KSMO: APAC NGS barriers, supportive care trials, ALK inhibitors, cancer vaccines & more

It's Day 2, and I'm rapidly running out of pages in my notebook. That's partly because of my terribly inefficient (some say illegible) handwriting, but also because there have just been so many interesting data points, conclusions, observations and discussions that my pen has been scribbling away virtually non-stop.

I'm not even going to attempt to go into too much detail on any given topic in this post, as it would simply take up too much space, but will just list out a bunch of things that caught my attention, starting where I left off yesterday (which was technically still Day 1, but anyway...). I will likely delve deeper into some of these points in future posts.

• The Philippines is made up of over 7,000 islands, but most of the comprehensive cancer centres are concentrated in the national capital region. That means that some patients need to travel for hours or even days to get treated. People have literally been building bridges to address this, but natural disasters keep on destroying them.

• One of the barriers to NGS testing from a patient perspective in Thailand is that patients are worried about germline mutations being identified, in which case their family would need to get tested too. Fear of genetic discrimination is also prevalent. Genetic counselling, sometimes remote, has been used to help increase NGS uptake

• While NGS is not reimbursed in China, the price is low, at around USD 50 for a CGP when performed in-house. Hence, it is usually not a problem from an affordability perspective, unlike in most of the rest of the region

• In Singapore, the most challenging group (from an NGS access perspective) is the lower-middle income cohort: they are not poor enough to qualify for MediFund, but they typically don't have private insurance either, leaving them out of options

• Australia is a massive country, with significant rural vs urban disparities, including when it comes to access to NGS. Teletrials have been started to address this, but they are not the norm, and are often not getting to those who would benefit from them the most

• In Taiwan, there is only very partial reimbursement for CGP (10-30% depending on the cancer), leading to fairly low NGS adoption

• Despite the increase in clinical trials for anti-cancer drugs, the number of new trials for symptom control (i.e. supportive care) remains very low. However, there are some promising new compounds for pain control and cachexia

• The question of whether to go for combination therapy (amivantinib + lazertinib) or TKI monotherapy for first line EGFR+ mNSCLC was brought up in multiple sessions, and led to some interesting debates. The answer also appeared to depend on who was sponsoring each particular session

• EHR analysis shows that >20% of ALK-positive mNSCLC patients die before they receive 2L treatment. I didn't note down where, but I think it was in the US? Furthermore, 50-60% of ALK-positive patients develop brain mets during the course of their disease

• Lunch served at sponsored events at KSMO is fantastic. I was given a bento box with raw tuna, raw salmon, various Korean sides, grilled fish, shrimps, excellent rice, some fruit, miso soup, and beef (I didn't eat the latter, because of this)

• Lorlatinib, which has very high brain penetration (explaining its efficacy in patients with brain mets), can cause increased appetite and hence weight gain. Perhaps GLP-1s have a role to play here, I wonder? Some of our recent - as of yet unpublished - research at Ipsos shows that a significant subset of oncologists are prescribing GLP-1s to their cancer patients

• We're going to be digesting a lot of cancer vaccine trial data in the coming years. There aren't many completed trials to date (especially large ones), but there are a lot of large currently ongoing trials

• Pathological complete response remains low in key perioperative trials in early NSCLC. There is a potential for increased pCR from adding novel targeted agents. This is still experimental, as is a trimodality approach (chemo + radiotherapy + IO)

• Neo-adjuvant therapy for early NSCLC has unique advantages but can risk surgery delay or even cancellation, plus need management of peri-operative immune-related AEs

• Breast cancer diagnoses peak at a much younger age in East Asia than in the West. The biology of breast cancer in those younger patients in East Asia is quite different, and their survival tends to be worse. Therefore, do the ESMO guidelines for early breast cancer make sense in this region? Based on sub-analysis of Asian patients, it turns out they do; in face, patients in Asia may even derive greater benefit from recommended adjuvant treatment than they do in the West

• What about RCC? Yes, ESMO guidelines make a lot of sense here too, but - major caveat - a lot of the drugs approved in the West are not reimbursed in e.g. Korea. Some interesting case studies from Korea were presented, where treatment was not in line with ESMO guidelines due to a lack of reimbursement. One patient in his 40s decided not to have adjuvant pembrolizumab treatment for this reason (couldn't afford it), and recurred after 2 years to mRCC. He was then offered IO treatment again, but again wasn't able to afford it due to lack of reimbursement. He opted for sunitinib, and his thankfully doing well on it

• Speaking of Korea, the ICER per QALY threshold is much lower in Korea than in many other high income countries. As many newly approved drugs are at multiples of this threshold, it is very hard for them to get reimbursed

• ctDNA testing has a lot of promise in solid tumours.. but I'm going to stop here, as I could easily write several more paragraphs on this topic, and I feel that I should perhaps leave this for another day