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LETTER TO THE EDITOR
Year : 2017  |  Volume : 54  |  Issue : 1  |  Page : 186-187
 

Practical solutions to epidermal growth factor receptor tyrosine kinase inhibitor dose modifications in resource-constrained settings: Thinking outside the (packaging) box


Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication1-Dec-2017

Correspondence Address:
Dr. N Singh
Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.219576

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How to cite this article:
Singh N, Prasad K T. Practical solutions to epidermal growth factor receptor tyrosine kinase inhibitor dose modifications in resource-constrained settings: Thinking outside the (packaging) box. Indian J Cancer 2017;54:186-7

How to cite this URL:
Singh N, Prasad K T. Practical solutions to epidermal growth factor receptor tyrosine kinase inhibitor dose modifications in resource-constrained settings: Thinking outside the (packaging) box. Indian J Cancer [serial online] 2017 [cited 2020 Mar 29];54:186-7. Available from: http://www.indianjcancer.com/text.asp?2017/54/1/186/219576


Sir,

The current era of precision medicine is characterized by an increasing use of sensitive techniques such as real-time polymerase chain reaction (PCR)/amplification refractory mutation system PCR and of ultra-sensitive techniques such as next-generation sequencing (NGS) to detect sensitizing mutations in the epidermal growth factor receptor (EGFR) gene, which are predictive of clinic benefit from EGFR tyrosine kinase inhibitors (TKIs).[1] Consequently, an increasing number of advanced/metastatic nonsmall cell lung cancer (NSCLC) patients are being initiated on EGFR-TKIs in the first-line setting.[2],[3] In addition for patients with relapsed or refractory disease and unknown EGFR mutation status who are not candidates for second-line chemotherapy due to suboptimal performance tissue and pending availability of/affordability for programmed death-1 (PD-1)/programmed death ligand-1 (PDL-1) immune checkpoint inhibitors, EGFR-TKIs continue to be useful treatment options in the second-/third-line setting as well.[4] An expert consensus opinion by medical oncologists on the management of EGFR-TKI-related dermatological toxicity and diarrhea – the two most common types of adverse effects from this class of drugs – is therefore welcome.[5] We were however intrigued that this consensus opinion carried no mention about the Multinational Association for Supportive Care in Cancer (MASCC)'s EGFR Inhibitor Skin Toxicity Tool © or of the Clinical Practice Guidelines published 5 years ago by MASCC's multinational interdisciplinary Skin Toxicity Study Group (that included dermatologists) both of which are freely accessible (http://www.mascc.org/skin-toxicities).[6]

One of the things that need to be considered while contemplating dose modification is the EGFR-TKI drug being used. Unlike afatinib and erlotinib for whom several dose strength preparations may be available (20, 30, 40, 50 mg in case of afatinib and 25, 100, 150 mg in case of erlotinib), gefitinib typically has a uniform dose strength (250 mg) preparation available. Moreover, the packing strength (minimum number of tablets that are bought by a patient) also varies from seven to as high as thirty. In such cases, either if the patient is immediately not able to afford buying another dosing strength or if the next recommended dosing strength is not available, one could consider using alternate options as shown in [Table 1]. Practicing personalized therapy in emerging economies is challenging and the same is applicable to the use of EGFR-TKI therapy in advanced/metastatic NSCLC also.[7] As we continue to be move forward with medical diagnostic and therapeutic advances, patient and system resource limitations encountered in routine clinical practice often compel us to think outside the (packaging) box and develop innovative solutions.
Table 1: Suggested dose modification schedules with any given dose strength formulation of an epidermal growth factor receptor-tyrosine kinase inhibitor

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Financial support and sponsorship

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Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Singh N, Bal A, Aggarwal AN, Das A, Behera D. Clinical outcomes in non-small-cell lung cancer in relation to expression of predictive and prognostic biomarkers. Future Oncol 2010;6:741-67.  Back to cited text no. 1
[PUBMED]    
2.
Maturu VN, Singh N, Bal A, Gupta N, Das A, Behera D. Relationship of epidermal growth factor receptor activating mutations with histologic subtyping according to International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society 2011 adenocarcinoma classification and their impact on overall survival. Lung India 2016;33:257-66.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Singh N, Vishwanath G, Aggarwal AN, Behera D. Clinical experience on use of oral EGFR-TKIs as first-line treatment of advanced NSCLC from a tertiary care centre in North India and implications of skin rash. Indian J Chest Dis Allied Sci 2014;56:149-52.  Back to cited text no. 3
[PUBMED]    
4.
Singh N, Aggarwal AN. Gefitinib plus docetaxel in non-small-cell lung cancer. Lancet 2009;373:541-2.  Back to cited text no. 4
    
5.
Parikh P, Prabhash K, Naik R, Vaid AK, Goswami C, Rajappa S, et al. Practical recommendation for rash and diarrhea management in Indian patients treated with tyrosine kinase inhibitors for the treatment of non-small cell lung cancer. Indian J Cancer 2016;53:87-91.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Lacouture ME, Anadkat MJ, Bensadoun RJ, Bryce J, Chan A, Epstein JB, et al. Clinical practice guidelines for the prevention and treatment of EGFR inhibitor-associated dermatologic toxicities. Support Care Cancer 2011;19:1079-95.  Back to cited text no. 6
[PUBMED]    
7.
Singh N, Aggarwal AN, Behera D. Management of advanced lung cancer in resource-constrained settings: A perspective from India. Expert Rev Anticancer Ther 2012;12:1479-95.  Back to cited text no. 7
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