The use of ALK inhibitors is one of the success stories in the precision medicine for treating advanced ALK-positive non-small cell lung cancer (NSCLC). However, the developing countries have significant cost constraints in using ALK inhibitors. The primary objective of this study was to investigate the treatment patterns and outcomes in Indian ALK-positive NSCLC patients.
An audit of a prospectively collected database of advanced ALK-positive NSCLC patients treated from Jan 2013 to Dec 2017 was conducted. Patients were divided into those who received ALK inhibitor in first-line (including upfront strategy, or after a few chemotherapy cycles), or who did not receive ALK inhibitor in the first line. SPSS version 20.0 was used for statistical analysis.
A total of 461 patients were available for analysis, 62.5% were males, median age 50 years (range 19-75) and 78.3% had ECOG PS 0-1. 169 (36.7%) patients were started on crizotinib upfront, 232 (50.3%) on chemotherapy, 12 (2.6%) received second/third-generation ALK inhibitors, and 22 (4.8%) patients were offered best supportive care. The main reasons for not starting crizotinib upfront included patients not willing to wait for the report (49.6%), financial constraints (21.3%), and symptomatic patients needing early initiation of therapy (13.3%). 78 (16.9%) patients were shifted to crizotinib after 1-2 cycles and 38 (8.2%) after 4-6 cycles of chemotherapy. The median progression-free survival on first-line therapy for the entire cohort was 14.1 months (m) (95% CI: 12.2-15.9), with a significant difference between patients receiving ALK inhibitor in first-line in any strategy vs. not in first-line [17.8 m (95% CI:14.9-20.8) vs. 5.9 m (95% CI:4.2-7.7), p<0.001). The median overall survival was 29.8 m (95% CI: 24.8-34.8), with 37.7 m (95% CI: 28.5-46.9) for ALK inhibitor in first-line vs. 20.2 m (95% CI: 15.6-24.7) for not in first-line (p<0.001). 295 (63.1%) received crizotinib completely free via various extramural support schemes.
A majority of our ALK-positive NSCLC patients were exposed to crizotinib through various support mechanisms. Those patients who could receive ALK inhibitors in the first-line had a significant survival advantage.
CTRI/2013/01/003335.
Tata Memorial Hospital, Mumbai.
Has not received any funding.
All authors have declared no conflicts of interest.