Particularly for EGFR and ALK we have many more agents approved to treat these patients. Some of the newer generation agents have in general more favourable side effect profiles and in general more favourable penetration into the brain system or the CNS penetration. The exact sequence there’s still some debate.
We know that we have more than one agent approved now first line for both EGFR and ALK. We have two agents now first line for ROS1, that’s all very exciting. We have agents that are coming down the pipe and some are approved that can counteract some resistant mechanisms and we have some exciting clinical trials. In the past as a clinician I never paid too much attention to the small phase I trials – twelve patients here, fifteen patients there. But with some of the new technology and the targeted agents you see in these populations response rates of 70-80% and durable response rates even for rare mutations or patients that have been previously treated with other targeted agents.

When a patient gets diagnosed with a targetable cancer, a lung cancer with a driver mutation, the goal is to delay chemotherapy as long as possible. We know for most drivers the immune checkpoint inhibitors probably aren’t as good as chemotherapies but the general consensus is to try to delay chemotherapy as much as possible. We don’t know for sure yet with the EGFR setting what will be the best drug to use first line, we’re waiting in the fall for the FLAURA trial which will shed some light on osimertinib progression free survival in the front line. For the ALK rearrangement patients we’ve seen that alectinib has a very long progression free survival compared with crizotinib in the worldwide study. So I’ll be reviewing that at our talk.