Lung Cancer Treatments in the U.S. and China
Based on 2018 global cancer statistics, lung cancer is the most common cancer in China, accounting for 18.1% of total cancer cases, while in the United States it is ranked second, with a 10.7% incidence rate (Cancer Communications, 2019). Over the last three years, many new anticancer medications have been approved in China, such as afatinib, osimertinib, and alectinib (National Medical Products Administration, 2020). As more treatment options become available, the official cancer guidelines both in the U.S and in China are constantly changing. This article will focus on the differences in treatment guidelines in metastatic non-small cell lung cancer (NSCLC). The guidelines discussed are the National Comprehensive Cancer Network (NCCN) in the United States and Chinese Society of Clinical Oncology (CSCO) in China.
To determine the treatment for lung cancer, it is critical to first know the histologic type of lung cancer. In both countries, histologic typing and biomarker typing are used. Histologic typing tells where the cancer originates. In NSCLC, the three major types are adenocarcinoma, squamous cell lung cancer, and large cell lung cancer. Biomarker testing, on the other hand, reveals the type of mutations in the cancer cells. In adenocarcinoma and large cell lung cancer, biomarker testing recommended by both guidelines include EGFR, ROS1, ALK, and BRAF. PD-L1 testing is recommended in all types of lung cancer in the United States (NCCN, 2020); however, in China, it is recommended only in squamous cell lung cancer (CSCO, 2020).
EGFR, ROS1, ALK and BRAF are all different types of cell proteins. Mutations of these proteins can lead to more rapid formation of cancer cells. A class of drugs called tyrosine kinase inhibitors (TKI) can stop them from sending signals to replicate cancer cells, thus de-accelerating the cancer’s growth (NCCN, 2020). PD-L1 on cancer cells protects cancer cells from being killed by the immune system. Immunotherapy targets immune cells or PD-L1 on cancer cells to boost the immune system to kill cancer cells (Nature Review, 2019).
Overactive EGFR Mutation:
EGFR mutation is a genetic mutation that results in abnormal cell growth. Studies showed that 48% of patients with lung cancer in China have EGFR gene mutation, compared to 23% of patients with EGFR mutation in America (American Journal of Cancer Research, 2015). However, national survey data showed that only 9.6% of NSCLC patients in China were tested for EGFR mutation (Journal of Thoracic Oncology, 2016). The five most preferred medications recommended by U.S. NCCN guidelines are osimertinib, erlotinib, afatinib, gefitinib and dacomitinib (NCCN, 2020). These five medications are all in the market in China and recommended by CSCO as first-line options. Apart from these medications, icotinib was developed in China and approved for metastatic NSCLC as an additional first-line therapy (CSCO, 2020).
First-line treatment options recommended by U.S. NCCN guidelines include alectinib (preferred), brigatinib, ceritinib, and crizotinib. Lorlatinib is recommended as a next-line option in the United States (NCCN, 2020). In China, crizotinib was previously the only TKI approved for the ALK mutation. In 2018, however, alectinib was approved and recommended as first-line therapy and ceritinib is now recommended as a second-line therapy. Lorlatinib and brigatinib are not on the market in China. Anlotinib was developed and approved in 2018 as a third-line therapy for metastatic NSCLC in China (CSCO, 2020; National Medical Products Administration, 2020).
Crizotinib and ceritinib are recommended as first-line therapies in the United States. The next-line therapy is lorlatinib (NCCN, 2020). While in China, crizotinib is the only TKI approved as a first-line treatment for ROS1 rearrangement. The ROS1 inhibitor entrectinib has not been approved in China as of 9/2020. That said, although entrectinib is not on the market in China, it is listed as a first-line therapy option for ROS1 rearrangement by China’s CSCO guidelines (CSCO, 2020; National Medical Products Administration, 2020).
Looking to learn more about different lung cancer treatment options available in China and in the United States? Reach out to RangeLight Health for a personalized second opinion from a top U.S.-based lung cancer specialist today.