In todays digitally advanced society, large volumes of patient-level data can be collected and compiled. With an ever-increasing demand upon healthcare resources, this could have numerous benefits. Speaking from the British Oncology Pharmacy Association (BOPA) 20th Annual Symposium 2017 in Glasgow, UK, Bryn Thomas of The Royal Marsden NHS Foundation Trust, London, UK discusses the advantages of the use of patient-level data in the NHS and the challenges in this area moving forwards, which include technical aspects, quality control and public perception.
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How is the role of the pharmacist changing as treatments in hematological cancers develop? Susannah Koontz Webb, PharmD, BCOP, FHOP, President of the Hematology Oncology Pharmacy Association (HOPA) discusses the treatment advances in blood cancers, and how the movement towards more targeted therapies means that patients can received tailored treatments and can receive more medications in an outpatient setting. These developments create new roles and challenges for pharmacists, making it an exciting time in the field. This interview was recorded at the British Oncology Pharmacy Association (BOPA) 20th Annual Symposium 2017 in Glasgow, UK. This video has been supported by…
Susannah Koontz Webb, PharmD, BCOP, FHOP, President of the Hematology Oncology Pharmacy Association (HOPA) discusses her session on Collaborative Projects at the British Oncology Pharmacy Association (BOPA) 20th Annual Symposium 2017 in Glasgow, UK. The session looked to discuss how organisations like HOPA and BOPA can work together to improve education, guidelines and practises for pharmacists on a global scale in order to optimise cancer care. Dr Koontz Webb describes some of the challenges in oncology pharmacy that could benefit from such partnerships and highlights the important of collaborative approaches. This video has been supported by Napp Pharmaceuticals Ltd through…
During the British Oncology Pharmacy Association (BOPA) 20th Annual Symposium 2017 in Glasgow, UK, we met with Susannah Koontz Webb, PharmD, BCOP, FHOP, President of the Hematology Oncology Pharmacy Association (HOPA) to hear about HOPA and its initiatives. HOPA is a US based organisation of pharmacists, dedicated to the care and education of cancer patients through providing tools and support to healthcare professionals. Dr Koontz Webb provides insight into HOPAs valuable activities and encouraging objectives. This video has been supported by Napp Pharmaceuticals Ltd through an unrestricted educational grant to Magdalen Medical Publishing.
An important question regarding the use of biosimilar rituximab is whether rapid infusion rates are safe, as they are for the original. Speaking from the British Oncology Pharmacy Association (BOPA) 20th Annual Symposium 2017 in Glasgow, UK, Simon Cheesman, BPharm, MRPharmS from University College London Hospital (UCLH), London, UK discusses an audit that his center performed for infusion-related reactions with biosimilar rituximab in order to address this concern, with encouraging results. The full results of this audit will be presented as a poster at the 59th American Society of Hematology (ASH) Annual Meeting and Exposition in Atlanta, GA. This content…
David Irvine from the Beatson Institute, Glasgow, UK discusses introducing CAR-T cells and other cellular therapies into clinical practice and how pharmacists can be involved in this advancement in oncology. Recorded at the BOPA 2017 meeting in Glasgow, UK.
Several major breakthroughs in the treatment of amyloid light-chain (AL) amyloidosis were presented at the American Society of Hematology (ASH) 2017 Annual Meeting and Exposition in Atlanta, GA. In this interview, Laurent Garderet, MD, PhD, of Saint Antoine Hospital, Paris, France, provides an overview of the exciting updates from the meeting, including new understanding of the disease, promising new treatment results with daratumumab and what these advances mean for amyloidosis treatment.
This is an exciting time in hemeonc, with new treatment paradigms across a range of malignant hematologies, including multiple myeloma (MM). The hot topic at the American Society of Hematology (ASH) 2017 Annual Meeting and Exposition in Atlanta, GA, was CAR T-cells, which have the potential to revolutionize the treatment of hematological malignancies. The preliminary results of the CAR T-cell data presented at the meeting for MM are discussed here by Laurent Garderet, MD, PhD, of Saint Antoine Hospital, Paris, France. Dr Garderet highlights the encouraging results and relatively low toxicities.
The use of frontline autologous stem cell transplantation (ASCT) for newly diagnosed multiple myeloma (MM) has been questioned due to the development of new drugs. However, as explained here by Laurent Garderet, MD, PhD, of Saint Antoine Hospital, Paris, France, it is thought that ASCT should not be delayed. Furthermore, Dr Garderet discusses whether double vs. single ASCT is more beneficial for patients, and what the results of the data for this, presented at the American Society of Hematology (ASH) 2017 Annual Meeting and Exposition in Atlanta, GA, may mean for the clinical management of MM.
The proteasome inhibitor carfilzomib has been investigated for the treatment of relapsed/refractory multiple myeloma (MM) in two Phase III clinical trials, ASPIRE (NCT01080391) and ENDEAVOUR (NCT01080391), with promising results. In this interview, Greg Friberg, MD, of Amgen Inc., Thousand Oaks, CA, discuses subanalyses of the robustness of the study data. Dr Friberg highlights how this data will help clinicians to determine the best treatment combinations for their patients. This video was recorded at the American Society of Hematology (ASH) 2017 Annual Meeting and Exposition in Atlanta, GA.
The American Society of Hematology (ASH) 2017 Annual Meeting and Exposition in Atlanta, GA presented exciting results from the ASPIRE trial (NCT01080391) for relapsed multiple myeloma (MM), testing the addition of the proteasome inhibitor carfilzomib to lenalidomide and dexamethasone therapy. Speaking from the meeting, Greg Friberg, MD, of Amgen Inc., Thousand Oaks, CA, discusses the positive follow-up data presented on patient outcomes.
The American Society of Hematology (ASH) 2017 Annual Meeting and Exposition in Atlanta, GA, presented exciting data on the use of ibrutinib for relapsed mantle cell lymphoma (MCL) from three clinical trials. In this interview, Graham Collins, MRCP, FRCPath, DPhil, of Oxford University Hospitals NHS Foundation Trust, Oxford, UK, discusses the striking results found for progression-free survival. Dr Collins highlights how this data may be translated into clinical use and change the standard of care for this group.
Treating cancer beyond progression is an important option to be considered in cases where the benefits outweigh the risks. Speaking from the American Society of Hematology (ASH) 2017 Annual Meeting and Exposition in Atlanta, GA, Graham Collins, MRCP, FRCPath, DPhil, of Oxford University Hospitals NHS Foundation Trust, Oxford, UK, discusses treating patients with lymphoma beyond progression. Dr Collins highlights data discussed from the Phase II CheckMate 205 study (NCT02181738), in which certain patients re-entered remission following PET-assessed progression following another course of treatment. He highlights how data such as this informs clinicians decisions on continuing treatment.
An update on the results of the Phase III ECHELON-1 study (NCT01712490), comparing ABVD vs. AVD plus brentuximab vedotin in the first-line setting for advanced classical Hodgkin Lymphoma, was highly anticipated at the American Society of Hematology (ASH) 2017 Annual Meeting and Exposition in Atlanta, GA. Speaking from the meeting, Graham Collins, MRCP, FRCPath, DPhil, of Oxford University Hospitals NHS Foundation Trust, Oxford, UK, discusses his take on the results presented. Dr Collins highlights the debate around the use of modified progression-free survival (mPFS) as an endpoint, the potential for bias, the use of bleomycin within the ABVD course and…
CAR T-cells are a particularly exciting therapeutic area, which was widely covered at the American Society of Hematology (ASH) 2017 Annual Meeting and Exposition in Atlanta, GA. In this video, Graham Collins, MRCP, FRCPath, DPhil, of Oxford University Hospitals NHS Foundation Trust, Oxford, UK, discusses his highlights of the CAR T-cell data presented at the meeting in regards to lymphoma. Dr Collins covers the promising longer-term results being seen now in overall and complete response rates, the main caveat to the data and the questions that we can expect to be answered by further studies.
Following on from the success of brentuximab vedotin, new antibody-drug conjugates (ADCs) for lymphoma are on the horizon. These successors utilize novel technologies, such as those that allow the determination of how many drugs are attached to the antibody, as well as more potent toxins. In this interview, Graham Collins, MRCP, FRCPath, DPhil, of Oxford University Hospitals NHS Foundation Trust, Oxford, UK, provides an overview of the Phase I study of ADCT-301 for relapsed or refractory Hodgkin and non-Hodgkin lymphoma (NCT02432235). Dr Collins discusses the differences between ADCT-301 and other ADCs, the very promising response rates seen in the trial…
Ropeginterferon Alfa-2b Induces High Rates of Clinical, Hematological and Molecular Responses in PV Patients. Two – year results from the First Prospective Randomized Controlled Trial
Anne S. Tsao, MD of MD Anderson Cancer Center discusses two reasons Osimertinib is good for first line treatment such as its good toxicity profile and how it crosses the blood brain barrier. With the recent FDA breakthrough designation for Osimertinib, it has been a big progress for EGFR mutated patients. Dr. Tsao used Osimertinib as first-line therapy to her patients, especially for newly diagnosed patients. Osimertinib is beneficial for two main reasons good toxicity profile and crossing blood brain barrier. These benefits reduces the arise of CNS metastases and the PFS was quite profound, as well as the overall…
Anne S. Tsao, MD of MD Anderson Cancer Center discusses third generation TKIs and how they cause less diarrhea, abdominal issues, skin rashes, and provide higher quality of life. However, doctors might need to watch out with Osimertinib and get baseline EKG and echo. In this way, QTc prolongation can be known. Patients also should be checked if they have concomitant medication that can cause QTc prolongation which can occur in minor group of patients. However, since Osimertinib crosses the blood brain barrier it is a associated with a very good quality of life.
Anne S. Tsao, MD of MD Anderson Cancer Center discusses profiling standards for NSCLC blood & tissue especially for oncogenic mutations. Profiling patients, especially for non-small cell lung cancer disease is very important. Dr. Tsao uses both blood-based and tumor tissue profiling, especially for patients who are suspected to have oncogenic driver mutations. Although oncogenic driver mutated patients may respond well to their targeted therapy, but they may not gain much benefit from immunotherapy. So, its important to profile them in order to get information that will help in the design of the overall treatment plan. The blood-based testing is…
Anne S. Tsao, MD of MD Anderson Cancer Center discusses Osimertinib in front-line for EGFR mutated resistance mechanisms and how they are not fully understood. New data of Osimertinib showing with progression free and overall survival benefit in the front-line setting, Dr. Tsao is giving Osimertinib for newly diagnosed EGFR mutated patients. However, the resistance mechanism for patients who receive Osimertinib front-line is not yet fully understood. There are reports that the C797S mutation maybe important and more data is needed to know whats the best treatment for those who are refractory to Osimertinib. One can always do chemotherapy and…
Beth Eaby-Sandy, MSN, CRNP of University of Pennsylvania talks about the serious illness conversation guides and how they can be helpful in creating mutual doctor / patient goals. In the University of Pennsylvania where Dr. Eaby-Sandy worked, they are doing data training or role-model training using the guide for patients. The guide is just a list of questions that will be asked to patients. Some of the questions like, Is it okay with you if we talk about your illness today?, May I share my understanding of where we are in your disease process?, Can you share your understanding of…
Vassiliki Papadimitrakopoulou, MD of MD Anderson Cancer Center discusses turning cold tumors into hot tumors using agents that address immune therapy resistance. Some of the emerging targets for this type of therapies are intratumoral injection with TLR-9 agonist or sting agonist that are currently explored in combination with checkpoint inhibitors in melanoma . There are also new studies exploring the same combinations in lung cancer.
Anne S. Tsao, MD of MD Anderson Cancer Center discusses mesothelioma trends in 2018 with PrECOG and Ipi Nivo v chemo. For mesothelioma, the most interesting area is on the front-line chemotherapy and immunotherapy combinations. In the United States, theres the PrECOG Trial and the Bristol-Myers Squibb and its response to trial of Ipi Nivo versus chemo. These are more interesting to see as they are all randomized trials and it’s challenging as there is a need for huge number of patients. However, in 2018, a preliminary readout will be made for these. So, stay updated!
Charles Rudin, MD, PhD of Memorial Sloan Kettering Cancer Center discusses small-cell lung cancer new approaches using immunotherapy. Small-cell lung cancer represents about 15% of all lung cancers and is a very difficult disease with historically poor outcome. There are newer approaches being used for small-cell lung cancer and the large interest is on immunotherapy, especially with drugs like nivolumab and ipilimumab that show significant activity during initial studies. For the initial Phase III, looking at chemotherapy with or without the CTLA-4 inhibitor, ipilimumab, was negative suggesting that the drug doesnt synergize well with chemotherapy. However, the data for nivolumab…
Beth Eaby-Sandy, MSN, CRNP of University of Pennsylvania explains that in patient conversations with loved ones, it’s the best to always engage with patient first and foremost. Doctors loyalty to their patients is very important. If the patient brings a family member or a significant other with them during the consultation or the discussion with the patient, it is really a great thing. However, doctors should not focus their attention to the other person, but to the patient. After all, its a patient-doctor or patient-nurse relationship and conversation. So, if the significant other or the companion ask questions to the…
Vassiliki Papadimitrakopoulou, MD of MD Anderson Cancer Center discusses NSCLC checkpoint inhibitors with the combinations of Epacadostat and IL-2 and IL-10. There has been a number of emerging signals with combination therapy over last year after exposure to first-line immune checkpoint inhibitors. Among the most significant data are in the combination of Epacadostat and IDO inhibitor with checkpoint inhibitors and the combinations of cytokine such as IL-2 and IL-10 with checkpoint inhibitors.
Anne S. Tsao, MD of MD Anderson Cancer Center discusses the new salvage guidelines for mesothelioma, including pembrolizumab & ipilimumab nivolumab. There are a lot of ongoing immunotherapy trials for mesothelioma. Whats clear and definite right now is, tremelimumab by itself is not a good regimen to be given to patents. However, for all the checkpoint inhibitors that were given, nivolumab by itself or pembrolizumab by itself have a 20% response rate in the salvage setting. In addition, based on the MAPS-2 Trial presented at ASCO this year, a 25% response rate is demonstrated in the salvage setting. Hence, the…
Charles Rudin, MD, PhD of Memorial Sloan Kettering Cancer Center discusses Rovalpituzumab Tesirine (Rova-T) a DLL3 target in SCLC. According to Dr. Rudin, Rova-T is an antibody drug conjugate that is directed to a cell surface target on small-cell lung cancer called DLL3. The drug directs attacks into the small-cell lung cancer cells, internalizes those molecules and releases the toxin inside the cell.Initial Phase I of the study has already been completed which focus on small-cell lung cancer patients. Results show that 1/3 of patients are having an objective response to the drug. This will be a new biomarker and…
Vassiliki Papadimitrakopoulou, MD of MD Anderson Cancer Center discusses checkpoint inhibitors as first line therapy, pembrolizumab alone and in combination with other checkpoint inhibitors. There are a number of clinical trials exploring the areas of using checkpoint inhibitors as first-line therapy for non-small-cell lung cancer. Pembrolizumab has been approved for patients with expression of 50% or more PD-L1 in their tumor. In addition, there is a preliminary data and accelerated approval from FDA for the combination of pembrolizumab with chemotherapy based on progression-free survival and overall response rate compared to standard chemotherapy. With that advancement, there are a number of…
Beth Eaby-Sandy, MSN, CRNP of University of Pennsylvania discusses patient conversation management and the “I hope but I worry” phrase. This phrase is universally used. Doctors or clinicians can use this phrase in order to be very open to patients at the same time set their expectations on what is the reality of their disease. This is not a phrase for serious illness conversation, but can be used every day with the patients. With the I hope phrase, doctors can align with the patient, especially on the treatment process. The I worry phrase refers to what is realistically going on…
Dr. Anne S. Tsao, MD of MD Anderson Cancer Center discusses about their study of LUME-MESO Trial for mesothelioma treatment. In this study, they use antiandrogenics in the front-line setting with the combination of Cisplatin, Pemetrexed and Nintedanib. This two-phase trial was presented at ASCO this year. Results showed an overwhelming superior progression-free survival (PFS) with the combination of Cisplatin, Pemetrexed and Nintedanib given for six cycles, followed by Nintedanib Maintenance Therapy. In the randomized Phase II of the trial, the demonstrated PFS had a median hazard ratio of around 0.57, which was statistically significant. Currently, there is an ongoing…
Charles Rudin, MD, PhD of Memorial Sloan Kettering Cancer Center discusses Osimertinib, its real world toxicity issues and comparison with 1st generation TKIs. Osimertinib has less toxicity than the first generation EGFR TKIs. From the FLAURA study, numerical data suggests similar toxicity profile, with both rash and diarrhea being significant component. Gastrointestinal (GI) toxicity is a problem with persistent diarrhea, but the skin toxicity is substantially less.
Beth Eaby-Sandy, MSN, CRNP of University of Pennsylvania discusses barriers to patient communication advertising, clinical jargon, and encouraging hopeful messages, especially on lung cancer patients. As clinicians, it is very important set the expectations of the patients first hand. This is because some patients, when they go to the doctors or an institution, they might think that their disease will surely be cured or be gone, which, in most lung cancer cases is not true. In addition, Dr. Eaby-Sandy stresses on the importance of good communication. It is very important to simplify the information, in a way that patients can…
Vassiliki Papadimitrakopoulou, MD of MD Anderson Cancer Center discusses the 2018 significant NSCLC trials including EMPOWER, KEYNOTE-189, & MYSTIC. This year will be very significant for clarification of the landscaping front-line therapy on non-small-cell lung cancer (NSCLC) with a number of trials and studies being mentioned. It is highly anticipated to see final and definitive results about the combination of checkpoint inhibitors in the front-line and the combination of checkpoint inhibitors and chemotherapy in order to solidify the existing data of these combinations.
Anne S. Tsao, MD of MD Anderson Cancer Center discusses IFCT MAPS trial, the PFS and overall benefit in front-line mesothelioma. There are a lot of trials looking into the combination of immunotherapy and chemo. However, this can only be done on clinical trial because its not yet known which among the patients will respond and whether or not this combination has any survival benefit. As of today, the only triplet combination data available is on the IFCT MAPS Trial, which is on the combination of bevacizumab with cisplatin and pemetrexed for six cycles of therapy, followed by the bevacizumab…
Charles Rudin, MD, PhD of Memorial Sloan Kettering Cancer Center talks about using Osimertinib in first line and possible shift to old practice afterwards. Osimertinib with positive data in the first line setting is very promising. Although FDA approval for Osimertinib is still pending, doctors can shift now to using it in the front-line setting based on the NCCN guidelines. This is already been adapted and according to available data, Osimertinib is a superior drug. So, the question now would be on what to use in the second and third line setting. Dr. Rudin said that patients might end up…
Advanced Forms of MPNs are Associated with Chromosomal Abnormalities Involved in Disease Progression
Joshua Bauml, MD of the University of Pennsylvania discusses thoracic oncology in 2018 and the importance of finding better biomarkers. Finding better biomarkers help in predicting responses to immunotherapy. What is used currently is PD-L1 which is a very imperfect biomarker. According to Dr. Bauml, even for patients who have high expressions in the non-small-cell lung cancer population, the response rate to pembrolizumab is only about 50%. This percentage is way far from the 80 or 90% that is usually seen in targeted therapy. And, as the combination immunotherapy is be incorporated moving forward, it is essential that, if additional…
Jessica S. Donington, MD of NYU Langone Health discusses pre-operative questions for NSCLC patient treatment. Determining resectable patients from a non-resectable patient is a surgeon-dependent thing. Only the surgeon can tell that a patient who is not clearly infiltrative with the disease is not a surgical candidate. There is also a discussion about what to do with pneumonectomy patients, about five to seven patients. Pneumonectomy is a challenging, dangerous after induction therapy and these patients are treated differently. They dont seem to be quite as bad and the morbidity and mortality issues in patients who get pre-operative chemotherapy, compared to…
Joshua Bauml, MD of the University of Pennsylvania discusses Osimertinib versus Erlotinib or Gefitinib in the FLAURA Trial. Osimertinib did very well in the FLAURA study for those patients with T790M mutation after progression on the first or second generation Tyrosine-kinase inhibitor (TKI). In the FLAURA study, Osimertinib is compared with either erlotinib or gefinitib and what transpired was a marked prolongation of the progression-free survival and these curves separated very early. Another most interesting thing is the trend, although not very statistically significant, but it seems there is an improvement in the overall survival, as well. Resistance mutations to…
Jessica S. Donington, MD of NYU Langone Health talks about the IASLC Lung Cancer Staging Project and why some factors are not included. Whats coming next and what arent certain other factors in play? There are a lot of factors like number of lymph nodes involved rather than lymph node location. Looking into things like lymphovascular invasion, lymphoro evasion, why they werent able to made it in the staging system? With the staging system and how it worked, it doesn’t only work for patients who have been resected and have pathological staging, but it also has to worked in clinical…
Joshua Bauml, MD of the University of Pennsylvania discusses the next generation sequencing assays that will allow more targeting in specific patients. A lot is known of targeted therapies for EGFR, ALK even ROS1. However, with the next generation sequencing assays, smaller and smaller groups of patients with molecularly distinct form of lung cancer can be identified. These groups of patients may respond better to targeted therapies rather than chemo. One of the most common genetic operations not thought of for lung cancer is BRAF. It is known the the BRAF V600E mutation can occur to patient population with lung…
Jessica S. Donington, MD of NYU Langone Health discusses IASLC lung cancer staging project, important changes and complexities. There are big changes involved, including further delineation of the T-stage by tumor size with cut-offs at 1, 2, 3, 4, 5 and 7 cm. More tumor size does matter in terms of the prognosis, and fortunately, the end stage didnt change at all. However, there are three additional M-stages: M1a (Interthoracic Metastatic Spread); M1b (Oligo Metastatic Spread) and M1c (Multiple Sites). Dr. Donington believes that some of these changes will translate into different treatment options. As for the complexities in the…
Joshua Bauml, MD of the University of Pennsylvania discusses MET Exon 14 Skipping Mutations and Crizotinib. This is an important genetic operation. These mutations ensure less degradation of MET on the cell surface. With this, they will have more activity. Now, crizotinib, which is already FDA approved and we know as an ALK inhibitor is actually a MET inhibitor. MET inhibition with crizotonib and cabozantinib has been found to have significant activity. MET Exon 14 Skipping mutations can be seen in two populations older adenocarcinoma patients (never or light smokers) and those with pleomorphic carcinoma or sarcomatoid carcinoma. The latter…
Jessica S. Donington, MD of NYU Langone Health discusses the changes in stage 3A NSCLC using immunotherapy in resectable patients. The immune checkpoint inhibitors have completely changed Stage 4 treatment, now going to Stage 3. For the first trial, they use immunotherapy in Stage 3 for unresectable patients. How about the surgically resectable patients? There are ongoing trials that look at immune checkpoint inhibitors in resectable Stage 3. Most of those are using those inhibitors in pre-operative setting. Looking from this setting is very important because tumor cells can be resected and checked what really happened. More trials are made…
Joshua Bauml, MD of the University of Pennsylvania discusses immunotherapy in lung cancer and the 15-20 percent response rate of unselected patients. Immunotherapy has completely changed the treatment landscape for non-small-cell lung cancer patients. However, not everyone responds well to this therapy. From the trend of the curve, in five years, there is around 15 or 20% progression free survival, which is very interesting. Unfortunately, for unselected patient population, there is only 15-20% response rate. This means it is important to identify better biomarkers to accurately predict the response to these agents.
Jessica S. Donington, MD of NYU Langone Health discusses the surgical dilemmas in the management of locally advanced NSCLC. Dr. Donington cites question related to 3A diseases like Should surgery be used at all? What kind of induction or timing? and more questions on immunotherapy for 3A. For resectable 3A disease, there is a strong evidence that patients who undergo lobectomy for their cancer, the use of induction therapy plus surgery still provide patients the better chance for cure. This change fairly dramatically for patients who might need extended resections by lobectomy, pneumonectomy and the like. The surgical short-term outcome…
Joshua Bauml, MD of the University of Pennsylvania discusses the fact that HER2 is over expressed in 60 percent of NSCLC. HER2 is another genetic operation considered in lung cancer. Many think of HER2 in breast cancer where drugs like trastuzumab and lapatinib have a clear role. However, HER2 is found to be over expressed in nearly 60% of non-small-cell lung cancer and mutated in the subgroup. HER2 mutated patients are non-smokers and predominantly female. Whats interesting is that, not all targeted therapies work in this disease. As an evidence, there was a randomized study with the addition of trastuzumab…
Corey J. Langer, MD, FACP of the University of Pennsylvania discusses how T790M testing is practically standard for EGFR activating patients. Recently FDA has recognized whats supposedly become standard clinical practice, at least in the world of patients with EGFR activating mutations. For two years, since early 2016, T790 testing is routinely obtained on tissue or tissues not available on blood specimen. Based on the results on individuals whose disease have progressed on front-line TKIs, either erlotinib gefitinib or afatinib, if T790 is detected, physicians are routinely been switching to osimertinib, which is better tolerated agent. For those patients who…