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After surgery for ALK-positive lung cancer, two years of alectinib kept 93.8 percent of patients disease-free at two years against 63.0 percent on chemotherapy.
The ALINA investigators, reported by Wu, Dziadziuszko, Ahn and colleagues with Solomon as senior author, randomised 257 patients with completely resected ALK-positive non-small-cell lung cancer of stage IB (tumours 4 cm or larger), II or IIIA to oral alectinib 600 mg twice daily for 24 months or four 21-day cycles of intravenous platinum-based chemotherapy. The primary endpoint was disease-free survival, tested hierarchically in stage II or IIIA and then in the intention-to-treat population.
With ADAURA for EGFR, ALINA completes the move of targeted therapy from the metastatic setting into the operating theatre's aftermath. The open question both share is whether an effect on disease-free survival becomes an effect on cure or only postpones recurrence until the drug stops.
Adjuvant treatment for lung cancer is now chosen by genotype. A resected ALK-positive tumour is treated with two years of a tablet instead of four cycles of platinum, which is a different life as well as a different outcome.
Every resected non-squamous lung cancer should be tested for EGFR mutations, because patients who carry one live longer if they take osimertinib for three years after surgery. The trial does not tell us whether adjuvant chemotherapy can be omitted, nor what happens on relapse after osimertinib, and the three-year duration was chosen empirically.
First-line ALK treatment moved to a drug designed for the brain, and brain metastasis prevention became an explicit design goal rather than a hoped-for side effect. ALK-positive lung cancer is now among the longest-surviving metastatic solid tumours.
The rule that a patient with a resected stage II or III lung cancer is offered chemotherapy and a patient with a small stage I tumour is not. Everything added to adjuvant treatment since has had to beat, or be added to, this 5 percent.
Shares Lung adjuvant cisplatin evaluation: a pooled analysis by the LACE Collaborative Group, Lung cancer roadmap: from Doll and Hill and the naming of tobacco, through the cytotoxic plateau, computed tomography screening, EGFR and ALK, immunotherapy by PD-L1, the perioperative trials and PACIFIC, to DLL3 in small-cell disease and a 2032 registry watch, Dormant cells and minimal residual disease, Neoadjuvant / adjuvant / perioperative and the tag lung-evidence.
Shares Measure brain metastasis prevention as a primary endpoint, not as a secondary one, Alectinib versus crizotinib in untreated ALK-positive non-small-cell lung cancer, Brain metastases (intracranial disease), ALK-positive non-small-cell lung cancer and the tag lung-evidence.
Shares Alectinib versus crizotinib in untreated ALK-positive non-small-cell lung cancer, Brain metastases (intracranial disease), ALK-positive non-small-cell lung cancer, Lung cancer roadmap: from Doll and Hill and the naming of tobacco, through the cytotoxic plateau, computed tomography screening, EGFR and ALK, immunotherapy by PD-L1, the perioperative trials and PACIFIC, to DLL3 in small-cell disease and a 2032 registry watch and the tag lung-evidence.
Shares Measure brain metastasis prevention as a primary endpoint, not as a secondary one, Brain metastases (intracranial disease), Lung cancer roadmap: from Doll and Hill and the naming of tobacco, through the cytotoxic plateau, computed tomography screening, EGFR and ALK, immunotherapy by PD-L1, the perioperative trials and PACIFIC, to DLL3 in small-cell disease and a 2032 registry watch, Dormant cells and minimal residual disease and the tag lung-evidence.
Shares Lung adjuvant cisplatin evaluation: a pooled analysis by the LACE Collaborative Group, Lung cancer roadmap: from Doll and Hill and the naming of tobacco, through the cytotoxic plateau, computed tomography screening, EGFR and ALK, immunotherapy by PD-L1, the perioperative trials and PACIFIC, to DLL3 in small-cell disease and a 2032 registry watch, Dormant cells and minimal residual disease, Minimal / molecular residual disease (MRD) and the tag lung-evidence.
Shares Lung cancer roadmap: from Doll and Hill and the naming of tobacco, through the cytotoxic plateau, computed tomography screening, EGFR and ALK, immunotherapy by PD-L1, the perioperative trials and PACIFIC, to DLL3 in small-cell disease and a 2032 registry watch, Dormant cells and minimal residual disease, Neoadjuvant / adjuvant / perioperative, Resectable stage I to III non-small-cell lung cancer and the tag lung-evidence.
Shares Lung adjuvant cisplatin evaluation: a pooled analysis by the LACE Collaborative Group, Lung cancer roadmap: from Doll and Hill and the naming of tobacco, through the cytotoxic plateau, computed tomography screening, EGFR and ALK, immunotherapy by PD-L1, the perioperative trials and PACIFIC, to DLL3 in small-cell disease and a 2032 registry watch, Neoadjuvant / adjuvant / perioperative, Cisplatin and the tag lung-evidence.
Shares Lung cancer roadmap: from Doll and Hill and the naming of tobacco, through the cytotoxic plateau, computed tomography screening, EGFR and ALK, immunotherapy by PD-L1, the perioperative trials and PACIFIC, to DLL3 in small-cell disease and a 2032 registry watch, Neoadjuvant / adjuvant / perioperative, Resectable stage I to III non-small-cell lung cancer, New England Journal of Medicine and the tag lung-evidence.