David S. Ettinger. The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA

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1 This material is protected by U.S. Copyright law. Unauthorized reproduction is prohibited. For reprints contact: Lung Cancer Clinical Implications of EGFR Expression in the Development and Progression of Solid Tumors: Focus on Non-Small Cell Lung Cancer David S. Ettinger The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA Key Words. EGFR Cancer therapy Lung cancer Anti-EGFR agents Learning Objectives After completing this course, the reader will be able to: 1. Describe the EGFR signaling pathway as a target for new anticancer agents. 2. Characterize the various EGFR agents developed for the treatment of NSCLC. 3. Identify the appropriate indications for the use of these new agents. CME Access and take the CME test online and receive 1 AMA PRA category 1 credit at CME.TheOncologist.com Abstract Dysregulation of the epidermal growth factor receptor (EGFR) signaling pathway is associated with the development and progression of malignancy, and EGFR-targeted therapies offer the promise of better treatment for many types of solid tumors, including non-small cell lung cancer. Anti-EGFR agents include monoclonal antibodies (mabs) targeting the EGFR extracellular receptor domain and small-molecule tyrosine kinase inhibitors (TKIs) targeting the EGFR intracellular kinase domain. Both mabs and TKIs have demonstrated encouraging results as monotherapies and in combination with chemotherapy and radiotherapy. This review provides a critical update on the status of these novel therapeutics. The Oncologist 2006;11: Introduction Lung cancer is a major cause of morbidity and mortality worldwide. In the U.S., 172,570 new cases and 163,510 related deaths were predicted for 2005, with lung cancer comprising ~29% of all cancer deaths [1, 2]. Between 80% and 87% of newly diagnosed lung cancers are non-small cell lung cancer (NSCLC). Advanced presentation and lack of effective treatment options afford poor prognoses [3, 4], and despite notable technological progress, improvements in NSCLC survival over the past two decades have been modest [5]. Correspondence: David S. Ettinger, M.D., The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Bunting Blaustein Cancer Research Bldg., 1650 Orleans Street, Room G88, Baltimore, Maryland , USA. Telephone: ; Fax: ; ettinda@jhmi.edu Received December 6, 2005; accepted for publication February 22, AlphaMed Press /2006/$20.00/0 The Oncologist 2006;11: This review focuses on new approaches in NSCLC therapy using monoclonal antibodies (mabs) and tyrosine kinase inhibitors (TKIs) targeting molecules involved in tumor growth and angiogenesis, including the epidermal growth factor receptor (EGFR) and vascular endothelial growth factor (VEGF). Current Concepts in Advanced NSCLC Chemotherapy Chemotherapy for advanced, inoperable NSCLC is generally palliative. The potential benefits of improved tumor

2 Ettinger 359 size, symptoms, and quality of life are mitigated by the disadvantages of increased hospitalization, inconvenience, cost, and serious adverse events [6]. The advent of paclitaxel, gemcitabine, vinorelbine, irinotecan, and topotecan and their combination with platinum drugs has modestly improved response rates (RRs) and survival (Table 1) [3, 6]. Although cisplatin combinations with any of the newer agents produce longer survival times than carboplatin combinations [7], no particular platinum-based regimen has demonstrated superior efficacy over any other. A randomized, controlled study comparing paclitaxel plus carboplatin with vinorelbine plus cisplatin in 202 patients with advanced NSCLC demonstrated fewer life-threatening toxicities and greater convenience and tolerability for paclitaxel plus carboplatin but a similar overall RR and median survival time [8]. A randomized, controlled study evaluating four platinum-containing regimens in 1,155 patients found that the overall RR and survival time did not differ significantly for paclitaxel plus cisplatin, gemcitabine plus cisplatin, docetaxel plus cisplatin, and paclitaxel plus carboplatin, although paclitaxel plus carboplatin had lower toxicity [9]. Other randomized, controlled studies showed that the gemcitabine plus cisplatin and gemcitabine plus paclitaxel did not produce a longer overall survival time compared with paclitaxel plus cisplatin [10] and that docetaxel plus cisplatin produced more favorable overall response and survival rates than vinorelbine plus cisplatin [11]. Median survival times for patients receiving these standard chemotherapy regimens have generally been 8 11 months. A triweekly docetaxel regimen is the current standard for second-line chemotherapy in NSCLC, with an approximately 12% RR and 6 8 months median survival time [12]. Weekly paclitaxel courses have been well received and have resulted in an approximately 9 months median survival time [13]. Pemetrexed, compared with docetaxel as second-line treatment for NSCLC in phase III studies, appeared to have similar efficacy but significantly fewer adverse effects [14]. Despite these advancements, a plateau of effectiveness appears to have been reached for the treatment of NSCLC with standard chemotherapy [3], and substituting one agent for another in combination chemotherapy regimens does not necessarily guarantee a significantly better overall RR and survival [15]. Current research efforts in both first- and second-line treatments for NSCLC focus on a number of promising agents targeted against the EGFR signaling pathway. EGFR Biology and Expression in NSCLC EGFR, a member of the HER/Erb-B family of receptor tyrosine kinases, mediates cell proliferation, differentiation, survival, angiogenesis, and migration [16]. This molecule consists of an extracellular domain that binds EGF, transforming growth factor alpha (TGF-α), and other growth factors; a short transmembrane region; and an intracellular tyrosine kinase domain. Ligand binding leads to homodimerization of EGFR or heterodimerization of EGFR with another receptor of the Erb-B family and phosphorylation of specific EGFR tyrosine residues [16]. Tyrosine-phosphorylated receptors then recruit intracellular signaling proteins, converting extracellular signals to intracellular signal transduction events [17]. Although EGFR plays an important role in maintaining normal cell function, dysregulation of EGFR signaling pathways contributes to the development of malignancy via effects on cell-cycle progression, inhibition of apoptosis, induction of angiogenesis, and promotion of tumor-cell motility and metastasis (Fig. 1) [18]. EGFR is known to be expressed more abundantly in malignant than in normal tissue, including 40% 80% of NSCLCs [18, 19]. Among the various histologic types of lung cancer, increased EGFR expression is most frequent in squamous and large-cell carcinomas and least frequent in small-cell carcinomas (Table 2) [20]. EGFR levels are also higher in pathological stage IV NSCLC than in stage I and II disease and are higher in cases with higher mediastinal involvement [21]. Mutant EGFRs, including EGFRvIII [22] and inframe deletions or amino acid substitutions around the tyrosine kinase domain ATP-binding pocket [23], have been reported. The tyrosine kinase mutants demonstrate enhanced tyrosine kinase activation in response to EGF and greater sensitivity to TKIs (see below). Although EGFR expression is important in the development and progression of malignancy, reports regarding its prognostic significance have been conflicting. Some studies found positive correlations among high levels of EGFR, tumor invasiveness [24], and poorer survival [25, 26], whereas others showed no correlation between EGFR expression and survival [27]. EGFR amplification in a subset of patients from the Iressa NSCLC Trial Assessing Combination Treatment (INTACT) study appeared to increase progression-free survival (PFS) [28], but sample size precluded definitive conclusions. Anti-EGFR Targeted Approaches to Treatment of NSCLC The role of EGFR in carcinogenesis led to the development and extensive evaluation of EGFR-blocking agents for cancer treatment [29, 30]. Two EGFR-targeted approaches have been explored: (a) mabs targeting the EGFR extracellular domain and (b) small-molecule TKIs targeting the intracellular EGFR tyrosine kinase domain. The beststudied of the anti-egfr mabs in NSCLC is cetuximab

3 360 EGFR Expression in NSCLC Table 1. Survival and tumor response rates in recent trials of chemotherapeutic agents in non-small cell lung cancer Treatment No. of patients Response (%) Median survival (months) 1-Year survival (%) Paclitaxel plus cisplatin a Gemcitabine plus cisplatin b Paclitaxel plus carboplatin c Paclitaxel plus carboplatin d Vinorelbine plus cisplatin e Gemcitabine plus cisplatin f NA Paclitaxel plus carboplatin g 123 NA Paclitaxel plus cisplatin h Gemcitabine plus cisplatin i Paclitaxel plus carboplatin j NA NA Vinorelbine plus cisplatin k NA NA Vinorelbine plus cisplatin l 394 NA Irinotecan plus cisplatin m NA NA Irinotecan plus cisplatin n NA NA Irinotecan plus cisplatin o NA Paclitaxel plus cisplatin p NA NA Paclitaxel plus cisplatin q NA 37 7 NA Paclitaxel plus cisplatin r NA NA Docetaxel plus cisplatin ~ % (2-yr) Docetaxel plus cisplatin ~ % (2-yr) Topotecan plus cisplatin s NA NA Topotecan plus carboplatin t >7.7 NA Topotecan plus vinorelbine u NA NA Topotecan, cisplatin, and gemcitabine v NA Topotecan, cisplatin, and gemcitabine w NA Topotecan plus etoposide x 19 5 NA NA Topotecan plus paclitaxel y NA NA Topotecan plus paclitaxel y NA NA a ECOG study 1594; paclitaxel, 135 mg/m 2 i.v. over 24 hours, day 1; cisplatin, 75 mg/m 2 i.v., day 2 every 3 weeks. b ECOG study 1594; gemcitabine, 1,000 mg/m 2, days 1, 8, and 15; cisplatin, 100 mg/m 2, day 1 every 4 weeks. c ECOG study 1594; paclitaxel, 225 mg/m 2 i.v. over 3 hours, day 1; carboplatin, AUC 6.0, day 1 every 3 weeks. d SWOG study; paclitaxel, 225 mg/m 2 i.v. over 3 hours, day 1; carboplatin, AUC 6.0, day 1 every 3 weeks. e SWOG study; vinorelbine, 25 mg/m 2 i.v., weekly; cisplatin, 100 mg/m 2 i.v., day 1 every 4 weeks. f Gemcitabine, 1,250 mg/m 2 i.v., days 1 and 8; cisplatin, 100 mg/m 2 i.v., day 1 every 3 weeks. g HOG study; paclitaxel, 200 mg/m 2 over 3 hours, day 1 every 3 weeks; carboplatin, AUC 6.0, day 1. h EORTC study 08975; paclitaxel, 175 mg/m 2 over 3 hours, day 1 every 3 weeks; cisplatin, 80 mg/m 2 i.v., day 1 every 3 weeks. i EORTC study 08975; gemcitabine, 1,250 mg/m 2,days 1 and 8; cisplatin, 80 mg/m 2, day 1 every 3 weeks. j Italian lung cancer trial; paclitaxel, 225 mg/m 2 over 3 hours, day 1; carboplatin, AUC 6.0, every 3 weeks. k Italian lung cancer trial; vinorelbine, 25 mg/m 2 i.v., weekly every 4 weeks; cisplatin, 100 mg/m 2, day 1. l Tax 326 study; vinorelbine, 25 mg/m 2 weekly; cisplatin, 100 mg/m 2 every 4 weeks. m CPT-11 Lung Cancer Study Group trial in Japan, stage IIIB/IV patients; irinotecan, 60 mg/m 2 i.v., days 1, 8, and 15; cisplatin, 80 mg/m 2 i.v., day 1 every 4 weeks. n CPT-11 Lung Cancer Study Group trial in Japan, stage IV patients only; irinotecan, 60 mg/m 2 i.v., days 1, 8, and 15; cisplatin, 80 mg/m 2 i.v., day 1 every 4 weeks. o CPT-11 Lung Cancer Study Group second trial, stage IIIB/IV patients; irinotecan, 60 mg/m 2 i.v., days 1, 8, and 15; cisplatin, 80 mg/m 2 i.v., day 1 every 4 weeks. p Paclitaxel, 100 mg/m 2, carboplatin, AUC 6.0. q Paclitaxel, 100 mg/m 2, carboplatin, AUC 2.0. r Paclitaxel, 150 mg/m 2, carboplatin, AUC 2.0. s Topotecan, 0.75 mg/m 2 on days 1 5 of a 21-day cycle; cisplatin, 75 mg/m 2, single dose on day 1. t Topotecan, 0.5 mg/m 2 on days 1 5 of a 21-day cycle; carboplatin, AUC 5 mg/ml per minute on day 1 of each cycle. u Topotecan, mg/m 2 on days 1 5 of a 21-day cycle; vinorelbine, mg/m 2 on days 1 and 5. v Topotecan, 1.0 mg/m 2 on days 1 5 of a 28-day cycle; gemcitabine, 1,000 mg/m 2 on days 1 and 15. w Topotecan, mg/m 2 on days 1 5 of a 28-day cycle; gemcitabine, 1,000 mg/m 2 on days 1, 8, and 15 of a 28-day cycle. x Topotecan, 0.85 mg/m 2 per day on days 1 3, and etoposide, 100 mg twice daily, on days 7 9 of a 21-day cycle. y Topotecan, mg/m 2 on days 1 5 of a 21-day cycle; paclitaxel, 175 mg/m 2 over 3 hours on day 1. Abbreviations: AUC, area under the concentration-versus-time curve; ECOG, Eastern Cooperative Oncology Group; EORTC, European Organization for Research and Treatment of Cancer; HOG, Hellenic Oncology Group; NA, data not available; SWOG, Southwest Oncology Group. From [3, 6, 11, 115, 117]. The Oncologist

4 Ettinger 361 Table 2. Frequency of high epidermal growth factor receptor (EGFR) expression in lung cancer by histologic characterization Histology EGFR expression, % (n) Small cell 0 (19) Adenocarcinoma 65 (563) Large cell 68 (72) Squamous 84 (754) Reprinted from Bunn PA Jr, Franklin W. Epidermal growth factor receptor expression, signal pathway, and inhibitors in non-small cell lung cancer. Semin Oncol 2002;29(suppl 14):38 44, with permission from Elsevier. Figure 1. Epidermal growth factor receptor (EGFR) signaling pathways. Abbreviations: MAPK, mitogen-activated protein kinase; PI3K, phosphatidylinositol 3ʹ kinase; STAT, signal transducer and activator of transcription. (Erbitux ; ImClone Systems, Inc., New York), although others such as panitumumab (ABX-EGF) and matuzumab (EMD72000) are currently in early phases of investigation [31 34]. Among the small-molecule TKIs, the best-studied are gefitinib (Iressa ; AstraZeneca Pharmaceuticals, Wilmington, DE) and erlotinib (Tarceva ; Genentech, Inc., South San Francisco, CA). Both mabs and TKIs generally have milder toxicity than conventional drugs, which are cytotoxic. Because they target cellular processes associated with tumor resistance to radiation (e.g., proliferation and angiogenesis), antibodies and TKIs have the potential to be combined effectively with radiotherapy in the treatment of NSCLC [35]. Anti-EGFR mabs Antibodies generally have the advantages of less frequent administration, induction of receptor downregulation, the potential to engage the host immune response in direct tumor cell cytotoxicity, and a favorable toxicity profile (notably the absence of gastrointestinal adverse effects). Antibodies specific for EGFR are among the first targeted therapies to demonstrate effectiveness in treating cancer, including NSCLC. Cetuximab Cetuximab, a chimeric human-murine IgG 1 mab, blocks ligand binding to EGFR, thereby diminishing receptor dimerization and autophosphorylation, and induces EGFR receptor downregulation, reducing the number of receptors on the cell surface. The immunoglobulin IgG 1 isotype of cetuximab may also engage host immune functions, such as antibody-dependent cellular cytotoxicity (ADCC) [36]. Preclinical studies with cetuximab showed that it enhanced the activity of cytotoxic drugs [37 39] and radiotherapy [39 41]. This may be related to its ability to block the nuclear import of EGFR and activation of DNA-dependent kinase (DNA-PK) necessary for the repair of radiation- and chemotherapy-induced DNA damage [42]. Early clinical studies in advanced NSCLC have reported promising responses for cetuximab administered as monotherapy or in combination with chemotherapy in chemotherapy-naïve and previously treated patients (Table 3). Monotherapy. A phase II study of cetuximab monotherapy in recurrent or metastatic EGFR-detectable NSCLC patients with one or more prior chemotherapy regimens demonstrated 2 of 29 (6.9%) partial responses (PRs) and 5 patients (17.2%) with stable disease [43]. Similar RRs (3.3% PR [2/60 patients], 25% stable disease [15/60 patients]) were shown in a subsequent phase II trial in patients with stage IIIB/IV recurrent or metastatic disease [44]. These studies showed that cetuximab is well tolerated, with rash as the most common toxicity. It is encouraging that recent phase II monotherapy data in advanced colorectal cancer (CRC) showed consistent RRs regardless of the number of prior lines of therapy (3 8) or sequence of prior agents [45]. Combination with Chemotherapy Regimens. The efficacy of cetuximab plus chemotherapy has been examined. In a phase I study in advanced tumors including NSCLC, 2 of 19 patients (10.5%) receiving multiple doses of cetuximab plus cisplatin had PRs [46]. A randomized, controlled trial in chemotherapy-naïve patients with advanced, EGFRexpressing NSCLC showed a higher RR for the cetuximab plus vinorelbine plus cisplatin regimen than for vinorelbine

5 362 EGFR Expression in NSCLC Table 3. Results of clinical trials with cetuximab in patients with advanced NSCLC (chemotherapy-naïve and treatmentrefractory/resistant patients) plus cisplatin alone (31.7% vs. 20.0%) [47]. Other studies of cetuximab combinations have reported similar RRs. Cetuximab combined with docetaxel in chemotherapyrefractory/resistant NSCLC resulted in a 28% (13/47) PR rate and 17% (8/47) stable disease rate [48]. Cetuximab added to paclitaxel plus carboplatin or to gemcitabine plus carboplatin in chemotherapy-naïve NSCLC led to RRs of 26% (n = 31) and 28.6% (n = 35), respectively [49, 50]. Combination with Radiotherapy Regimens. To date, cetuximab studies in lung cancer have focused on tumor responses as endpoints and have not been designed to demonstrate significant survival benefits. However, longer survival has been shown in studies on other tumor types. A recent phase III international trial comprising 424 patients with locally-advanced squamous-cell carcinoma of the head and neck (SCCHN), a difficult-to-treat population, demonstrated the first significant survival benefit for a targeted therapy, cetuximab, in combination with highdose radiation, compared with radiation alone. Patients receiving radiation therapy without cetuximab showed a median survival of 28 months, and patients receiving radiation with cetuximab showed a median survival of 54 months [51]. The 2-year and 3-year survival times were also significantly longer in the cetuximab-treated population. Currently, cetuximab is the only EGFR-targeted agent shown to improve survival significantly in a curative setting in SCCHN. Partial response, n (%) Stable disease, n (%) Description of study n Monotherapy Phase II, monotherapy; patients with recurrent or metastatic disease; 1 prior therapy [43] 29 2 (6.9%) 5 (17.2%) Combination therapy Phase I study, various advanced tumors including lung cancer; combination therapy of cetuximab with cisplatin; evaluation at 4 weeks [46] 19 2 (10.5%) 11 (58%) Phase II randomized, controlled trial, chemotherapy-naïve, advanced, EGFR +, NSCLC; combination therapy of vinorelbine/cisplatin with cetuximab [47] (31.7%) 18 (43.9%) Phase II study, chemotherapy-refractory/resistant patients with advanced NSCLC; combination therapy of cetuximab and docetaxel [48] (27.7%) 8 (17%) Phase I/II study, chemotherapy-naïve, stage IV NSCLC patients; paclitaxel plus carboplatin and cetuximab [118] 31 9 (29%) 11 (35.5%) Phase IB/IIA study, chemotherapy-naïve, stage IV NSCLC patients; combination therapy of cetuximab with gemcitabine plus carboplatin [50, 119] 33 8 (24.2%) 14 (42.4%) Phase II study, stage IIIB/IV, recurrent or metastatic NSCLC with at least one 60 2 (3.3%) 15 (25%) prior platinum, EGFR + or EGFR ; cetuximab monotherapy [44] Phase II study, stage IIIA/B NSCLC; cetuximab plus radiation, carboplatin, and 34 NA (toxicity study in progress) paclitaxel; end points are safety and compliance (RTOG 0324 trial a ) [120] a Study is ongoing. Abbreviations: EGFR, epidermal growth factor receptor; NA, not available; NSCLC, non-small cell lung cancer; RTOG, Radiation Therapy Oncology Group. Cetuximab has been well tolerated in all clinical trials conducted. The most common treatment-related adverse effect, which occurs in most patients, is a self-limiting acneiform rash generally occurring in the first 2 3 weeks. The rash stabilizes or resolves with continued therapy and disappears completely without scarring once treatment is stopped [15, 52]. The occurrence of rash with cetuximab reflects the widespread distribution of EGFR in epithelial tissue, and a number of studies have reported a correlation between rash and response to cetuximab [45, 52, 53]. A current clinical trial (EVEREST, a phase II trial using cetuximab in escalating doses combined with irinotecan to achieve higher rates of skin rash and response in patients with metastatic colorectal cancer previously treated with irinotecan) is exploring dose-to-rash treatment strategies. Less commonly (1.5% reported in the U.S., data on file), infusion reactions have occurred in some patients. These reactions generally respond to treatment with corticosteroids, antihistamines, and bronchodilators administered alone or in combination [52] and are rarely fatal (<1 in 1,000). Important questions remain regarding the relevance of EGFR detection as a requirement for cetuximab therapy. A retrospective analysis of cetuximab for EGFR-undetectable CRC (as determined by immunohistochemistry [IHC]) showed four PRs (25%; 95% confidence interval [CI], 4% 46%), and 7 of 16 EGFR-undetectable patients achieved some degree of tumor control [54]. In an analysis of EGFR staining intensity versus RR or survival in cetuximab- The Oncologist

6 Ettinger 363 treated CRC patients, the RRs for 1+, 2+, and 3+ tumors were uncorrelated [55]. These findings suggest that, aside from EGFR detection by IHC, evaluation of other markers such as activated, nonphosphorylated, and mutated receptors, EGFR ligands, and downstream effector molecules may lead to more accurate prognostic indicators of cetuximab responsiveness. Matuzumab Matuzumab (EMD 72000) is a humanized anti-egfr mab currently in phase II trials for gastric, esophageal, and lung cancers [4]. One of these trials is investigating the effect of matuzumab in combination with the chemotherapy agent pemetrexed as a second-line therapy in patients with advanced NSCLC [57]. Panitumumab Panitumumab (ABX-EGF) is a human IgG 2 mab that targets EGFR and, unlike cetuximab, mediates its effect through mechanisms other than ADCC. In a phase I study of 88 renal cancer patients, three patients had PRs, two had minor responses, and 44 (50%) had stable disease after 8 weeks of treatment with panitumumab [31, 42]. The frequency of an acneiform skin rash was also directly proportional to the dose of panitumumab and was associated with longer PFS. Panitumumab is being evaluated as monotherapy for patients with metastatic CRC and advanced solid tumors, and also in combination with chemotherapy for unresectable or recurrent colorectal, lung, breast, bladder, and ovarian cancer [56]. EGFR TKIs Small-molecule TKIs are another class of EGFR-targeted agents. TKIs can be orally administered, have a rapid onset of action, and potentially have better tumor penetration than mabs [15]. Among drugs of this class, the two most extensively evaluated in NSCLC are gefitinib and erlotinib. Both have demonstrated single-agent activity in NSCLC, and greater sensitivity to either gefitinib or erlotinib has been correlated with somatic mutations in the receptor kinase domain and/or increased EGFR gene copy number [58] (see below). Other TKIs undergoing testing in early-phase clinical trials include PKI 166, GW , EKB 569, and CI-1033 [59]. In preclinical studies, all these agents inhibited the growth of EGFR-expressing human cancer cell Table 4. Results of clinical trials with gefitinib in patients with advanced NSCLC (chemotherapy-naïve and treatmentrefractory/resistant patients) No. of patients Description of study evaluable for response Partial response, n (%) Stable disease, n (%) Monotherapy Randomized, placebo-controlled, multicenter phase III trial (ISEL) [69]; 250 mg/day (8%) 304 (31.7%) Randomized, double-blind, parallel-group, multicenter phase II trial (IDEAL-1) [63] 250 mg/day 500 mg/day (17.5%) 19 (18.1%) 37 (35.9%) 34 (32.4%) Randomized, double-blind, phase II trial (IDEAL-2) [62, 64] 250 mg/day 500 mg/day (12%) 10 (8.8%) 32 (31.4%) 30 (26.3%) Open-label, expanded-access program; 250 mg/day [65] (4.1%) 60 (34.9%) Open-label, expanded-access program; 250 mg/day [67] 60 2 (3.3%) 23 (38.3%) Compassionate use in patients for whom prior chemotherapy failed; 250 mg/day [68] 33 3 (9%) 14 (42%) Expanded-access program; 250 mg/day [121] (7%) 46 (38%) Chemotherapy-naïve patients; 250 mg/day [122] (61%) Compassionate use program in Israel; 250 mg/day [123] (12.2%) 40 (22.1%) Phase II study, chemotherapy-naïve patients; 250 mg/day [124] (30%) 16 (40%) Expanded-access program, London; 250 mg/day [125] (6%) 68 (55%) Patients for whom chemotherapy had failed, at least one of which was platinum-based; 250 mg/day [126] 66 3 (4.5%) 26 (39.4%) Patients with advanced bronchioalveolar lung cancer; 500 mg/day [70] 69 (chemotherapy-naïve) 9 (13%) 21 (30%) 22 (chemotherapy-pretreated) 2 (9%) 8 (36%) (continued)

7 364 EGFR Expression in NSCLC Table 4. (continued) Other monotherapy studies n Response rate Criteria Patients pretreated with at least one course of platinum-containing chemotherapy; 250 mg/day [127] 41 Median, 85 days Time to progression Median, 96 days Overall survival Compassionate use in patients who were able to tolerate chemotherapy; 250 mg/day [66] (failed with second-line rate 21, % (comparable 1-year survival chemotherapy) chemotherapy) A community practice experience; maintenance on 250 mg/day [89] compared with IDEAL-2 lines and showed additive or synergistic growth inhibitory effects when combined with chemotherapeutic agents or radiotherapy [20, 60 62]. Gefitinib Gefitinib, an anilinoquinazoline, was the first TKI selective for EGFR evaluated in NSCLC. It is orally active and given once daily. Studies conducted on gefitinib in NSCLC are summarized in Table 4. Monotherapy. Two randomized, double-blind trials of gefitinib monotherapy in daily doses of 250 mg or 500 mg given to patients with advanced NSCLC who had previously received chemotherapy regimens the Iressa Dose Evaluation in Advanced Lung Cancer (IDEAL)-1 and IDEAL-2 recorded objective RRs of 10% 19% [63, 64]. In both studies, symptoms improved in 35% 43% of % (vs. IDEAL-2, 42%) Partial response, n n (%) Disease control rate Stable disease, n (%) Combination therapy Phase I/II study in combination with rofecoxib; 250 mg/day [128] 33 2 (6.1%) 9 (27.3%) Randomized, double-blind, placebo-controlled, multicenter phase III trial, INTACT-1; cisplatin and gemcitabine plus gefitinib [72] 250 mg/day 500 mg/day 0 mg/day Randomized, double-blind, placebo-controlled, multicenter phase III trial, INTACT-2; paclitaxel and carboplatin plus gefitinib at 250 mg/day 500 mg/day 0 mg/day [73, 74] Phase II study with gefitinib and docetaxel in patients that have failed or are unsuitable for platinum chemotherapy [129] Phase I study; radiation therapy (60 Gy/30 fractions/6 weeks), with gefitinib at dose 1, paclitaxel added at dose levels 2, 3, and 4 [75] Randomized, noncomparative phase II study in elderly patients; gefitinib 250 mg/day plus vinorelbine and gemcitabine [76] (47.9%) 159 (48.2%) 150 (46.3%) No difference in survival/response rate NA 9.8 months 8.7 months 9.9 months 21 (13 evaluated) 3 (23%) 9 (69%) 14 9 (64.3%) a 6 (42.3%) b (12.5%) 3 (8.6%) 7 (29.2%) 13 (37.1%) Phase II trial, first-line therapy of elderly patients; docetaxel plus gefitinib, 250 mg/day [77] 10 5 (50%) 3 (30%) a Assessed by computerized tomography scan. b Assessed by 18 Fluorodeoxyglucose-positron emission tomography scan. Abbreviations: IDEAL, Iressa Dose Evaluation in Advanced Lung Cancer; INTACT, Iressa NSCLC Trial Assessing Combination Treatment; ISEL, Iressa Survival Evaluation in Lung Cancer; NA, not available. patients. Although no significant differences in efficacy were found between the 250- and 500-mg daily doses of gefitinib, adverse effects occurred more frequently with the higher dosage [63, 64]. In the first study, greater efficacy was found in Japanese than in non-japanese patients (27.5% vs. 10.4%, p =.0023) [63]. Results from three institutional studies of single-agent gefitinib therapy used on a compassionate basis in patients with advanced NSCLC for whom standard treatment had failed or who were not suitable for systemic chemotherapy were recently presented (Table 4) [65 68]. In the largest of these studies, involving 21,064 patients with stage III/ IV NSCLC who received one or more doses of gefitinib, median survival was 5.3 months, and the 1-year survival rate was 29.9% [66]. These results are comparable with those obtained with chemotherapy in a second-line clinical setting. The Oncologist

8 Ettinger 365 A phase III randomized, multicenter study of gefitinib in refractory advanced NSCLC, the Iressa Survival Evaluation in Lung Cancer (ISEL) trial, recently concluded that gefitinib provided no significant survival benefit over best supportive care across the total population of patients studied [69]. However, significant survival benefit was observed in specific subpopulations, including patients of Asian descent (n = 342; median survival 9.5 vs. 5.5 months; p =.01) and patients with no smoking history (n = 375; median survival, 8.9 vs. 6.1 months; p =.012) [69]. A study in patients with advanced bronchioalveolar cell carcinoma (BAC), a subtype of NSCLC with distinctive clinical, pathologic, and radiographic characteristics that is generally considered chemoresistant, found that singleagent gefitinib therapy of 500 mg daily achieved tumor RRs of 21% and 10% in chemotherapy-naïve and previously treated patients, respectively. Median survival times were 12 and 10 months, respectively [70]. In this same study, increased EGFR gene copy number, as detected by fluorescence in situ hybridization (FISH), was associated with longer survival (median survival >18 months vs. 8 months; p =.042) [71]. Combination with Chemotherapy Regimens. Two double-blind, placebo-controlled trials the Iressa NSCLC Trial Assessing Combination Therapy (INTACT)-1 and INTACT-2 trials evaluated whether the addition of gefitinib to gemcitabine plus cisplatin or paclitaxel plus carboplatin provides additional clinical efficacy over chemotherapy alone in chemotherapy-naïve patients with advanced NSCLC. Both indicated no benefit from gefitinib in objective RR or survival [72, 73]. One potential explanation for the failure of gefitinib to provide clinical benefit is that concurrent cytotoxic agents abrogate its efficacy by directly or indirectly altering EGFR expression [74]. It has been suggested, therefore, that sequential therapy, in which chemotherapy regimens are preceded or followed by gefitinib, or intercalated therapy, in which high doses of gefitinib are given as a bolus between chemotherapy regimens, may be better strategies, and trials to test these hypotheses are currently in progress [15]. Preliminary results from other studies of gefitinib used in combination with chemotherapy have provided some encouraging results [75 77]. In one study, in which gefitinib was given in combination with concurrent paclitaxel plus carboplatin and radiation therapy in patients with stage III NSCLC, a complete RR of 27% and a PR rate of 64% were achieved in 11 evaluable patients [75]. The available clinical data on gefitinib indicate significant variability in responsiveness. Recent studies suggest that greater response to EGFR inhibitors is related to mutations in exons of the EGFR tyrosine kinase domain, which increase growth factor signaling (Table 5) [23, 28,34, 63, 78 80]. Mutations were significantly associated with adenocarcinoma, history of no smoking, and female gender [81, 82]. On the other hand, some reports describe the existence of tumors with a different type of EGFR mutation in this domain a threonine-to-methionine substitution at position 790 (T790M) that renders resistance instead of sensitivity to gefitinib [81, 83 85]. In addition, a mutation in the K-ras gene, which mediates EGFR signaling, may also confer resistance to TKIs [28, 79]. If confirmed, these findings suggest that screening for such mutations may identify patients who are more, or less, likely to respond to gefitinib. Measurement of EGFR expression by IHC was not useful for predicting responsiveness to gefitinib in the patients enrolled in the IDEAL or INTACT studies [86, 87]. However, IHC coupled with FISH to detect increased EGFR gene copy number may help to predict which patients are likely to benefit from gefitinib therapy [88]. Other factors that might be predictive of responsiveness include a better performance status and the appearance of rash while on gefitinib treatment [89, 90]. Gefitinib has been generally well tolerated, with skin rash and diarrhea occurring in 40% 60% of patients. Other less common adverse effects include nausea, vomiting, pruritus, dry skin, and asthenia [91, 92]. Potential danger of gefitinib-associated lung toxicity in a subset of NSCLC patients with previous thoracic irradiation or poor performance status has also been reported [93]. Erlotinib Like gefitinib, erlotinib is an orally-active, EGFR-specific quinazoline TKI that demonstrated antitumor activity in xenograft models [3, 15, 19, 94]. In addition to firstline treatment for advanced pancreatic cancer, erlotinib is currently approved for second-line treatment of locally advanced or metastatic NSCLC. Several clinical studies of erlotinib in advanced NSCLC have been reported (Table 6). Monotherapy. A phase II study of erlotinib (150 mg daily) in 57 advanced NSCLC patients demonstrated two complete responses (4%) and 5 PRs (9%). The median overall survival time was 8.4 months, with a 40% 1-year survival rate. Patients with skin rash survived significantly longer than those without rash, suggesting skin rash as a potential marker of erlotinib response [95]. Erlotinib (150 mg daily) resulted in a 25.4% PR rate (15 of 59 evaluable patients) in BAC patients. Greater erlotinib responsiveness was shown in never-smoking patients (37%) and adenocarcinoma with BAC (30%) [96].

9 366 EGFR Expression in NSCLC Table 5. Epidermal growth factor receptor (EGFR) mutations in non-small cell lung cancer Frequency Gene Mutation Location (n/total patients) Study Effect Reference EGFR Deletions and EGFR TK domain, 18% (14/78) IDEAL response to Lynch et al. point mutations exons % (32/312) INTACT gefitinib (SD and [28] survival) EGFR EGFR EGFR Amplification (mean, 8 ) Deletions and insertions Substitutions Deletions Point mutations L858R, L861Q, G719C (exon 19) 858 (exon 21), other codons 8% (7/90) 7% (24/312) 89% (8/9 responsive pts) 80% (2/25 untreated pts) 28.8% (17/59) 25.4% (15/59) (total 56%, 33/59) in nonsmokers, women, pts with adenocarcinomas IDEAL INTACT INTACT: response to gefitinib (SD) response to gefitinib (PR) response to gefitinib (tumor response, CEA) Lynch et al. [23] Mitsudomi et al. [130] EGFR Substitution T790M 2/6 pts Pao et al. [84] EGFR Substitution T790M 1 pt resistance to gefitinib; pt relapsed EGFR Substitution L858R (exon 21) and T790M EGFR EGFR K-ras EGFR + K-ras EGFR + K-ras EGFR + K-ras Deletions Missense mutations Transversions Deletions Transversions (smokers) Transitions (nonsmokers) Exon 19 Exon 21 2 pts resistance to gefitinib 19 (exon 19) 18 (exon 21) Total: 32% (38/120) 719 and % (12/64) SWOG S (exon 2) 30% (19/63) SWOG S0126 See above See above 6% (4/63) SWOG S0126 Not specified in abstract Not specified in abstract EGFR exons 18 21; K-ras exon 2 EGFR exons 18 21; K-ras exons 2 & 3 24% (9/37) 12% (4/34) 7.8% (15/191) 14.7% (24/163) Phase II erlotinib study TALENT response to gefitinib (survival; 25.1 vs months) Response to gefitinib (survival) Resistance to gefitinib (1/19 responded) (No response to gefitinib) All responded to erlotinib None responded No significant correlations with response Kobayashi et al. [83] Toyooka et al. [85] Toyooka et al. [85] Gumerlock et al. [79] Kris et al. [101] Gatzemeier et al. [100] EGFR K-ras EGFR Not specified Deletions Point mutations EGFR, PI3K K-ras (exon 19) 858 (exon 21) and 719 (exon 18) Exon 20 0% (0/15) 53.3% (8/15) 40% (111/277) in nonsmokers, females, patients with adenocarcinomas 1 responder Not specified (abstract) Not known Giaccone et al. [131] Kosaka et al. [81] Duplications/ insertions Abbreviations: CEA, carcino-embryonic antigen; IDEAL, Iressa Dose Evaluation in Advanced Lung Cancer; INTACT, Iressa NSCLC Trial Assessing Combination Treatment; PI3K, phosphatidylinositol 3ʹ kinase; PR, partial response; pt, patient; SD, stable disease; SWOG, Southwest Oncology Group; TALENT, a phase III study of gemcitabine plus cisplatin with or without erlotinib in advanced NSCLC; TK, tyrosine kinase. A recent double-blind, placebo-controlled phase III study comparing erlotinib with placebo in patients (n = 731) with stage IIIB/IV NSCLC and one to two prior chemotherapy regimens the National Cancer Institute of Canada Clinical Trials Group (NCIC CTG) trial BR.21 reported the first evidence of an EGFR inhibitor prolonging survival in chemotherapy-refractory NSCLC [97, 98]. Patients receiving erlotinib (n = 488) at 150 mg daily demonstrated significantly longer overall survival (6.7 months vs. 4.7 months) and PFS (2.2 months vs. 1.8 months) than those The Oncologist

10 Ettinger 367 Table 6. Results of clinical trials with erlotinib (150 mg daily) in patients with advanced non-small cell lung cancer (NSCLC) Study Monotherapy Placebo-controlled, randomized, phase III trial with patients for whom first- or second-line therapy failed [98] Erlotinib, n = 488 Placebo, n = 243 receiving placebo. The overall erlotinib RR was 8.9%. The median response duration was 34.2 weeks. RRs were higher among specific subpopulations, including women, Asians, nonsmokers, and patients with adenocarcinoma, reminiscent of similar results with gefitinib [98]. Response was associated with higher EGFR gene copy number, but no survival advantage was seen in patients with higher EGFR expression or mutations in exons 19 and 21 [99]. Mutation frequency in EGFR or K-ras was not correlated with tumor sensitivity or responsiveness to erlotinib in one study [100]; in another study, 9 of 37 patients with EGFR mutations responded well to erlotinib, and 4 of 34 patients with K-ras mutations did not respond to erlotinib (Table 5) [101]. Combination with Chemotherapy Regimens. As with the gefitinib INTACT studies [72, 73], erlotinib showed no survival advantage when combined with a two-drug chemotherapy regimen. In a randomized, placebo-controlled study of 1,059 previously untreated advanced NSCLC Partial response (%) Phase II, open-label, chemotherapy-naïve patients aged 70 years [132] 4/30 (13.3%) Phase II open-label trial of patients previously treated with platinumbased chemotherapy [95] Phase II open-label trial, BAC patients [96] Total Never smoked Smoke 5 pack-years Smoke 6 pack-years Phase II, chemotherapy-naïve, stage IIIB/IV, PS 0 2, NSCLC patients; 150 mg/day erlotinib for 6 weeks [131]; nonprogression rate, 55% (mostly in women, adenocarcinomas/bac, and nonsmokers) Combination therapy TRIBUTE study: phase III, prospective, placebo-controlled, randomized, previously untreated patients; erlotinib or placebo, with six cycles of carboplatin plus paclitaxel and maintenance monotherapy [102] Erlotinib, n = 526 Placebo, n = 533 TRIBUTE study, subgroup analysis: patients that have never smoked [102, 103] Erlotinib, n = 69 Placebo, n = 44 TALENT study: Phase III, prospective, placebo-controlled, untreated patients; erlotinib or placebo, with six cycles of gemcitabine and cisplatin, followed by maintenance monotherapy [104] Erlotinib Placebo 15/59 (25%) 7/19 (37%) 3/7 (43%) 5/33 (15%) 12/53 (23%) Overall survival (months) Year survival % % % Abbreviations: BAC, bronchioalveolar carcinoma; PS, performance status score; TRIBUTE, a phase III study of gemcitabine plus cisplatin with or without erlotinib in advanced NSCLC % patients, erlotinib (150 mg daily) with six cycles of paclitaxel plus carboplatin followed by maintenance monotherapy showed no significant differences in overall RR, response duration, median survival, or time to progression (TTP) compared with paclitaxel plus carboplatin alone [102]. However, patients who never smoked showed longer survival with erlotinib (23 vs. 10 months) [103]. A placebo-controlled study of erlotinib (150 mg daily) plus gemcitabine plus cisplatin in 1,172 patients with previously untreated, advanced NSCLC showed no improvement in overall survival or TTP compared with gemcitabine plus cisplatin alone [104]. Erlotinib tolerability is similar to that of gefitinib. Skin rash and diarrhea are the most common adverse effects [59]. Preliminary results of a study of erlotinib administered at 1,200, 1,600, or 2,000 mg weekly suggest that 1,600 mg/ week is tolerable for advanced NSCLC patients refractory to previous chemotherapy. Weekly high-dose therapy (i.e., >2,000 mg) is being investigated [105].

11 368 EGFR Expression in NSCLC EGFR and Tumor Angiogenesis: Another Rational Approach to NSCLC Treatment New blood vessel formation is required for the growth and progression of most tumors. The EGFR is also involved in angiogenesis: the EGFR ligands EGF and TGF-α induce angiogenesis, and TGF-α promotes the expression of VEGF, which induces vascular growth and vascular cell permeability [18, 106], providing a strong rationale for combined anti-vegf/anti-egfr therapy. VEGF expression is upregulated in many tumors, resulting in an imbalance between pro- and antiangiogenic factors in the tumor microenvironment, promoting vascularization and growth [106, 107]. At least four isoforms of VEGF exist, VEGF-A through VEGF-D, and three isoforms of membrane-bound VEGF receptors have been identified (VEGFR-1, VEGFR-2, and VEGFR-3), each with distinct roles in angiogenesis [108]. Antiangiogenesis in NSCLC Treatment Several angiogenesis inhibitors have been studied in NSCLC [109]. They include antibodies to VEGF and VEGFR and inhibitors of VEGFR tyrosine kinase [108]. The best-studied angiogenesis inhibitor is bevacizumab (rhumab-vegf), an anti-vegf antibody that has been evaluated in combination with chemotherapeutic agents and erlotinib in advanced or recurrent NSCLC. In a randomized, controlled trial involving 99 patients with previously untreated stage IIIB/IV or recurrent NSCLC, bevacizumab added to paclitaxel plus carboplatin improved overall response and TTP compared with paclitaxel plus carboplatin alone. The median TTP was significantly greater for patients receiving a high-dose (15 mg/kg) bevacizumab regimen than for those receiving a low-dose (7.5 mg/kg) bevacizumab regimen (7.4 vs. 4.2 months; p =.023). In contrast, no significant difference in TTP was found for the low-dose bevacizumab group versus paclitaxel plus carboplatin alone [110]. Preliminary results from a phase I/II study of bevacizumab plus erlotinib in previously treated stage IIIB/IV or recurrent NSCLC patients showed PRs in 8 of 40 (20.0%) and stable disease in 26 of 40 (65%) patients. The median overall survival time and TTP were 12.6 and 6.2 months, respectively [111]. The recent Eastern Cooperative Oncology Group (ECOG) E4599 trial compared paclitaxel plus carboplatin with bevacizumab (PCB) and without bevacizumab (PC) in advanced NSCLC [112]. This was the first phase III trial to demonstrate a survival advantage obtained from a first-line treatment combining a targeted biologic with chemotherapy, reporting encouraging tumor RRs (27% for PCB vs. 10% for PC), PFS (6.4 vs. 4.5 months) and median survival rates (12.5 vs months) with bevacizumab. Bevacizumab appears to be generally well tolerated. Combination with paclitaxel plus carboplatin showed modest changes to the chemotherapy regimen toxicity profile [110]. However, some bevacizumab-associated adverse effects warrant special attention, including hypertension, proteinuria, and hemorrhage. Most cases of hemorrhage with bevacizumab have been minor, but some serious pulmonary hemorrhages have occurred, which often results from angiogenesis inhibition; also, poorly developed neovessels in large, centrally located tumors may be more prone to hemorrhage into the necrotic tumor cavity [110]. Eligibility restrictions in clinical trials of bevacizumab in NSCLC have included a history of myocardial infarction or stroke, significant peripheral vascular disease, central nervous system or brain metastasis, lung carcinoma of squamous cell histology or close proximity to a major vessel, and use of anticoagulants, aspirin, or nonsteroidal antiinflammatory drugs. Promising results have been reported for combined anti- EGFR and anti-vegf therapy, notably the Bowel Oncology with Cetuximab Antibody (BOND)-2 study, which showed that concurrent administration of cetuximab and bevacizumab is feasible and can result in improved RRs in bevacizumab-naïve patients with advanced CRC [113] (see above). In addition, ZD6474, an orally available small-molecule kinase inhibitor of both EGFR and VEGFR, is being explored for efficacy in NSCLC and other cancers. Phase II trials of ZD6474 in combination with standard chemotherapies in first- and second-line settings for advanced or metastatic NSCLC are ongoing. Preliminary data have shown that ZD6474 combined with docetaxel provided an 18.2% (2/11) PR rate and a 63.4% (7/11) SD rate for 12 weeks in NSCLC patients who had previously failed first-line platinum-based chemotherapy [114]. ZD6474 combined with carboplatin plus paclitaxel as a first-line therapy in NSCLC (IIIB IV) demonstrated a 39% (7/18) PR rate in a randomized, double-blind trial [115]. The Oncologist Summary and Conclusions Current treatments for advanced NSCLC have resulted in only modest response rates, and drug resistance is common. Based on identification of tumor-specific molecular signaling pathways, targeted therapies offer potentially greater clinical benefit. Newer therapies targeted against the EGFR signaling pathway offer the promise of improved NSCLC treatment, leading to longer patient survival. Recent studies with the anti-egfr antibody cetuximab, the EGFR TKIs gefitinib and erlotinib, and the anti-vegf antibody bevacizumab have been encouraging. Important findings include: (a) enhanced vinorelbine/cisplatin efficacy by cetuximab in chemotherapy-

12 Ettinger 369 naïve patients with advanced, EGFR-detectable NSCLC; (b) enhanced efficacy of paclitaxel/carboplatin by bevacizumab in chemotherapy-naïve patients with advanced or recurrent NSCLC; (c) activity of the TKIs gefitinib and erlotinib as second- or third-line monotherapy in prolonging survival (erlotinib) or improving symptoms (gefitinib and erlotinib) in advanced NSCLC patients failing prior chemotherapy; and (d) evidence of the activity of gefitinib and erlotinib in patients with BAC. Despite their activity as a second- or third-line therapy in advanced NSCLC and augmentation of chemotherapeutic agent activity in preclinical studies, neither gefitinib nor erlotinib conferred a survival advantage in previously untreated NSCLC when administered with two-drug chemotherapy regimens (gemcitabine plus cisplatin and paclitaxel plus carboplatin). The reasons for their apparent lack of benefit when used concomitantly with platinum-containing regimens are unclear but may involve direct or indirect alteration of EGFR expression by cytotoxins. Thus, different administration schedules may be required (e.g., TKI administered before or after standard chemotherapy). On the other hand, cetuximab is well tolerated, with skin rash as its most common toxicity, and has resulted in longer survival in patients with SCCHN when combined with radiation therapy without exacerbating radiation toxicity, unlike chemotherapeutic agents. References 1 American Cancer Society. Cancer Facts & Figures Available at 2 Jemal A, Murray T, Ward E et al. Cancer statistics, CA Cancer J Clin 2005;55: Herbst RS. Targeted therapy using novel agents in the treatment of nonsmall-cell lung cancer. Clin Lung Cancer 2002;3(suppl 1):S30 S38. 4 Kim ES, Vokes EE, Kies MS. Cetuximab in cancers of the lung and head & neck. Semin Oncol 2004;31(suppl 1): Gatzemeier U. Targeting the HER1/EGFR receptor to improve outcomes in non-small-cell lung cancer. Oncology (Williston Park) 2003;17(suppl 12): Ettinger DS. Is there a preferred combination chemotherapy regimen for metastastic non-small cell lung cancer? The Oncologist 2002;7: Hotta K, Matsuo K, Ueoka H et al. Meta-analysis of randomized clinical trials comparing cisplatin to carboplatin in patients with advanced nonsmall-cell lung cancer. J Clin Oncol 2004;22: Kelly K, Crowley J, Bunn PA Jr et al. Randomized phase III trial of paclitaxel plus carboplatin versus vinorelbine plus cisplatin in the treatment of patients with advanced non--small-cell lung cancer: a Southwest Oncology Group trial. J Clin Oncol 2001;19: Schiller JH, Harrington D, Belani CP et al. Comparison of four chemotherapy regimens for advanced non-small-cell lung cancer. N Engl J Med 2002;346: To optimize the efficacy of EGFR inhibitors in advanced NSCLC, further research is necessary to establish their mechanism of action. Identification of accurate biomarkers may also help to identify appropriate patients. It is not yet clear whether measurement of EGFR tumor expression will be useful for predicting response, and study results appear conflicting. Skin rash and clinical characteristics (e.g., a history of never smoking, better performance status, and adenocarcinoma) may be useful for predicting response, and further studies in this area may prove fruitful. EGFR and K-ras mutants affecting gefitinib sensitivity and pharmacogenomic approaches may help identify patients likely to respond to therapy. Both EGFR and angiogenesis inhibitors have the potential to improve NSCLC survival, and the results of studies investigating combination therapy, including multiple biologic agents (e.g., anti-egfr plus anti-vegf therapy), in various tumors are eagerly anticipated. Disclosure of Potential Conflicts of Interest Dr. Ettinger has acted as a consultant for Bristol-Myers Squibb, AstraZeneca, and Genentech; performed contract work with a research study for Bristol-Myers Squibb, IMClone, and OSI; and has received support from Bristol- Myers Squibb, IMClone, and OSI for said research study. 10 Smit EF, van Meerbeeck JP, Lianes P et al. Three-arm randomized study of two cisplatin-based regimens and paclitaxel plus gemcitabine in advanced non-small-cell lung cancer: a phase III trial of the European Organization for Research and Treatment of Cancer Lung Cancer Group--EORTC J Clin Oncol 2003;21: Fossella F, Pereira JR, Von Pawel J et al. Randomized, multinational, phase III study of docetaxel plus platinum combinations versus vinorelbine plus cisplatin for advanced non-small-cell lung cancer: the TAX 326 study group. J Clin Oncol 2003;21: Barlesi F, Jacot W, Astoul P et al. Second-line treatment for advanced nonsmall cell lung cancer: A systematic review. Lung Cancer 2006;51: Camps C, Caballero C, Blasco A et al. Weekly paclitaxel as second/thirdline treatment in advanced non-small cell lung cancer patients: efficacy and tolerability. Anticancer Res 2005;25: Hanna N, Shepherd FA, Fossella FV et al. Randomized phase III trial of pemetrexed versus docetaxel in patients with non-small-cell lung cancer previously treated with chemotherapy. J Clin Oncol 2004;22: Langer CJ. Emerging role of epidermal growth factor receptor inhibition in therapy for advanced malignancy: focus on NSCLC. Int J Radiat Oncol Biol Phys 2004;58: Janmaat ML, Giaccone G. The epidermal growth factor receptor pathway and its inhibition as anticancer therapy. Drugs Today (Barc) 2003;39(suppl C): Schlessinger J. Cell signaling by receptor tyrosine kinases. Cell 2000;103: