This study involves patients with EGFR-mutated NSCLC and asymptomatic brain metastases. This is an open-label, randomized study, comparing the continuation of Osimertinib treatment alone to Osimertinib treatment combined with early intervention stereotactic radiosurgery (SRS). The current first line of care for EGFR-mutated NSCLC is administration of Osimertinib, a small molecule that penetrates the blood brain barrier (BBB) well and controls majority, but not all, of the brain metastases. We hypothesize that relatively early intervention with SRS to brain metastases that are still visualized by MRI 2 months-post initiation of Osimertinib treatment, LUNG- will improve long term brain control, cognitive abilities and potentially overall survival. Patients with EGFR-mutated NSCLC and asymptomatic brain metastases will be treated with Osimertinib for 2 months. Brain MRI scans will be collected pre-Osimertinib and 2 months after treatment start. Patients with asymptomatic brain metastases present after 2 months of Osimertinib will be randomized into one of two study arms. Arm A patients will be treated with SRS while continuing Osimertinib, while arm B patients will continue with Osimertinib alone. Patients will be assessed based on brain and whole body progression by RECIST. Patients will also be assessed for CNS-PFS and body-PFS, cognitive function, Quality of life and overall survival status via routine follow-up tests.
Newly diagnosed metastatic NSCLC, not amenable to curative surgery or curative radiotherapy.
Documented EGFR mutation (at any time since the initial diagnosis of NSCLC) known to be sensitive to Osimertinib - These include exon 19 del; L858R (exon 21); G719X (exon 18); L861G (exon 21); S768I (exon 20) and T790M (exon 20) NOTE: Mutation analysis is to be done as per local practice.
An MRI showing brain metastases. At randomization, number of brain lesions is under 20. Patients with over 20 brain lesions at randomization MRI will be suitable for whole brain radiation, and will not be randomized.
Brain metastases are asymptomatic or with minor symptoms (ECOG≤2) at study randomization.
Anti EGFR TKI treatment.
Checkpoint inhibitors immunotherapy for metastatic NSCLC.
Whole brain radiation (WBRT) and/or Stereotactic Radiosurgery (SRS).
Medications or herbal supplements known to be potent inducers of CYP3A4 and are unable to stop use within the recommended wash out period prior to receiving the first dose of Osimertinib.
Parallel
Stereotactic surgery
RadiationAt two month (8 weeks) post Osimertinib start, patients will be randomized into one of the two study arms. Arm A patients will be treated with stereotactic surgery (SRS). In both arms Osimertinib treatment will continue.
Brain control: CNS-PFS
Lesions that did not disappear after two months of Osimertinib treatment will be better controlled with SRS
whole body PFS
Whole body progression will be delayed when Osimertinib is combined with early treatment of SRS
Cognitive function
Patient cognitive function will improve after SRS treatment
Quality of life (QOL)
Patient QOL will improve after SRS treatment
Time to whole brain radiation
Time until whole brain radiation will be given will prolong for patients who receive early SRS treatment
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