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Molecular profiling and biomarker-targeted therapy are transforming patient care in intrahepatic cholangiocarcinoma (iCCA)1

DNA icon
~50%
of patients
with iCCA
have actionable genomic alterations2-5

FGFR2 fusions are among the most common actionable genomic alterations in iCCA4,6,7

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10% 16%
of patients with iCCA have FGFR2 fusions4,6,7
  • FGFR2 fusions are detectable early in disease progression and are key drivers of tumor growth8,9
  • FGFR2 fusions are detectable early in disease progression and are key
    drivers of tumor growth8,9
  • Molecular profiling is necessary to identify FGFR2 fusions and rearrangements
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NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Recommend molecular testing for patients with unresectable or metastatic cholangiocarcinoma10,*,†,‡

“Given emerging evidence regarding actionable targets for treating cholangiocarcinoma, molecular testing of unresectable and metastatic tumors is recommended.”10

*See the Guidelines online at NCCN.org for the full recommendation.

NCCN makes no warranties of any kind whatsoever regarding their content, use, or application and disclaims any responsibility for their
application or use in any way.

Category 2A: Based upon lower-level evidence, there is uniform NCCN consensus that the intervention is appropriate.

 
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NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Recommend molecular testing for patients with unresectable or metastatic cholangiocarcinoma10,*,†,‡

“Given emerging evidence regarding actionable targets for treating cholangiocarcinoma, molecular testing of unresectable and metastatic tumors is recommended.” 10

*See the Guidelines online at NCCN.org for the full recommendation.

NCCN makes no warranties of any kind whatsoever regarding their content, use, or application and disclaims any responsibility for their
application or use in any way.

Category 2A: Based upon lower-level evidence, there is uniform NCCN consensus that the intervention is appropriate.

Testing for FGFR2 fusions or rearrangements can inform treatment in
iCCA2,11-13

Testing for FGFR2 fusions or rearrangements can inform treatment in iCCA2,11-13

An assay should meet the following criteria to identify FGFR2 fusions or rearrangements:

check mark iconDetects fusions with a wide range of fusion partners (whether known or unknown)
check mark iconSpecifically detects FGFR2 fusions (distinct from FGFR2 mutations)

Not all next-generation sequencing-based (NGS) tests meet these criteria

Be sure to use an NGS test that can detect both known and unknown fusion partners

A high-sensitivity NGS-based assay, such as FoundationOne® CDx, can detect FGFR2 fusions, including those with known or unknown fusion partners.

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In patients with CCA, FGFR2 fusions may have a wide variety of fusion partners, both known (frequently occurring) as well as unknown (rare, or patient-specific fusions), including those unique to a single patient.14
FGFR2 fusions are distinct from FGFR2 mutations.14

FGFR2 Fusion Partners in CCA14

graphic of chart – FGFR2 Partners in CCA graphic of chart – FGFR2 Partners in CCA

N-of-One fusion partners are unique to a single patient

Adapted from Silverman IM, et al. Cancer Discovery. 2021;11:326-339.

 

In patients with CCA, FGFR2 fusions may have a wide variety of fusion partners, both known (frequently occurring) as well as unknown (rare, or patient-specific fusions), including those unique to a single patient.14

FGFR2 fusions are distinct from FGFR2 mutations.14

FGFR2 Fusions in CCA
Graphic of DNA Play Icon
Hear from Dr Milind Javle as he discusses the role molecular profiling plays in identifying actionable genomic alterations in patients with cholangiocarcinoma. Watch the Video >
Identifying FGFR2 Fusions in CCA: Assay Selection
Graphic of DNA through a magnifying glass
Hear from Dr Milind Javle as he discusses important considerations for selecting an assay to identify FGFR2 fusions in patients with cholangiocarcinoma. Watch the Video >

References:

1. Hallinan N, Finn S, Cuffe S, Rafee S, O'Byrne K, Gately K. Targeting the fibroblast growth factor receptor family in cancer. Cancer Treat Rev. 2016;46:51-62. 2. Lowery MA, Ptashkin R, Jordan E, et al. Comprehensive molecular profiling of intrahepatic and extrahepatic cholangiocarcinomas: potential targets for intervention. Clin Cancer Res. 2018;24(17):4154-4161. 3. Sia D, Losic B, Moeini A, et al. Massive parallel sequencing uncovers actionable FGFR2-PPHLN1 fusion and ARAF mutations in intrahepatic cholangiocarcinoma. Nat Commun. 2015;6:6087. 4. Ross JS, Wang K, Gay L, et al. New routes to targeted therapy of intrahepatic cholangiocarcinomas revealed by next-generation sequencing. Oncologist. 2014;19(3):235-242. 5. Chun YS, Javle M. Systemic and adjuvant therapies for intrahepatic cholangiocarcinoma. Cancer Contr. 2017;24(3):1-7. 6. Farshidfar F, Zheng S, Gingras MC, et al. Integrative genomic analysis of cholangiocarcinoma identifies distinct IDH-mutant molecular profiles. Cell Rep. 2017;18(11):2780-2794. 7. Graham RP, Barr Fritcher EG, Pestova E, et al. Fibroblast growth factor receptor 2 translocations in intrahepatic cholangiocarcinoma. Hum Pathol. 2014;45(8):1630-1638. 8. Arai Y, Totoki Y, Hosoda F, et al. Fibroblast growth factor receptor 2 tyrosine kinase fusions define a unique molecular subtype of cholangiocarcinoma. Hepatology. 2014;59(4):1427-1434. 9. Borad MJ, Gores, GJ, Roberts LR. Curr Opin Gastroenterol. 2015;31(3):264-268. 10. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Hepatobiliary Cancers V.5.2021. © National Comprehensive Cancer Network, Inc. 2021. All rights reserved. Accessed September 21, 2021. To view the most recent and complete version of the guideline, go online to NCCN.org. 11. Javle MM, Murugesan K, Shroff RT, et al. J Clin Oncol. 2019;37(15 suppl):4087. 12. Hollebecque A, de Bono JS, Plummer R, et al. Ann Oncol. 2019;30(suppl 1):mdz029. 13. Frampton GM, Fichtenholtz A, Otto GA, et al. Nat Biotechnol. 2013;31(11):1023-1031. 14. Silverman IM, Hollebecque A, Friboulet L, et al. Clinicogenomic Analysis of FGFR2-Rearranged Cholangiocarcinoma Identifies Correlates of Response and Mechanisms of Resistance to Pemigatinib. Cancer Discov. 2021 Feb;11(2):326-339. doi: 10.1158/2159-8290.CD-20-0766. Epub 2020 Nov 20.

INDICATIONS AND USAGE

PEMAZYRE® is indicated for the treatment of adults with previously treated, unresectable locally advanced or metastatic cholangiocarcinoma with a fibroblast growth factor receptor 2 (FGFR2) fusion or other rearrangement as detected by an FDA-approved test.

This indication is approved under accelerated approval based on overall response rate and duration of response. Continued approval for this indication may be contingent upon verification and description of clinical benefit in a confirmatory trial(s).

IMPORTANT SAFETY INFORMATION

Ocular Toxicity

Retinal Pigment Epithelial Detachment (RPED): PEMAZYRE can cause RPED, which may cause symptoms such as blurred vision, visual floaters, or photopsia. Clinical trials of PEMAZYRE did not conduct routine monitoring including optical coherence tomography (OCT) to detect asymptomatic RPED; therefore, the incidence of asymptomatic RPED with PEMAZYRE is unknown.

Among 466 patients who received PEMAZYRE across clinical trials, RPED occurred in 6% of patients, including Grade 3-4 RPED in 0.6%. The median time to first onset of RPED was 62 days. RPED led to dose interruption of PEMAZYRE in 1.7% of patients, and dose reduction and permanent discontinuation in 0.4% and in 0.4% of patients, respectively. RPED resolved or improved to Grade 1 levels in 87.5% of patients who required dosage modification of PEMAZYRE for RPED.

Perform a comprehensive ophthalmological examination including OCT prior to initiation of PEMAZYRE and every 2 months for the first 6 months and every 3 months thereafter during treatment. For onset of visual symptoms, refer patients for ophthalmologic evaluation urgently, with follow-up every 3 weeks until resolution or discontinuation of PEMAZYRE. Modify the dose or permanently discontinue PEMAZYRE as recommended in the prescribing information for PEMAZYRE.

Dry Eye: Among 466 patients who received PEMAZYRE across clinical trials, dry eye occurred in 27% of patients, including Grade 3-4 in 0.6% of patients. Treat patients with ocular demulcents as needed.

Hyperphosphatemia and Soft Tissue Mineralization

PEMAZYRE can cause hyperphosphatemia leading to soft tissue mineralization, cutaneous calcification, calcinosis, and non-uremic calciphylaxis. Increases in phosphate levels are a pharmacodynamic effect of PEMAZYRE. Among 466 patients who received PEMAZYRE across clinical trials, hyperphosphatemia was reported in 92% of patients based on laboratory values above the upper limit of normal. The median time to onset of hyperphosphatemia was 8 days (range 1-169). Phosphate lowering therapy was required in 29% of patients receiving PEMAZYRE.

Monitor for hyperphosphatemia and initiate a low phosphate diet when serum phosphate level is >5.5 mg/dL. For serum phosphate levels >7 mg/dL, initiate phosphate lowering therapy and withhold, reduce the dose, or permanently discontinue PEMAZYRE based on duration and severity of hyperphosphatemia as recommended in the prescribing information.

Embryo-Fetal Toxicity

Based on findings in an animal study and its mechanism of action, PEMAZYRE can cause fetal harm when administered to a pregnant woman. Oral administration of pemigatinib to pregnant rats during the period of organogenesis caused fetal malformations, fetal growth retardation, and embryo-fetal death at maternal exposures lower than the human exposure based on area under the curve (AUC) at the clinical dose of 13.5 mg.

Advise pregnant women of the potential risk to the fetus. Advise female patients of reproductive potential to use effective contraception during treatment with PEMAZYRE and for 1 week after the final dose. Advise males with female partners of reproductive potential to use effective contraception during treatment with PEMAZYRE and for 1 week after the final dose.

Adverse Reactions

Serious adverse reactions occurred in 45% of patients receiving PEMAZYRE. Serious adverse reactions in ≥2% of patients who received PEMAZYRE included abdominal pain, pyrexia, cholangitis, pleural effusion, acute kidney injury, cholangitis infective, failure to thrive, hypercalcemia, hyponatremia, small intestinal obstruction, and urinary tract infection. Fatal adverse reactions occurred in 4.1% of patients, including failure to thrive, bile duct obstruction, cholangitis, sepsis, and pleural effusion.

Permanent discontinuation due to an adverse reaction occurred in 9% of patients who received PEMAZYRE. Adverse reactions requiring permanent discontinuation in ≥1% of patients included intestinal obstruction and acute kidney injury.

Dosage interruptions due to an adverse reaction occurred in 43% of patients who received PEMAZYRE. Adverse reactions requiring dosage interruption in ≥1% of patients included stomatitis, palmar-plantar erythrodysesthesia syndrome, arthralgia, fatigue, abdominal pain, AST increased, asthenia, pyrexia, ALT increased, cholangitis, small intestinal obstruction, alkaline phosphatase increased, diarrhea, hyperbilirubinemia, electrocardiogram QT prolonged, decreased appetite, dehydration, hypercalcemia, hyperphosphatemia, hypophosphatemia, back pain, pain in extremity, syncope, acute kidney injury, onychomadesis, and hypotension.

Dose reductions due to an adverse reaction occurred in 14% of patients who received PEMAZYRE. Adverse reactions requiring dosage reductions in ≥1% of patients who received PEMAZYRE included stomatitis, arthralgia, palmar-plantar erythrodysesthesia syndrome, asthenia, and onychomadesis.

Clinically relevant adverse reactions occurring in ≤10% of patients included fractures (2.1%). In all patients treated with pemigatinib, 1.3% experienced pathologic fractures (which included patients with and without cholangiocarcinoma [N=466]). Soft tissue mineralization, including cutaneous calcification, calcinosis, and non-uremic calciphylaxis associated with hyperphosphatemia were observed with PEMAZYRE treatment.

Within the first 21-day cycle of PEMAZYRE dosing, serum creatinine increased (mean increase of 0.2 mg/dL) and reached steady state by Day 8, and then decreased during the 7 days off therapy. Consider alternative markers of renal function if persistent elevations in serum creatinine are observed.

The most common adverse reactions (incidence ≥20%) were hyperphosphatemia (60%), alopecia (49%), diarrhea (47%), nail toxicity (43%), fatigue (42%), dysgeusia (40%), nausea (40%), constipation (35%), stomatitis (35%), dry eye (35%), dry mouth (34%), decreased appetite (33%), vomiting (27%), arthralgia (25%), abdominal pain (23%), hypophosphatemia (23%), back pain (20%), and dry skin (20%).

Drug Interactions

Avoid concomitant use of strong and moderate CYP3A inhibitors with PEMAZYRE. Reduce the dose of PEMAZYRE if concomitant use with a strong or moderate CYP3A inhibitor cannot be avoided. Avoid concomitant use of strong and moderate CYP3A inducers with PEMAZYRE.

Special Populations

Advise lactating women not to breastfeed during treatment with PEMAZYRE and for 1 week after the final dose.

Reduce the recommended dose of PEMAZYRE for patients with severe renal impairment as described in the prescribing information.

Reduce the recommended dose of PEMAZYRE for patients with severe hepatic impairment as described in the prescribing information.

INDICATIONS AND USAGE

PEMAZYRE® is indicated for the treatment of adults with previously treated, unresectable locally advanced or metastatic cholangiocarcinoma with a fibroblast growth factor receptor 2 (FGFR2) fusion or other rearrangement as detected by an FDA-approved test.

This indication is approved under accelerated approval based on overall response rate and duration of response. Continued approval for this indication may be contingent upon verification and description of clinical benefit in a confirmatory trial(s).