both studies and extensive biomarker analyses have been reported.15,16 FASTACT-2 was a phase

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III, randomized, controlled study assessing the efficacy and safety of an intercalated regimen of erlotinib and first-line chemotherapy versus intercalated placebo and chemotherapy in Asian patients with advanced NSCLC. Patients were not selected based on EGFR mutation

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status, but biomarker analysis did demonstrate that the significant efficacy benefit of intercalated erlotinib was driven by this patient subgroup.17 BeTa was a phase III

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randomized study evaluating bevacizumab plus erlotinib for the treatment of recurrent or refractory NSCLC. Patients were not selected based on EGFR mutation status but tumor biopsy material was requested at study entry for biomarker analysis.18 The phase III ATLAS study assessed bevacizumab with or without erlotinib in the maintenance treatment setting.19 Provision of tumor tissue for biomarker assessment was optional.

Mutation Testing Methodology

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ACCEPTED MANUSCRIPT Tumor sampling was mandatory for MERIT, SATURN, and TITAN and optional for TRUST, ATLAS, BeTa, and FASTACT-2; informed consent was obtained from all patients contributing samples. EGFR mutation testing was carried out using different methods across the different clinical studies. For MERIT and TRUST, microdissection (manual or laser

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capture) of tumor cells was carried out on formalin-fixed paraffin-embedded tissue samples. DNA was then extracted from the microdissected cells and EGFR exons 18–21 were

amplified by polymerase chain reaction (PCR) then sequenced for EGFR mutation status assessment. In SATURN and TITAN, DNA lysates were obtained from macro- or

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microdissected tissue samples; these samples had to have at least 5000 tumor cells and a minimum 60% tumor cell content. Exons 18–21 were amplified by PCR, with multiple

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independent products sequenced. Mutations other than the most commonly known resistance and activating mutations had to be identified in at least two PCR products, in order to be confirmed. For FASTACT-2, EGFR mutation analysis was carried out using the cobas® 4800 system (Roche Molecular Diagnostics, Pleasanton, CA, USA), which is able to

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detect the most common activating and resistance mutations, as well as less common mutations in exons 18–21. In addition, blood samples were tested using the cobas® 4800 EGFR mutation blood test (in development). In the ATLAS study, analyses of EGFR

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mutations in exons 18–21 were performed using Somatic Mutation Scanning by Surveyor® Endonuclease Digestion and Analysis on WAVE HS (Transgenomics Inc., Omaha, NE,

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USA) using cells captured by manual macrodissection or laser microdissection. In the BeTa study, EGFR mutations in exons 18–21 were analyzed by denaturing high performance liquid chromatography (Transgenomics Inc., Omaha, NE, USA).

RESULTS To effectively assess the efficacy of erlotinib in patients with the rare mutations identified, it is important to consider the intent-to-treat population results and, where

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ACCEPTED MANUSCRIPT available, subgroups with classical EGFR mutations from each study shown in Supplementary Table 1.

Individual Patient Data for Rare Mutations

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Efficacy results for individual patients with rare mutations in MERIT, SATURN, TITAN, TRUST, ATLAS, BeTa, and FASTACT-2 are presented in Tables 1–4 (Table 1, rare

mutations in exon 18; Table 2, rare mutations in exon 19; Table 3, rare mutations in exon 20; Table 4, rare mutations in exon 21). Of the samples tested for biomarkers, the frequency of

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rare mutations identified in this analysis ranged from 1.7% (8/467) in the SATURN study to 7.4% (27/364) in ATLAS. Some mutations were associated with greater clinical benefit with

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EGFR TKI therapy, or with improved prognosis regardless of treatment, showing both predictive and prognostic effects of certain rare mutations, while others appeared to have a detrimental effect on survival. Some of these rare mutations are detailed below, evaluating

Exon 18 Mutations G719

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the results from this analysis compared with data from the literature.

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One of the more frequently observed ‘rare’ mutations is the point mutation at G719 (n = 10 out of 24 exon 18 mutations in this analysis). The mutation to cysteine (G719C)

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appears to confer a PFS and OS benefit, with one patient from the SATURN study reporting a partial response, PFS of 500 days and OS of 795 days (over 2 years). When combined with the K714N mutation in one patient in BeTa, an OS of 973 days (longer than 2.5 years) was observed. A point mutation to alanine was also seen at G719. In SATURN, a G719A mutation plus T725M resulted in PFS of 169 days and OS of 343 days; while in TRUST, a patient with G719A had PFS of 463 days and OS of 488 days. A patient with an unknown G719 mutation in FASTACT-2 achieved OS of 1008 days (over 2.5 years). When compared

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ACCEPTED MANUSCRIPT with the PFS and OS results from the overall populations of each study, the G719A mutation appeared to be sensitizing, but to a lesser extent than the G719C mutation.

Literature Review

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Substitutions at G719 with alanine or cysteine have been shown to confer sensitivity to EGFR TKIs in several previous studies. This is because the point mutation alters the P-loop of the receptor structure to allow the receptor a higher affinity to adenosine triphosphate (ATP), therefore favoring activation.20 Han et al. reported three gefitinib-treated patients with

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G719A mutations. Of these patients, two achieved partial responses, with one patient

reporting time to progression of 22 months (~669 days) and OS of longer than 26 months

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(~791 days).21 Point mutations at G719 resulted in patients (n = 15) achieving a response rate of 53.3%, median PFS of 8.1 months (~247 days) and median OS of 16.4 months (~499 days) when treated with gefitinib or erlotinib.22 Baek et al. reported that in a subgroup where 6/11 patients had G719 mutations, median PFS was 5.1 months (~155 days) and median

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OS was 18.3 months (~557 days) in a retrospective analysis.9 When patients with point mutations at G719 (n = 18) were treated with afatinib, they achieved an objective response rate (ORR) of 77.8%, PFS of 13.8 months and OS of 26.9 months in a study by Yang et al.10

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Chui et al. reported 78/161 (48.4%) patients with rare mutations had a single G719 mutation. Following treatment with gefitinib or erlotinib, the ORR was 36.8% with a disease control rate

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(DCR) of 72.4%. However, a compound mutation of G719 + L861Q (exon 21) (5.6%) or G719+S768I (exon 20) (6.2%) demonstrated a higher ORR (88.9% and 50%, respectively) and a greater DCR (100% for both).8

S720 Poor response and short OS was observed with the S720P mutation with OS of 1 year (MERIT 435 days and BeTa 462 days). Other exon 19 mutations generally had shorter PFS and OS than the previously mentioned mutations, with

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best response of progression or stable disease. However, these results were comparable with the overall study population results, so EGFR TKI treatment is unlikely to be of reduced

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benefit in these patients.

Literature Review

To our knowledge, no previous publications have reported K757R mutations. The E746G mutation was reported in combination with an L861Q mutation in a study by Wu et al., with the patient achieving partial response to EGFR TKI therapy.22 Deletions at E746 were reported in a study by Peng et al. in two patients, who both received gefitinib treatment. One patient had a stable disease status, a PFS of 8 months and an OS of >8 months, and 10

ACCEPTED MANUSCRIPT the other patient achieved a partial response, a PFS of 15 months and an OS of >58 months.24 Exon 19 insertions, L747F and P733L, have both been reported as sensitizing rare exon 19 mutations20 and several rare mutations in exon 19 have been reported as resistance mutations including D761Y, E746V, and L747S, showing the varied responses

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different point mutations in one exon can elicit.20 The L747F mutation may confer sensitivity by inhibiting the αC-helix adopting the inactive position,25 while the D761Y resistance

mutation appears to confer resistance by altering the receptor interaction with ATP.20 In two case studies by Agbarya et al. and Chan et al., data from female patients with

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p.K745_E746insIPVAIK exon 19 insertions were reported and in both cases the patients

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responded to EGFR TKI treatment.26,27

Exon 20 Mutations

T790M is known to cause EGFR TKI resistance,28 which is generally consistent with the short PFS seen in patients with this mutation in our analysis. However, when combined

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with exon 18 mutations, response of stable disease and PFS of >1 year was seen in two patients from the TRUST study. However, in the case of double mutations, the mutant allele frequency (MAF) must be considered as if the MAF for T790M was particularly low when in

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combination with another mutation, the outcome would be skewed towards the other mutation, while still detecting the presence of the T790M resistance mutation. S768I

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appeared to confer sensitivity to erlotinib, with a patient from FASTACT-2 reaching OS of 1909 days (>5 years) and a female Asian patient from the TRUST study with an additional V774M mutation having OS of 1106 days (>3 years). Across the exon 20 mutations reported, eight appeared to be insertions. P.A767_S768INSSVSS and P.M766_A767INSASV from the TITAN study were associated with short PFS and OS. Conversely, the P.D770_N771INSSVD mutation was associated with longer OS (599 and 881 days) in two patients in the SATURN study.

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ACCEPTED MANUSCRIPT Literature Review Masago et al. published a case report of a patient with an S768I mutation who had achieved a partial response and PFS of >1 year on second-line gefitinib treatment.29 Other reports have identified the S768I mutation as a resistance mutation22,30 or as a mutation less

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sensitive to erlotinib or gefitinib than to dual EGFR and vascular endothelial growth factor receptor inhibitor AEE788.31Chiu et al. reported seven patients with the S768I mutation who achieved an ORR of 33.3% and DCR of 66.7%, although patients with a compound S768 mutation (n = 10) showed a greater PFS of 11.9 months compared with 6.5 months for the

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single mutation.8 A study in Norway identified three patients with S768I mutations, two of whom went on to receive EGFR TKI treatment. One patient had a partial response to first-

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line gefitinib, with time on treatment of 14 months, whereas the other patient received second-line erlotinib for 1 month until disease progression. 32 The conflicting reports highlight how difficult it can be to obtain a consensus on whether a mutation is resistant, activating, or neutral when so few cases are reported. Exon 20 mutations may function by altering the

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kinase domain conformation.20

While many exon 20 mutations have reported conferring resistance to erlotinib by altering the P-loop and thus reducing the ATP-binding pocket,25 a retrospective study by

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Naidoo et al. reported a V769_770insASV insertion that resulted in PFS of 19.8 months (~602 days) and OS of 24 months (~730 days) and a patient with a D770_N771insGT

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insertion achieving OS of 55 months (~1674 days), demonstrating the variability of rare mutation effects.33 Another retrospective study analyzed 1086 patients for EGFR mutations and identified 27 (2.5%) patients with exon 20 insertions, with the most common variant being V769_D770insASV.34 In this study, exon 20 insertions were associated with a median PFS of 16 months and were more commonly found in never-smokers and Asian patients.34

Exon 21 Mutations 12

ACCEPTED MANUSCRIPT Response varied among the specific exon 21 mutations. Generally rare mutations in exon 21 resulted in PFS of ATC in exon 20 (S768I). Jpn J Clin Oncol 2010;40:1105– 1109.

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30. Pallan L, Taniere P, Koh P. Rare EGFR exon 20 S768I mutation predicts resistance to targeted therapy: a report of two cases. J Thorac Oncol 2014;9:75.

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31. Kancha R, von Bubnoff N, Peschel C, et al. Functional analysis of epidermal growth factor receptor (EGFR) mutations and potential implications for EGFR targeted therapy. Clin Cancer Res 2009;15:460–467. 32. Lund-Iversen M, Kleinberg L, Fjellbirkeland L, et al. Clinicopathological characteristics of 11 NSCLC patients with EGFR-exon 20 mutations. J Thorac Oncol. 2012;7:1471–1473.

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ACCEPTED MANUSCRIPT 33. Naidoo J, Sima C, Rodriguez K, et al. Epidermal growth factor receptor exon 20 insertions in advanced lung adenocarcinomas: clinical outcomes and response to erlotinib. Cancer 2015;Epub ahead of print. 34. Oxnard GR, Lo P, Nishino M, et al. Natural history and molecular characteristics of

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lung cancers harboring EGFR exon 20 insertions. J Thor Oncol. 2013;8:179–184. 35. Wantanbe S, Minegishi Y, Yoshizawa H, et al. Effectiveness of gefitinib against non– small-cell lung cancer with the uncommon EGFR mutations G719X and L861Q. J Thorac Oncol. 2014;9:189–194.

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36. Imielinski M, Greulich H, Kaplan B, et al. Oncogenic and sorafenib-sensitive ARAF

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mutations in lung adenocarcinoma. J Clin Invest 2014;124;1582–1586.

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TABLE 1. Efficacy Data for Rare Mutations in Exon 18 of EGFR

Smoking

First Trial

PS

Line

Status

Medication Docetaxel

Sex

Race

TITAN

64

Male

Caucasian

0

2

Current

SATURN

58

Male

Caucasian

1

1

Former

SATURN

58

Female

Asian

1

1

Never

SATURN

59

Male

Caucasian

0

1

Current

MERIT

50

Male

Asian

1

2

TRUST

67

Female

Caucasian

1

2

TRUST

50

Female

Asian

1

TRUST

38

Male

Asian

2

FASTACT-2

61

Female

Asian

FASTACT-2

63

Female

Asian

0

1

Actual Mutation Exon 18

or Censored (C) at Database

PFS, Response

days

OS, days

Closure

P.G719Aa

PD

25

25

C

Erlotinib

P.E709A; P.G719S

SD

253

509

C

Erlotinib

P.G719C

PR

500

795

C

Erlotinib

P.G719A; P.T725M

SD

169

343

D

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years

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Tx

Erlotinib

P.E709K; P.G719A

PD

42

259

D

Never

Erlotinib

P.G719Ab

SD

463

488

D

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Never

2

Never

Erlotinib

P.E709_T710DELINSD

PD

38

52

D

2

Never

Erlotinib

P.V689Mb

SD

491

873

D

1

Never

Carboplatin/

P.G719UNKc

SD

225

1084

D

P.G719UNKd

PR

130

1008

D

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Protocol

ECOG

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Age,

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Death (D)

1

gemcitabine Never

Carboplatin/ gemcitabine

22

ATLAS

72

Male

Caucasian

1

1

Former

Bevacizumab +

P.L707Se

PD

42

235

C

P.I715V

SD

413

413

C

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P.S720P

PD

78

285

C

T727STOP

PD

1

464

D

P.S720P

SD

109

302

C

P.F723L

PD

81

311

C

P.G719C

SD

453

673

D

erlotinib ATLAS

41

Male

Caucasian

1

1

Current

Bevacizumab + erlotinib

ATLAS

73

Male

Caucasian

1

1

Former


67

Female

Black

1

1

Former


61

Male

Caucasian

1

1

Current

Bevacizumab +

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ATLAS

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ATLAS

erlotinib

ATLAS

64

Male

Caucasian

1

1

Current


73

Female

Hispanic

1

1

ATLAS

70

Male

Hispanic

0

1

ATLAS

59

Male

Caucasian

1

1

Current

Bevacizumab

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ATLAS

Former

Bevacizumab

P.G719A

PD

84

227

C

Former

Bevacizumab +

P.S720F

PD

2

89

C

P.V736A

NE

177

183

D

70

Male

Asian

BETA

77

Female

Caucasian

BETA

74

Female

Caucasian

BETA

64

Female

Caucasian

1

1

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ATLAS

EP

erlotinib

Former


1

2/3

Former

Erlotinib + placebo

P.K714N; P.G719C

SD

359

973

C

0

2/3

Former

Erlotinib + placebo

P.Y727C

SD

191

269

D

0

2/3

Former

Erlotinib +

P.I706T; P.G874S

SD

423

444

C

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bevacizumab Caucasian

a

Exon 21 L833F mutation in addition.

b

Exon 20 mutation in addition.

c

Patient received second-line erlotinib.

d

Patient received second-line gefitinib.

e

Exon 19 N7565 mutation in addition.

f

Exon 19 deletion in addition.

0

2/3

Former

Erlotinib + placebo

P.A722Vf

PD

39

429

C

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Female

SC

61

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BETA

ECOG PS, Eastern Cooperative Oncology Group performance status; NE, non-evaluable; OS, overall survival; PFS, progression-free survival; PR, partial response; PD,

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progressive disease; SD, stable disease; Tx, treatment.

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ACCEPTED MANUSCRIPT

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Smoking

PS

Line

Status

Sex

Race

TITAN

69

Male

Caucasian

0

2

Current

MERIT

77

Female

Asian

2

2

Former

MERIT

73

Female

Asian

1

2

Never

MERIT

41

Male

Asian

1

2

ATLAS

72

Male

Caucasian

1

1

58

Male

Caucasian

BETA

63

Female

Caucasian

BETA

54

Male

Caucasian

1

2/3

Censored


Docetaxel

(C) at PFS,

Database

Response

days

OS, days

Closure

P.D761N

SD

101

178

D

Erlotinib

P.I744V

PD

82

136

D

Erlotinib

P.L747FS

PD

122

211

D

Never

Erlotinib

P.K757R

SD

250

435

D

Former

Bevacizumab +

P.N756Sa

PD

42

235

C

P.K745Eb

NE

85

282

D

EP

BETA

Medication

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years

First Trial

or

SC

Tx

AC C

Protocol

ECOG

M AN U

Age,

Death (D)

Former

erlotinib Bevacizumab + erlotinib

0

2/3

Never

Erlotinib + placebo

P.E746G

NE

415

462

C

0

2/3

Former

Bevacizumab +

P.V717A

SD

79

292

D

erlotinib

25

ACCEPTED MANUSCRIPT

67

Female

Caucasian

1

a

Exon 18 L7675 mutation in addition.

b

Y827C, V845M, H870Y exon 21 mutations in addition.

c

V851A exon 21 mutation in addition.

2/3

Former

Erlotinib + placebo

P.A755Tc

SD

215

329

C

RI PT

BETA


AC C

EP

TE D

M AN U

SC


26

ACCEPTED MANUSCRIPT


Tx

Smoking

First Trial

Sex

Race

PS

Line

Status

Medication

TITAN

54

Male

Asian

1

2

Current

Docetaxel

TITAN

56

Male

Asian

1

2

Never

SATURN

64

Female

Caucasian

1

1

Former

SATURN

53

Female

Caucasian

1

1

Never

SATURN

51

Female

Caucasian

1

1

TRUST

67

Male

Caucasian

2

2

TRUST

60

Male

Caucasian

2

TRUST

67

Female

Caucasian

1

TRUST

70

Male

Caucasian

TRUST

62

Female

Asian



PFS, Response

days

OS, days

Closure

P.A767_S768INSSVSS

PD

17

64

D

Docetaxel

P.M766_A767INSASV

SD

81

115

D

Erlotinib

P.T790M

PD

47

134

C

Erlotinib

P.D770_N771INSSVD

SD

84

599

C

TE D

M AN U

years

Erlotinib

P.D770_N771INSSVD

PR

128

881

C

Never

Erlotinib

P.ALA767_VAL769DUP

SD

71

155

D

EP

Never

2

Never

Erlotinib

P.A763_Y764INSFQEA

PR

532

731

D

2

Never

Erlotinib

P.T790Ma

SD

463

488

D

1

2

Never

Erlotinib

P.H773_V774INSAH

PD

53

390

D

1

2

Never

Erlotinib

P.S768I; P.V774M

SD

166

1106

C

AC C

Protocol

ECOG

SC

Age,

RI PT

Death (D)

27

ACCEPTED MANUSCRIPT

85

Female

Caucasian

1

2

Never

Erlotinib

P.V769_D770INSASV

NE

642

642

D

TRUST

38

Male

Asian

2

2

Never

Erlotinib

P.T790Ma

SD

491

873

D

FASTACT-2

61

Female

Asian

0

1

Never

Carboplatin/

P.S768Ia

SD

225

1084b

D

P.S768I

PR

371

1909b

C

P.S768I

SD

169

939

D

Bevacizumab

P.A763Vb

CR

689

827

D

Bevacizumab +

P. P772S

NE

75

75

C

P.D746Ab

PR

424

435

D

P.V774M

PD

36

82

C

P.K860E

PD

39

127

D

gemcitabine FASTACT-2

62

Male

Asian

0

1

Never

Carboplatin/

erlotinib 56

Female

Asian

1

1

Never

Carboplatin/

M AN U

FASTACT-2

SC

gemcitabine plus

RI PT

TRUST

gemcitabine

ATLAS

57

Male

Caucasian

1

1

Former

ATLAS

71

Male

Caucasian

1

1

Former

ATLAS

33

Female

Black

1

1

TE D

erlotinib

Never


61

Male

Male

Asian

Caucasian

BETA

67

Female

Caucasian

BETA

70

Male

Caucasian

1

1

1

Current

EP

BETA

58

2/3

AC C

ATLAS

Former


Erlotinib + bevacizumab

1

2/3

Never

Erlotinib + placebo

INS

PD

42

354

D

1

2/3

Former

Erlotinib + placebo

T790M

PR

296

498

D

28

ACCEPTED MANUSCRIPT

69

Male

Caucasian

0

2/3

Never

Erlotinib + placebo

T790Mc

PD

40

665

C

BETA

60

Female

Caucasian

1

2/3

Former

Erlotinib + placebo

T790Mb

NE

27

27

D

BETA

50

Female

Caucasian

1

2/3

Former

Erlotinib +

S768I; V769L

PR

83

125

D


b


c


M AN U

a

SC

bevacizumab

RI PT

BETA

CR, complete response; ECOG PS, Eastern Cooperative Oncology Group performance status; NE, non-evaluable; OS, overall survival; PFS, progression-free survival; PR,

AC C

EP

TE D

partial response; PD, progressive disease; SD, stable disease; Tx, treatment.

29

ACCEPTED MANUSCRIPT


ECOG

Tx

Smoking

First Trial

Sex

Race

PS

Line

Status

Medication

TITAN

60

Male

Asian

1

2

Never

Erlotinib

TITAN

51

Male

Caucasian

1

2

Current

TITAN

64

Male

Caucasian

0

2

Current

SATURN

47

Female

Caucasian

0

1

Current

SATURN

63

Male

Caucasian

0

1

TRUST

42

Female

Caucasian

2

2

TRUST

56

Male

Caucasian

2

FASTACT-2

48

Female

Asian

1

63

Female

Caucasian

ATLAS

62

Female

Caucasian


PFS, Response

days

OS, days

Closure

P.L861Q

PD

18

18

D

Pemetrexed

P.P848L

PD

50

173

D

Docetaxel

P.L833Fa

PD

25

25

C

Erlotinib

P.P848L

SD

78

655

C

TE D

Placebo

P.H835L; P.L833V

SD

85

308

D

Current

Erlotinib

P.D837N

SD

52

52

D

EP

Former

2

Current

Erlotinib

P.K860N

SD

354

354

D

1

Never

Carboplatin/

P.L861Q

PR

141

175

D

AC C

ATLAS


M AN U

years

Protocol

SC

Age,

RI PT

Death (D)

gemcitabine

1

1

Former

Bevacizumab

P.L858Q; P.V834A

PD

36

137

C

1

1

Current

Bevacizumab +

P.R841G; P.A859V

PD

39

52

C

30

ACCEPTED MANUSCRIPT

erlotinib 78

Male

Caucasian

1

1

Former


ATLAS

52

Female

Caucasian

1

1

Current


53

Female

Caucasian

0

1

Former


69

Female

Caucasian

1

1

Former

85

691

D

P.L858Rb

SD

126

728

D

P.L858R; L861P

PD

212

348

C

Bevacizumab +

PR

85

407

C

P.A840V; P.A859T

M AN U

ATLAS

SD

SC

ATLAS

P.H870Y

RI PT

ATLAS

erlotinib

ATLAS

23

Male

Caucasian

0

1

Never

ATLAS

72

Female

Caucasian

1

1

Current

Bevacizumab

P.G836S

PD

46

763

D

Bevacizumab +

P.G836S

PR

429

642

D

P.A871V

SD

125

313

D

erlotinib

88

Male

Caucasian

0

1

Former

Bevacizumab +

TE D

ATLAS

erlotinib

Former

Bevacizumab

P.V843Ib

SD

127

511

D

1

Former

Bevacizumab

P.Q849S

NE

78

184

C

1

Current

Bevacizumab

P.G824D; P.V851A

PD

78

293

C

Former

Erlotinib +

Y827C; V845M; H870Yc

NE

85

282

D

P.H835R

PR

417

460

C

43

Female

Caucasian

1

1

ATLAS

70

Male

Caucasian

1

ATLAS

71

Female

Black

0

BETA

58

Male

Caucasian

61

Female

Hispanic

AC C

BETA

EP

ATLAS

1

1

2/3

2/3

bevacizumab Never

Erlotinib + placebo

31

69

Male

Caucasian

0

2/3

Never

Erlotinib + placebo

P.L858Rb

PD

40

665

C

BETA

69

Male

Caucasian

1

2/3

Current

Erlotinib + placebo

P.R831C; P.T854Id

SD

116

116

D

BETA

64

Female

Caucasian

0

2/3

Former

Erlotinib +

P.G874Se

SD

423

444

C

P.L861Q

SD

234

339

C

PD

39

104

D

RI PT

BETA

SC

ACCEPTED MANUSCRIPT

bevacizumab BETA

72

Male

Caucasian

1

2/3

Former

Erlotinib + bevacizumab

47

Female

Black

1

2/3

Former

BETA

67

Female

Caucasian

1

2/3

Former

BETA

64

Female

Caucasian

0

2/3

Former

Erlotinib + placebo

P.T854I

M AN U

BETA

Erlotinib + placebo

P.V851Af

SD

215

329

C

Erlotinib +

P.L838V; P.L858R

SD

211

430

C

P.A859T

NE

36

687

C

P.D855V

SD

173

259

C

bevacizumab

BETA

78

Female

Caucasian

0

2/3

Former

Erlotinib +

BETA

53

Female

Caucasian

0

2/3

TE D

bevacizumab

Former

Erlotinib +


b

Exon 20 T790M mutation in addition.

c

Exon 19 K745E in addition.

d


e

Exon 18 I706T mutation in addition.

f

Exon 19 A755T mutation in addition.

AC C

a

EP

bevacizumab

32

ACCEPTED MANUSCRIPT


AC C

EP

TE D

M AN U

SC

RI PT


33

ACCEPTED MANUSCRIPT

ITT population

Erlotinib: 36.3 weeks

Erlotinib: 19.3 months

Control: 43.0 weeks

Control: Not reached



Erlotinib: Not reached

Control: 11.1weeks

Control: 11.0 months

Control: 13.0 weeks


MERIT9



Erlotinib: NA

Erlotinib: NA

TRUST10,12


Erlotinib: 13.5



Control: 8.6 weeks

Control: 5.5 months



M AN U

TE D

FASTACT-215


SC

OS

SATURN2,14

OS

EGFR mutation-positive subgroup PFS

TITAN13

PFS

EP

Study

RI PT

Supplementary Table 1. Efficacy outcomes in ITT and classical EGFR mutation populations of TITAN, SATURN, MERIT, TRUST, FASTACT2, ATLAS and BeTa.

ATLAS17

AC C

Control: 6.0 months


Erlotinib: 18.3 months Control: 15.2 months

months Erlotinib: 16.8 months

Erlotinib: 31.4 months Control: 20.6 months

Control: 6.9 months





Control:3.7 months


Control: 2.8 months

Control: 14.3 months 34

ACCEPTED MANUSCRIPT



Erlotinib: NA

Erlotinib: Not reached

Control: 1.7 months

Control: 9.2 months

Control: NA


RI PT

BeTa16

AC C

EP

TE D

M AN U

SC

NA, Not applicable

35