Epidermal growth factor receptor-tyrosine kinase inhibitors, which is the best choice?

For the treatment of epidermal growth factor receptor (EGFR) mutation-positive advanced non-small cell lung cancer (NSCLC), we have typically used an EGFR-tyrosine kinase inhibitor (EGFR-TKI), gefitinib or erlotinib (1-4). In addition, recent clinical trials have revealed the efficacy of afatinib as an irreversible blocker of the ErbB family (5,6). The effect of afatinib on overall survival of patients with EGFR common mutation-positive [exon 19 deletion (del19), exon 21 L858R point mutation (L858R)] lung adenocarcinoma through an analysis of data from two open-label, randomized, phase III trials has been reported (7). Overall survival for EGFR common mutation-positive NSCLC patients treated with afatinib was significantly longer than for those treated with chemotherapy. In particular, overall survival for del19-positive NSCLC patients was apparently longer in the afatinib group than in the chemotherapy group. Since gefitinib or erlotinib was used in the chemotherapy group as an EGFR-TKI, these results lead us to consider which EGFR-TKI is the best choice for EGFR mutation-positive NSCLC as a first-line treatment.