Would you offer immunotherapy to a patient with stage II NSCLC with an EGFR exon 20 mutation?
In patients with EGFR exon 20 mutated stage II NSCLC, would you offer adjuvant immunotherapy?
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Data from Tsuji et al., PMID 38287788 and Naidoo et al., JCO 2022 suggest that patients with EGFRm NSCLC do not benefit from durvalumab after concurrent CRT. While the majority of patients studied had tumors driven by classic sensitizing mutations, atypicals were included in the series from Japan. Biologically Exon 20 ins are like classic EGFR mutations, just targeted differently.
Based on this data, I would not be enthusiastic about durvalumab after CRT in a patient with a tumor driven by EGFR Exon 20.
I would perhaps consider it if the patient had a heavy tobacco history AND a high tumor PD-L1, however, the full NGS panel would need to be available and consistent with a smoking-associated cancer that has a concurrent EGFR before I would recommend durvalumab.
I believe the question is referring to adjuvant therapy following surgery and not after CRT.
The SOC in fit stage 2 patients is surgery followed by adjuvant therapy.
The choice for adjuvant therapy depends on the presence or absence of EGFR activating mutation and PDL-1 status.
Patients who lack these are candidates for chemotherapy.