ALK-Positive Lung Cancer Treatment Options

If you've just been diagnosed with ALK-positive lung cancer, of course the first thing you could ask is: what is the stage of your cancer?

If it's an early stage, you're going for cure, usually with surgery or radiation. But that ALK positivity can still influence the choice of chemotherapy that might be added in either before surgery or after surgery or during radiation, because ALK-positive lung cancer is particularly sensitive to one type of chemotherapy called pemetrexed-based chemotherapy. So it influences decisions even in the early stage.

Most of its fame comes, however, from influencing treatment in the stage IV setting when you have metastatic disease. Because now, instead of going to chemotherapy as your initial treatment, you're going to go to pills, ALK inhibitors, which tend to be orally delivered pills.

There's a couple of ones that are really good in the first-line setting. One is called alectinib; the other is called brigatinib. They have very similar efficacy. They differ somewhat in terms of their side effects. They differ somewhat in terms of how many pills you have to take. And they will control your disease, on average, for several years.

However, the cancer will evolve and eventually start to grow. If it does, sometimes it's only a single site of disease growing, in which case you can zap it with radiotherapy and stay on the same pill.

Sometimes, however, that's not feasible and you might want to know how has the cancer evolved. You can either just go on to another ALK inhibitor, hoping ALK is still driving the cancer, or you can actually re-biopsy it and prove that.

If you find an ALK mutation, then a next-generation ALK inhibitor after the one you've already been on might be the right idea.

If you don't, it doesn't mean you won't respond, but it reduces the chances. What it actually increases the chances of is that you have a second driver, something other than ALK driving your cancer. We're still trying to figure out what those are, but sometimes you can add in another pill and get the cancer back under control.

And if all of that fails, you go back to that pemetrexed-based chemotherapy.