When my oncologist’s nurse called in 2013 to tell me that I had an EGFR mutation, I burst into tears. I didn’t cry because I was diagnosed with stage IV metastatic non-small cell lung (NSCLC) cancer at 47 years old—those tears had already been exhausted. Instead, I cried because in the time between diagnosis and biomarker testing results, I had learned that having an EGFR mutation meant that I would not need to undergo chemotherapy immediately and could instead have my lung cancer treated with an oral medication, taken daily. My tears were tears of relief.
Recently presented findings from the FLAURA2 trial suggest that combining osimertinib—the current first-line standard-of-care EGFR-targeted therapy medication—with platinum-based chemotherapy, may be a better initial treatment than osimertinib alone. With the addition of chemotherapy, there is a progression free survival (PFS) benefit of about 9 months and a “manageable” safety profile. Is that enough to recommend such a combination treatment to all newly diagnosed patients?
While we ponder that question, let’s talk about my reaction to finding out I had an EGFR mutation a bit more. As a married mother of two young sons, I had several questions running through my mind upon my diagnosis with lung cancer that had metastasized to my bones and brain.
Will I see my children grow up?
How will my husband keep working if he has to take care of me?
What will my quality of life on treatment be like?
Will I still be able to be an active participant in my family’s lives?
How will this impact us financially?
I obviously wanted to extend my life as long as possible, but I also had concerns about what that life would be like. I think this is the true crux of the issue regarding combining chemotherapy and osimertinib upfront.
Patients want improved efficacy, but not necessarily at the expense of their quality of life. Combination treatment comes with increased toxicities, which make maintaining a normal life more difficult. Even grade 1 side effects such as diarrhea or nausea can make it difficult to hold a job or enjoy activities. Increased side effects also come with more doctor’s appointments and additional medications to treat these issues. Many of these medications are not covered by insurance.
Because of my ability to take an EGFR targeted therapy, I was able to actively raise my children, get involved in advocacy work for lung cancer research, and travel for both advocacy and personal reasons. I was able to limit my scans and visits to my oncologist to every 3 months as long as I was doing well on a treatment. And I was able to live my life fairly normally the rest of the time. I wasn’t tied to an every-three-week chemotherapy cycle. I could “forget” (even though I never really forgot) that I had advanced lung cancer for more extended periods of time.
A possible additional 9 months of PFS would not have been enough for me to choose to start treatment with a combination of chemotherapy and osimertinib.
However, patients are all different, just as all people are different. My assessment of the risk-benefit ratio will not be the same as another patient’s assessment. And even my choice might be different if the PFS benefit was 2 years instead of 9 months.
It is important to keep in mind, though, that there is a definite cost to increased visits to the clinic—both emotionally and financially—for most patients. Besides increased expenses due to transportation, child care, lost wages, hospital meals, and other burdens, it is draining to spend more of your precious time in a clinic. An infusion that should only take an hour or two often results in an all-day experience once logistics and delays are factored into the process. As a result, patients often end up exhausted and frustrated, missing time that they could spend with their loved ones making memories.
Before determining whether combination osimertinib and chemotherapy should be the new first-line standard-of-care treatment for patients with EGFR positive lung cancer, we need to consider all potential issues.
Yes, we need more mature information about overall survival improvements, more complete PFS data, and additional subset analyses, but we also need to consider patient needs and goals, particularly their quality of life.
This combination may not be right for everyone.