Ramucirumab/Erlotinib Combo Improves PFS in Frontline EGFR+ NSCLC

Maura N. Dickler, MD

The combination of ramucirumab (Cyramza) and erlotinib (Tarceva) significantly improved progression-free survival (PFS) compared with placebo and erlotinib as a frontline treatment for patients with metastatic EGFR-mutant non—small cell lung cancer (NSCLC), meeting the primary endpoint of the RELAY trial (NCT02411448).¹

The safety profile of the combination was consistent with what has been previously reported in clinical trials evaluating each agent alone, reported Eli Lilly and Company, the manufacturer of ramucirumab, in a press release. Regarding safety, the most common (>5%) grade ≥3 adverse events (AEs) that occurred at a higher rate (≥5% difference) on the ramucirumab/erlotinib arm compared with those who received erlotinib/placebo were hypertension, dermatitis acneiform, and diarrhea.

Full findings will be presented at an upcoming medical meeting. Based on these findings, Eli Lilly and Company stated that it will be submitting applications to regulatory agencies later in 2019.

"We are excited about these results, which show Cyramza plus erlotinib significantly delayed disease progression in this patient population. The RELAY trial is another example of Lilly's deep commitment to providing new treatment options to patients with lung cancer," Maura Dickler, MD, vice president of late phase development of Lilly Oncology, said in the press release. "We would like to thank the patients, investigators and clinical trial sites that are participating in the RELAY study, and we look forward to working with regulatory authorities globally on our submissions."

The international, placebo-controlled, three-part, phase III RELAY trial enrolled 543 patients with stage IV EGFR-mutant NSCLC, including exon 19 deletions and L858R mutations. In part A of the trial, safety and tolerability was assessed with the combination of ramucirumab at 10 mg/kg intravenously (IV) every 2 weeks plus oral erlotinib at 150 mg daily. In part B, patients were randomized to receive the combination of ramucirumab/erlotinib or placebo/erlotinib as a first-line therapy. Treatment was administered until discontinuation criteria were met.

Additionally, there was a third experimental arm (part C) that included IV ramucirumab combined with either oral gefitinib (Iressa) or oral osimertinib (Tagrisso); both TKIs are approved in the frontline setting for patients with EGFR-mutant NSCLC.

To be eligible for enrollment, patients had to have a cytologically or histologically confirmed diagnosis of stage IV EGFR-mutant NSCLC as defined by the American Joint Committee on Cancer Staging Criteria for Lung Cancer, be eligible for first-line erlotinib, at least 1 measurable lesion, and a life expectancy of at least 3 months.

Those with an EGFR T790M mutation, known leptomeningeal carcinomatosis, serious illness condition, ongoing treatment with CYP3A4 inducers or strong inhibitors, ongoing therapy with nonsteroidal anti-inflammatory drugs for ≥2 months, history of gross hemoptysis, significant bleeding disorders, and radiographic evidence of major blood vessel invasion or encasement by cancer, or evidence of intratumor cavitation were excluded from enrolling.

The coprimary endpoint of RELAY was PFS and number of patients with ≥1 treatment-related AEs. Secondary endpoints included overall survival (OS), objective response rate (ORR), disease control rate, duration of response, pharmacokinetics, number of patients with anti-ramucirumab antibodies, change from baseline on the Lung Cancer Symptom Scale, and change from baseline on the EuroQol 5-Dimension, 5-Level Questionnaire.

In December 2014, the FDA approved ramucirumab in combination with docetaxel as a treatment for patients with metastatic NSCLC whose tumor has progressed during or following treatment with platinum-based chemotherapy. The label also stipulates that patients with EGFR or ALK aberrations should first receive FDA-approved agents targeting these aberrations prior to ramucirumab.

The approval was based on findings from the phase III REVEL trial, in which the combination led to a 1.4-month improvement in OS versus docetaxel alone. The median OS was 10.5 months in the combination arm versus 9.1 months in single-agent docetaxel arm (HR; 0.857; 95% CI, 0.751-0.98; P = .0235).²

REVEL enrolled 1253 patients with squamous (26.2%) and nonsquamous (73.8%) stage IV disease, who had an ECOG performance status ≤1. Patients were randomized 1:1 to 75 mg/m² of docetaxel in combination with 10 mg/kg of ramucirumab (n = 628) or placebo (n = 625) on day 1 of a 3-week cycle. Treatment was administered until disease progression or unacceptable toxicity.

Additional results showed that the median PFS was also improved with the combination of ramucirumab and docetaxel at 4.5 months compared with 3.0 months for docetaxel alone (HR, 0.762; 95% CI, 0.68-0.86; P <.0001).

References

1. Lilly's Cyramza® (Ramucirumab) Phase 3 RELAY Trial Met Primary Endpoint, Significantly Improving Progression-Free Survival in First-Line Treatment of Patients With Metastatic EGFR-Mutated Non-Small Cell Lung Cancer. Eli Lilly and Company. Published March 12, 2019. https://bit.ly/2UtkdPW. Accessed March 12, 2019.
2. Garon EB, Ciuleanu T-E, Arrieta O, et al. Ramucirumab plus docetaxel versus placebo plus docetaxel for second-line treatment of stage IV non-small-cell lung cancer after disease progression on platinum-based therapy (REVEL): a multicentre, double-blind, randomised phase 3 trial. Lancet Oncol. 2014;384(9944):665-673. doi: 10.1016/S0140-6736(14)60845-X.