Autori
Ossato Andrea, Damuzzo Vera, Del Bono Luna, Gasperoni Lorenzo, Lupi Tiziano, Colicchio Arianna, Gori Stefania, Inno Alessandro

Rivista
Translational Lung Cancer Research (TLCR)

Topic
Confronti Indiretti di Efficacia

Impact Factor
3,5

Abstract

In metastatic ALK-positive non-small cell lung cancer (mNSCLC), ALK tyrosine kinase inhibitors (ALKi) represent the established standard of care. While second- and third-generation ALKi (including alectinib, brigatinib, ensartinib, envonalkib, and lorlatinib) have demonstrated superior efficacy compared with the first-generation inhibitor crizotinib in randomized trials, the absence of direct head-to-head comparisons limits the definition of their relative clinical benefit. We performed an updated indirect comparison of next-generation ALKi using data from pivotal randomized controlled trials. Seven first-line trials in ALK-positive mNSCLC were identified, and individual patient data were reconstructed from published Kaplan-Meier curves to estimate treatment effects using Cox proportional hazards models and restricted mean survival time (RMST) analyses, with crizotinib as a common comparator. All next-generation ALKi demonstrated significant progression-free survival (PFS) benefit versus crizotinib. In indirect comparisons, lorlatinib showed superior PFS compared with alectinib [hazard ratio (HR) 0.61; 95% confidence interval (CI): 0.43-0.85], brigatinib (HR 0.48; 95% CI: 0.33-0.71), ensartinib (HR 0.60; 95% CI: 0.40-0.90), and envonalkib (HR 0.42; 95% CI: 0.28-0.62). RMST analyses indicated increasing separation between lorlatinib and alectinib over time, suggesting a more sustained PFS benefit with lorlatinib. Among patients with baseline brain metastases (BMs), lorlatinib showed the strongest PFS effect compared with alectinib, brigatinib, ensartinib, and envonalkib. For overall survival (OS), alectinib demonstrated a statistically significant benefit versus crizotinib, while no significant differences were observed among next-generation ALKi. This indirect comparison indicates that lorlatinib provides the most durable PFS and the strongest intracranial disease control, although ALKis are characterized by distinct toxicity profiles. In the absence of clear OS differences at present, first-line treatment selection should integrate efficacy, intracranial activity, tolerability, and emerging molecular features within a personalized therapeutic framework.

Link PubMed del paper: https://pubmed.ncbi.nlm.nih.gov/42291358/