Angioinhibition in the Management of NSCLC

At the virtual 2020 Personalized Therapies in Thoracic Oncology meeting, Edward B. Garon MD, MS, Director of the Thoracic Oncology Program, David Geffen School of Medicine at UCLA, California, engaged in a stimulating debate regarding the relevancy of angio-inhibition in the management of NSCLC.

While his opponent, Helen J. Ross, MD, Thoracic Medical Oncology, Phoenix, AZ, argued that angio-inhibition is no longer relevant in the management of NSCLC in 2020, Dr Garon advocated in its favor.

“There really is no debate about this, of course angio-inhibition is still relevant in the management of non–small-cell lung cancer in the year 2020. Anti-angiogenic therapy is really a pillar of medical oncology care in non–small-cell lung cancer patients,” stated Dr Garon.

Although there is a lot of enthusiasm around immunotherapy and targeted therapy, Dr Garon pointed out that anti-angiogenic therapy improves outcomes for patients, including overall survival (OS) when given with frontline chemoimmunotherapy, second-line chemotherapy, or EGFR inhibition.

It also improves outcomes for patients when added to frontline chemotherapy, according to the EGOG 4599 trial. In this randomized trial, treatment-naive patients with stage IIIB/IV nonsquamous NSCLC were given paclitaxel and carboplatin either with or without anti-angiogenic therapy (bevacizumab).

Those in the paclitaxel and carboplatin plus bevacizumab (BPC) group had a median OS of 12.3 months, while those taking paclitaxel and carboplatin alone (PC) saw a median OS of 10.3 months. Furthermore, the median progression-free survival (PFS) in the BPC group and the PC group was 6.2 months and 4.5 months, respectively.

Similar results occurred when adding anti-angiogenic therapy to chemoimmunotherapy. According to the IMpower150 trial, patients who received bevacizumab in combination with carboplatin, paclitaxel, and atezolizumab had a higher PFS at both 6 (66.9%; 95% CI, 61.9-71.8) and 12 (36.5%; 95%CI, 31.2-41.9) months than those who did not. The median progression-free survival was 8.3 months, while those taking bevacizumab in combination with carboplatin, paclitaxel but no atezolizumab had a median PFS of 6.8 months.

Dr Garon continued on to mention that EGFR mutant patients appear to derive disproportionate benefit from anti-angiogenic therapy. In the IMpower150 study, patients with the EGFR mutation who received bevacizumab in combination with carboplatin, paclitaxel, and atezolizumab had a higher median PFS at 9.7 months and a median OS of 29.4 months, while patients receiving the same treatment but had ITT with liver metastases had a median OS of 13.2 months.

“In EGFR mutation positive patients, they appear to be a group that deprives particular benefit from anti-angiogenic therapy. There has now been benefit seen when you add anti-angiogenic therapy in this population to chemoimmunotherapy,” concluded Dr Garon.—Alexandra Graziano