The current strategy is to test for treatment resistance at the time of radiological progression and design subsequent treatment based on the mechanism of resistance. However, upon disease progression patients tend to deteriorate quickly and 30% - 40% of patients will not be in the clinical condition to receive next line treatment. Therefore, there is a potential for early resistance identification and directing treatment against it in order to improve patient outcome.
Next Generation Sequence (NGS) technology rapidly evolves and it is now feasible to use circulating tumor DNA (ctDNA) as a BioSource for comprehensive analysis of the molecular make up of tumors. ctDNA based techniques are able to detect the emergence of drug resistance mechanisms with high sensitivity and prior to radiological progression (12-14). This technique might identify drug resistant clones before subclonal resistance (resistance of the new clone to targeted treatment) develops and allow to eliminate the new clone with short-term additional treatment, while continuing treatment of the main oncogenic driver (EGFR exon 19 del / exon 21 L858R) with the EGFR TKI. Continuous ctDNA based monitoring will reveal the success of the additional treatment and in case the follow-up ctDNA sample shows elimination of the EGFR TKI resistant clone, the add-on treatment will be discontinued. Continuous ctDNA based monitoring might identify a new resistant clone at a later point in time and temporary treatment of this clone can be initiated. The EGFR TKI will remain the backbone of therapy and will not be discontinued (see treatment strategy 1 in Figure 3). This continuous track and treat strategy could potentially lead to a better outcome. In this study the investigators will track all known EGFR TKI resistance mechanisms over time and select one (MET amplification) for the track and treat strategy. Treatment strategy 1: Track and treat strategy. ctDNA based resistance monitoring. As soon as a resistant clone is detected with ctDNA, treatment will be added to the EGFR TKI. ctDNA will be continuously screened for resistant clones. Upon disappearance of the resistant clone, add-on treatment will be discontinued, while the EGFR TKI will be continued at any time. Multiple resistance mechanisms can be treated serially. Treatment strategy 2: routine care. Treatment with an EGFR TKI will be continued until radiological progression.
Study Type
INTERVENTIONAL
Allocation
NA
Purpose
TREATMENT
Masking
NONE
Enrollment
104
every six weeks during treatment and upon radiological progression blood will be drawn to analyse ctDNA with Avenio ctDNA (Expanded panel) to detect all known EGFR TKI resistance mechanisms.
The Netherlands Cancer Institute-Antoni van Leeuwenhoek
Amsterdam, North Holland, Netherlands
Erasmus MC, Universitair Medisch Centrum Rotterdam
Rotterdam, Netherlands
percentage of patients in which a drug resistant clone can be detected with ctDNA
To identify the percentage of patients in which a drug resistant clone can be detected with ctDNA before the emergence of radiological progression.
Time frame: Trough study completion, an average of 2 years
the success rate of crizotinib and osimertinib combination treatment to eliminate MET amplification
To determine the success rate of crizotinib and osimertinib combination treatment to eliminate MET amplification, defined by disappearance of the MET amplification clone in a subsequent ctDNA sample.
Time frame: Trough study completion, an average of 2 years
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