The landscape of non-small cell lung cancer (NSCLC) treatment has dramatically evolved with the identification of specific genetic alterations that drive tumor growth. These molecular biomarkers have enabled the development of targeted therapies that significantly improve patient outcomes compared to traditional chemotherapy. This report provides a comprehensive overview of established and emerging biomarkers in NSCLC along with their associated targeted therapies, including both approved drugs and those in development as of April 2025.
Overview of Biomarker Testing in NSCLC
Biomarker testing has become essential in the standard of care for NSCLC patients. Initially focusing on a limited set of genetic alterations, the scope of testing has expanded significantly as new actionable targets have been identified. Currently, routine biomarker testing in NSCLC involves investigating all potentially druggable alterations, with comprehensive genomic profiling of DNA and RNA using next-generation sequencing (NGS) panels allowing near-complete detection of these alterations.
The primary biomarkers routinely tested in NSCLC include EGFR mutations, ALK rearrangements, and ROS1 fusions. However, the diagnostic landscape has significantly expanded to include additional biomarkers such as BRAF mutations, MET alterations, KRAS mutations, NTRK fusions, RET fusions, and ERBB2 (HER2) mutations. Testing modalities vary by biomarker and include real-time PCR, immunohistochemistry (IHC), fluorescence in situ hybridization (FISH), and next-generation sequencing (NGS), with the latter increasingly becoming the preferred comprehensive approach.
Comprehensive Table of NSCLC Biomarkers and Associated Therapies
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Key Biomarkers and Their Targeted Therapies in Detail
EGFR (Epidermal Growth Factor Receptor)
EGFR mutations are present in approximately 15-20% of NSCLC cases, with deletions in exon 19 and the L858R missense mutation in exon 21 accounting for about 90% of all EGFR mutations. These mutations result in constitutive signaling via the PI3K-AKT and RAS-MEK-ERK pathways.
Five EGFR tyrosine kinase inhibitors (TKIs) have received regulatory approval: erlotinib, gefitinib, afatinib, osimertinib, and amivantamab. The first-generation TKIs (erlotinib and gefitinib) were followed by the second-generation afatinib, and later by the third-generation osimertinib, which is particularly effective against the T790M resistance mutation that often emerges during treatment with earlier-generation TKIs. Amivantamab represents a different approach as it’s approved specifically for EGFR exon 20 insertion mutations, which are generally resistant to traditional EGFR TKIs.
ALK (Anaplastic Lymphoma Kinase)
ALK rearrangements were first identified in NSCLC in 2007 and occur in approximately 3-8% of cases1. Since the first ALK-TKI (crizotinib) was developed, patient prognosis has improved considerably, with five TKIs now approved by the FDA.
The development sequence of ALK inhibitors represents the evolution of targeted therapy in NSCLC. Crizotinib was FDA-approved in 2011, followed by ceritinib (2014), alectinib (2015), brigatinib (2017), and lorlatinib (2018)1. Each subsequent generation has shown improved efficacy and ability to overcome resistance mechanisms that develop during treatment with earlier-generation inhibitors.
Clinical trials have consistently shown superior outcomes with ALK TKIs compared to chemotherapy. For instance, in the PROFILE-1014 trial, crizotinib demonstrated a 74% objective response rate (ORR) compared to 45% with platinum-based chemotherapy. More recent trials have shown even better results with newer ALK inhibitors. In the ALEX trial, alectinib showed an ORR of 82.9% versus 75.5% with crizotinib.
Despite these advances, resistance remains a challenge. Approximately 50-60% of patients develop resistance to second-generation ALK TKIs through ALK kinase-domain mutations. The G1202R mutation is particularly problematic, though lorlatinib has shown activity against this resistance mutation. A newer ALK inhibitor in development, XMU-MP-5, is designed to overcome crizotinib resistance mutations, including L1196M and G1202R, and has shown promising results in preclinical studies.
ROS1
ROS1 gene fusions share biological similarities with ALK rearrangements. Crizotinib was the first drug approved for ROS1-positive NSCLC. Despite its efficacy, resistance mutations can develop, including G2032R, D2033N, L1951R, and S1986Y/F.
Newer ROS1 inhibitors such as entrectinib and lorlatinib have been developed to address some of these resistance mechanisms. Entrectinib has the additional benefit of CNS penetration for patients with brain metastases. Repotrectinib is another drug mentioned in the research results, though its development status is not clearly specified.
BRAF V600E
BRAF mutations are reported in 2-8% of NSCLC cases, with approximately 50% being the V600E mutation. The combined therapy of dabrafenib (a BRAF inhibitor) and trametinib (a MEK inhibitor) has been approved for BRAF V600E-mutated NSCLC, based on the success of this combination in melanoma.
Another BRAF/MEK inhibitor combination, encorafenib and binimetinib, is currently being studied in a clinical trial (NCT03915951) for BRAF V600E-mutated NSCLC. BRAF mutations can also emerge as a resistance mechanism to other targeted therapies, such as EGFR TKIs.
Additional Emerging Biomarkers
FGFR Inhibitors
Current Development Status:
- Compound 10: An AI-designed FGFR2/3 inhibitor by Insilico Medicine shows preclinical efficacy against resistance mutations (e.g., FGFR2 V564F, FGFR3 G697C) acquired after treatment with approved FGFR inhibitors like erdafitinib.
- Combination Therapies: Clinical trials are exploring FGFR inhibitors with immune checkpoint blockers (e.g., pembrolizumab) and kinase inhibitors to overcome resistance.
- Next-Gen Inhibitors: Novel agents leveraging nanotechnology for targeted delivery and CRISPR-based FGFR modulation are in early development1.
Active Clinical Trials:
- NCT03915951: Testing encorafenib (BRAF inhibitor) + binimetinib (MEK inhibitor) in BRAF V600E-mutant NSCLC, including cohorts with FGFR aberrations.
- AI-Driven Trials: Insilico Medicine plans to advance Compound 10 into Phase I trials by late 2025.
NRG1 Fusions
Approved Therapy:
- Zenocutuzumab: Received FDA accelerated approval in January 2025 for NRG1 fusion-positive NSCLC and pancreatic adenocarcinoma. In the eNRGy trial, 33% of NSCLC patients achieved durable responses (median duration: 7.4 months) with manageable toxicity.
Ongoing Research:
- Detection Methods: RNA-based sequencing is now the gold standard for identifying NRG1 fusions, improving diagnostic accuracy.
- Expanded Applications: Trials are evaluating zenocutuzumab in other NRG1+ cancers (e.g., breast, colorectal).
KEAP1/NFE2L2 Mutations
Prognostic Impact:
- KEAP1 mutations correlate with resistance to KRAS G12C inhibitors (e.g., sotorasib) and shorter overall survival (6-month OS: <50% vs. 80% in KEAP1-wild-type).
- Co-mutations with STK11 or TP53 worsen outcomes, driving research into metabolic-targeted therapies.
Clinical Trials:
- LungMAP S1900D: Phase II trial comparing TAK228 (mTORC1/2 inhibitor) + docetaxel vs. standard chemotherapy in KEAP1/NFE2L2-mutant lung squamous cell carcinoma (LUSC).
- NCI #10327: Phase I/IB trial combining TAK228 with CB-839 (glutaminase inhibitor) in KEAP1/NFE2L2-mutant NSCLC.
Emerging Strategies:
- Targeting NRF2 pathway activation (via KEAP1 loss) with antioxidants or NRF2 inhibitors.
- Metabolic reprogramming approaches to address KEAP1/STK11-driven vulnerabilities.
Key Trends Shaping Development
- AI and Nanotechnology: Accelerating drug discovery (e.g., Insilico’s Compound 10) and enabling precision delivery systems.
- Basket Trials: Expanding access to targeted therapies for rare biomarkers like NRG1.
- Biomarker-Driven Combinations: Pairing KEAP1/NFE2L2-targeted agents with chemotherapy or metabolic inhibitors to overcome resistance.
For real-time updates on clinical trials, consult the NIH ClinicalTrials.gov database or oncology research networks like LungMAP.
Conclusion
The field of biomarker-targeted therapy in NSCLC has evolved rapidly, with numerous drugs approved and many more in development. This personalized approach has significantly improved outcomes for patients with specific genetic alterations. The emergence of comprehensive genomic profiling through NGS has facilitated the identification of actionable mutations and appropriate therapies.
Despite these advances, challenges remain, including the development of resistance mechanisms, identification of effective therapies for rare mutations, and ensuring access to molecular testing. The ongoing development of novel targeted therapies and strategies to overcome resistance will likely continue to improve outcomes for NSCLC patients.
The future of NSCLC treatment will likely involve increasingly sophisticated molecular profiling, combination targeted therapies to prevent or overcome resistance, and integration with other treatment modalities such as immunotherapy. This comprehensive approach, tailored to each patient’s unique tumor profile, represents the continuing evolution of precision medicine in lung cancer.
Source: Cells 2022; The Lancet Europe 2024; Oncology Review 2025; eCancer 2025.
Incase i have a question my father is negative result for efgr or alk but he is nsclc stage 4 possible he can also take oral meds for that if its still megative in efgr or alk can or only intravenous fluid chemo only?
Thanks for reaching out. If EGFR and ALK are negative, oral targeted therapies specific to those mutations will not be an option. Chemotherapy (IV) and immunotherapy (IV) are standard treatments for stage 4 NSCLC without EGFR or ALK mutations – Immunotherapy drugs such as pembrolizumab (Keytruda), atezolizumab (Tecentriq), nivolumab (Opdivo), and cemiplimab (Libtayo) can be used, either alone or in combination with chemotherapy, depending on specific tumor markers like PD-L1 expression. The exact treatment plan should be personalized based on your father’s overall health, tumor markers, and preferences, so discussing all options with his oncologist is very important. Hope that helps; otherwise, you can reach out directly to us via Facebook Messenger, our team can support you further.