More Options, More Questions: How Pharmacists Are Managing EGFR-Positive Non-Small Cell Lung Cancer

In an interview with Pharmacy Times^®, Shelby Quinn, PharmD, BCOP, oncology clinical pharmacy specialist at Levine Cancer in Charlotte, North Carolina, discussed advancements in the treatment of non-small cell lung cancer (NSCLC), particularly the use of osimertinib (Tagrisso; AstraZeneca Pharmaceuticals LP) in earlier stages, which has revolutionized treatment for metastatic patients. Her insights were presented at the HOPA Annual Meeting 2025 in Portland, Oregon.

Pharmacy Times: From your perspective, what have been the most game-changing developments in the treatment of EGFR-mutant NSCLC over the past few years?

Shelby Quinn, PharmD, BCOP: Honestly, there have been so many recent advancements in this area—hence why it’s been really debated. I think one of the game-changing things more recently has been putting osimertinib in earlier-stage treatment, because that has completely changed the landscape on how we treat patients in the metastatic setting, especially if they’re progressing on osimertinib or have disease recurrence on osimertinib in the early-stage setting.

I think this also is setting a precedent for other oral targeted therapies to start moving their way into the early-stage setting. So not only are we going to see that with EGFR, we’ll start seeing it with ALK and other, you know, targeted therapies. And that’s going to change the landscape for many, many different cancer types.

Pharmacy Times: With osimertinib now being used in adjuvant and metastatic settings, how do you think clinicians should approach sequencing or timing these therapies?

Quinn: So we don’t really know the answer to that, honestly, and so that’s what—in my presentation and with my co-presenters—we’re talking a lot about that. We’ll be presenting the data, but there’s really no right answer anymore. Before, it was very simple: you know, EGFR mutation, metastatic setting, osimertinib most commonly, or another EGFR TKI. Now we have all of these other different combinations—you know, which patients should get what, which regimen—it really, you know, depends. There are a lot of different toxicities, different dosing administrations, and all those things that we have to think about now.

And maybe they have high-risk features, whether it’s brain metastases or TP53 mutation—all those things now play a really important role in how we’re selecting treatments. And it’s a lot of discussion with the patient as well, especially when we talk about toxicity. So, it is not cut and dry. It’s much more complex now—hence why there’s a lot of discussion in this area.

Pharmacy Times: Do you feel current guidelines are keeping pace with the rapidly emerging evidence in EGFR-mutant NSCLC?

Quinn: I do—I feel like the guidelines are great at updating quickly once evidence has been published. But with that being said, they don’t help you—kind of how we already discussed—they don’t help you determine which treatment should be best for which patient. You know, it just lists, “Okay, this is a recommendation, this is a recommendation, this is a recommendation.” Doesn’t tell you how to choose one over the other. So sure, they may be updating, but it’s not necessarily giving you a layout of how you should be treating patients. It’s just more so telling you, “These have been studied, and there’s good data for them,” but it’s really up to you to figure out what’s best for your patient based on their disease and their condition.

So I feel like they do update, but there are still a lot of nuances as a pharmacist in this space and with your healthcare team that you work with to identify the best treatment for them.

Pharmacy Times: With so many new agents and combinations emerging, what areas of comparative data do you feel are most urgently needed to help guide practice?

Quinn: Honestly—kind of how we’ve been talking about sequencing, right? Like a lot of the new drugs, especially—or regimens—especially in the metastatic setting, they’re all compared to OC, which is great because that’s the standard, that’s always best. But now we don’t have them compared to each other. So, what we have to do—which is not unusual in cancer—is we have to do cross-trial analysis, which is not ideal, because you may not have the same type of patients. You know, really, you want to have a head-to-head trial. So that would be ideal.

Do I think that’s going to happen? The answer is no.

Pharmacy Times: Are there any ongoing trials or investigational strategies you’re particularly excited about that could further shift the standard of care?

Quinn: I think there are a lot of new investigative agents coming now in the second-line setting. Again, a lot of them are following osimertinib single agents. So, if a patient’s now getting osimertinib with chemo or amivantamab [Rybrevant; Janssen Biotech, Inc]—amivantamab chemo now—or, you know, those patients aren’t going to be included in that trial. So there’s going to be a lot of differences in how we are thinking about second-line treatments.

I mean, sequencing is something in lung cancer we always have in the back of our mind, because we have—you know, patients with metastatic lung cancer will always progress. So, we always have to be thinking, “Okay, what happens when that happens? What’s next? Do we have other options?” I’ve had patients who have been on 6 or 7 lines of therapy—they blow through their therapy—but we are always in the back of our minds thinking, “Okay, we’re going to recommend this treatment now, but I am thinking if they progress, this is what we would likely do next.”

So it’s just how our mindset is. We always have to be thinking about that—what’s next—especially if it’s something, you know, if they’re in a good state and they are willing and can tolerate therapy. Of course, not everybody’s going to get to that point. Some people may not tolerate their first treatment and say they’re done. A lot of that is patient discussion.

But there are a lot of investigative agents moving, especially in the second-line setting. We’re seeing a lot of antibody-drug conjugates coming into lung cancer, and so that’s kind of the next exciting wave of drugs that we’re seeing.

Pharmacy Times: Can you share some information about HOPA’s CE program you presented on?

Quinn: Myself and my co-presenters are specifically talking about all this new data that has come out that’s changed the landscape for treatment of these EGFR-mutant non-small cell lung cancer patients. So, we’re talking about that early stage setting and the caveats in those trials, and we’ll be linking those to patient cases that we will debate amongst each other on how we may treat the patient based on those caveats.

And then, similarly, in the metastatic setting, we talk about all those trials and critique those trials and then discuss patient cases. And so hopefully by doing that, we can go through and critique these trials, have our audience and other pharmacists’ kind of think through the patients that they see, and be able to go through a case together and see our different perspectives on these treatments.

We’re probably not going to select the same treatment for our patients, and so we’ll be discussing a lot of that, and hopefully that will be really applicable to patients, pharmacists, and other healthcare professionals in practice.