Battle of brains.

October 30, 2017. The rapidly changing treatment paradigm of ALK-rearranged non-small cell lung cancer (NSCLC) can make your head spin. A couple of months ago, alectinib ousted crizotinib as the gold standard with published results of the ALEX trial. Now there’s a new show in town that goes by the name lorlatinib, and it boasts better brain control (at least in a lab). It turns out, the record for shortest reigning gold standard is not the title alectinib (read: Roche Pharma) was hoping for...so it’s making a counter-campaign with a secondary analysis of the ALEX trial presented in abstract form at ESMO this fall. Almost half of ALEX-enrollees had brain mets at baseline, and these patients achieved significantly higher rates of intracranial disease control at one year with alectinib versus crizotinib, regardless of whether they did (criz: 50% -> alec: 91%) or did not (criz: 38% -> alec: 80%) receive prior radiation. Interestingly, even those without brain mets at baseline had far higher rates of freedom from developing future brain mets (criz: 68% -> alec: 95%). Despite being a secondary analysis, these are big results. But only time will tell if alectinib can stand up to lorlatinib (or maybe even radiosurgery) to reign supreme as first-line treatment of ALK-rearranged NSCLC brain mets.