Trends of drug licensing in China: From bring-in to go-global

Global medicine R&D has shown a stabilized trend after fleeting prosperity lately. Despite of discouraging whole picture, the role of China in cross-border out-licensing activities of medical therapeutics keeps rising, which started since 2020 and further boosted in 2023. A holistic analysis of drug and technology licensing, involving Chinese enterprises from 2019 to 2023, revealed 807 license-in deals and 401 license-out deals. In-licensing showed a decreasing trend, while out-licensing was the opposite. Increasing ingenuity of Chinese products has led to a shift from an import-oriented to an export-oriented situation, such as antibody-drug-conjugates, and cell/gene therapies. With supportive policies of Chinese government, southeast Asia is becoming an important downstream market for out-licensed drugs. Biotech innovators are emerging as a dominant force with core innovation capacity. China is embracing international collaboration by showing favorable markets and high-level innovative products.

The application of HER2-ADC in future: More than expression

We analyzed the potential of HER2-targeted antibody-drug conjugates (ADCs) in treating NSCLC with activating HER2 mutations. We identified specific mutations, notably G776delinsVC, that are associated with higher therapeutic response rates, suggesting a refined approach for precision treatment. Further validation and exploration are crucial for potential breakthroughs in ADC therapy.

Breaking boundaries: Current progress of anticancer NK cell-based drug development

Natural killer (NK) cell therapy is emerging as a cancer treatment. NK cells are innate cytotoxic lymphocytes that act as first-line responders to kill target cells without prior encounters. NK cells recognize cancer cells, virus-infected cells, and other types of stressed cell through a reservoir of germline-encoded receptors. NK cells are safe for allogeneic applications. Therefore, they are the ideal off-the-shelf cell, which overcome the low efficiency issue caused by the patient-by-patient nature of autologous cell therapy. Unlike T cells, NK cells cannot form a strong immune memory; therefore, they suffer from short in vivo persistence. However, different from T cells, NK cells have a reservoir of innate immune receptors targeting a variety of malignant cells. In addition, they can utilize antibody guidance in target recognition. With suitable engineering, NK cells can function as universal anticancer drugs that are not restricted to HLA and cancer types, which will benefit the large cohort of patients with rare cancer types and patients with no convenient drug targets for precision and personalized medicine. Here, we summarize and discuss the designs of current anticancer NK cell therapies.

CEA-regulated Oncolytic Virus Anticancer Therapy: A Promising Strategy for Rare Solid Tumors

BACKGROUND

Rare solid tumors have attracted much more attention due to the great unmet clinical need, limited treatment options, and poor prognosis. As the most thoroughly studied tumor marker, carcinoembryonic antigen (CEA) can not only overexpress in various common solid tumors but also in several rare solid tumors. Oncolytic virus therapy has achieved excellent anticancer effects in the past decades. Due to the specific high expression of CEA in certain tumor tissues but not in normal tissues, CEA has been applied to improve the tumor specificity of gene expression.

METHODS

The studies of CEA expression in rare solid tumors and CEA-regulated oncolytic virus therapy were reviewed.

RESULTS

We showed the types of rare solid tumors with the overexpression of CEA. Elevated serum CEA levels can indicate the diagnosis, response of surgery or system therapy, distal metastasis, recurrence, and survival. Due to high tumor specificity, CEA-regulated OA therapy has demonstrated a surprising antitumor effect for common CEA-positive tumors in preclinical trials.

CONCLUSION

These data suggested that CEA could be a diagnostic and prognostic biomarker for several rare solid tumors. We proposed the hypothesis that CEA-regulated oncolytic virus therapy could be a promising therapeutic strategy for CEA-positive rare solid tumors.

[Correlation between the efficacy of epidermal growth factor receptor tyrosine kinase inhibitors and EGFR mutations in advanced squamous cell lung cancer]

OBJECTIVE

To investigate the frequency of epidermal growth factor receptor (EGFR) mutations and their correlation with the efficacy of tyrosine kinase inhibitors (EGFR-TKI) in advanced squamous cell lung cancer.

METHODS

This retrospective study enrolled 79 patients with advanced squamous cell lung cancer who received EGFR-TKI at Department of Thoracic Medical Oncology in Peking University Cancer Hospital from June 2004 to June 2011. Among them, 67 patients had tissue and/or plasma EGFR exon 19 and 21 mutation detection in order to make an analysis on the relationship between EGFR mutation and the TKI's effect.

RESULTS

The disease control rate (DCR) was 56% in all the patients. The median progression free survival (mPFS) and median overall survival (mOS) was 3.7 months (95%CI: 2.0 - 5.0) and 11.5 months (95%CI: 6.6 - 14.2), respectively. Of the 67 patients who received EGFR mutation detection, there were 31 patients harboring EGFR-mutation, for whom the DCR was 71% (22/31), and mPFS and mOS was 6.3 months (95%CI: 2.2 - 10.0) and 13.5 months (95%CI: 7.3 - 18.6) respectively. 36 patients' EGFR status were wild type, for whom the DCR was 44% (16/36), mPFS and mOS was 2.2 months (95%CI: 1.1 - 4.0) and 6.4 months (95%CI: 4.0 - 12.0). There were 17 patients who received erlotinib and 7 patients who received gefitinib as second or more line treatment. mPFS and mOS were 7.9 months and 15.8 months in the erlotinib group, respectively; and the mPFS and mOS were both 6.3 months in gefitinib group; the difference between the 2 groups did not reach statistical significance. Cox-regression analysis showed that EGFR mutation was significantly correlated with PFS and OS (P < 0.05, respectively). EGFR mutation was significantly correlated with DCR by Chi-square test, P < 0.05.

CONCLUSIONS

EGFR mutation was a predictor for advanced squamous cell lung cancer to EGFR-TKI. However, the effect was inferior in advanced squamous cell lung cancer as compared to lung adenocarcinoma. Erlotinib tended to be superior to gefitinib.

Identification of Tumor Antigens and Immune Subtypes of Malignant Mesothelioma for mRNA Vaccine Development

BACKGROUND

mRNA-based cancer vaccines have been considered a promising anticancer therapeutic approach against various cancers, yet their efficacy for malignant mesothelioma (MESO) is still not clear. The present study is designed to identify MESO antigens that have the potential for mRNA vaccine development, and to determine the immune subtypes for the selection of suitable patients.

METHODS

A total of 87 MESO datasets were used for the retrieval of RNA sequencing and clinical data from The Cancer Genome Atlas (TCGA) databases. The possible antigens were identified by a survival and a genome analysis. The samples were divided into two immune subtypes by the application of a consensus clustering algorithm. The functional annotation was also carried out by using the DAVID program. Furthermore, the characterization of each immune subtype related to the immune microenvironment was integrated by an immunogenomic analysis. A protein-protein interaction network was established to categorize the hub genes.

RESULTS

The five tumor antigens were identified in MESO. FAM134B, ALDH3A2, SAV1, and RORC were correlated with superior prognoses and the infiltration of antigen-presenting cells (APCs), while FN1 was associated with poor survival and the infiltration of APCs. Two immune subtypes were identified; TM2 exhibited significantly improved survival and was more likely to benefit from vaccination compared with TM1. TM1 was associated with a relatively quiet microenvironment, high tumor mutation burden, and enriched DNA damage repair pathways. The immune checkpoints and immunogenic cell death modulators were also differentially expressed between two subtypes. Finally, FN1 was identified to be the hub gene.

CONCLUSIONS

FAM134B, ALDH3A2, SAV1, RORC, and FN1 are considered as possible and effective mRNA anti-MESO antigens for the development of an mRNA vaccine, and TM2 patients are the most suitable for vaccination.

Development and validation of a drug clinical trial participation feelings questionnaire for cancer patients

OBJECTIVE

The study was designed to develop and validate a new drug clinical trial participation feelings questionnaire (DCTPFQ) for cancer patients.

METHODS

Data collection and analysis involved a combination of qualitative and quantitative methods. There were two phases to this study. Phase Ⅰ involved developing a questionnaire to establish a list of items to be included in the pool: A theoretical framework was constructed based on the transitions theory and the Roper-Logan-Tierney theory. After incorporating a theoretical framework, interviewing participants, and reviewing the literature, 44 items were generated. After a Delphi consultation and a pilot test, 36 items proceeded to item analysis and exploratory factor analysis (EFA), and a four-factor structure with 21 items was formed. Confirmatory factor analysis (CFA), test-retest reliability, criteria-related validity, and internal consistency tests were conducted in phase II to examine the psychometric properties.

RESULTS

There were 21 items on the DCTPFQ, ranging from 1 (fully disagree) through 5 (fully agree). As a result of EFA and CFA, the four factors of DCTPFQ could be verified, including cognitive engagement, subjective experience, medical resources, and relatives and friends' support. Test-retest reliability of the DCTPFQ was 0.840, and Cronbach's alpha was 0.934. DCTPFQ is significantly correlated with the Fear of Progression Questionnaire-short form (r = 0.731, p < 0.05) and the Mishel's Uncertainty in Illness Scale (r = 0.714, p < 0.05).

CONCLUSION

The DCTPFQ is a useful tool for measuring the drug clinical trial participation feelings among cancer patients.

[Effect of pemetrexed plus platinum for chemotherapy-naive advanced non-small cell lung cancer]

OBJECTIVE

To evaluate the effect of pemetrexed plus platinum for chemotherapy-naive advanced non-small cell lung cancer (NSCLC), and to explore thymidylate synthetase (TS) expression as the predictive and prognostic factor for this treatment.

METHODS

This retrospective study enrolled 51 patients with chemotherapy-naive advanced NSCLC (non-squamous) treated at Department of Thoracic Medical Oncology in Beijing Cancer Hospital from Jan 2008 to Oct 2009. All patients received pemetrexed plus platinum as first-line treatment. TS expression was detected in 30 patients who had enough tissue samples by immunohistochemistry.

RESULTS

The objective response rate (ORR) was 37.3%. Median progression-free survival (PFS) was 5.3 months (95%CI: 3.9 - 6.7), and median overall survival (OS) was 19.0 months (95%CI: 11.6 - 26.4). Univariate analysis showed that gender, pathology, smoking status and response were significantly correlated with OS. Cox-regression analysis showed that pathology was an independent prognostic factor. Rate of Grade 3/4 adverse events was low. In 30 patients with enough tissue samples were available, TS expression positive rate was 33.3% (10/30). Chi-square test showed that TS expression was not associated with ORR. Multivariate analysis showed that pathology, response and TS expression (P = 0.003, 0.005 and 0.001, respectively) were the prognostic factors.

CONCLUSION

The therapeutic effect and tolerance of pemetrexed plus platinum regiment were definite as first-line treatment for chemotherapy-naive advanced NSCLC, and TS expression was an independent prognostic factor.

[Prognosis related clinical and molecular factors in malignant pleural mesothelioma]

OBJECTIVE

To identify potential prognosis related clinical and molecular factors in malignant pleural mesothelioma (MPM).

METHODS

Seventy-nine patients with MPM treated in Beijing Cancer Hospital from June 1996 to May 2012 were enrolled in this study. Clinical and pathological data were collected, including age, gender, smoking status, treatment, response, and molecular biomarkers such as thymidylate synthetase (TS) expression, echinoderm microtubule-associated protein-like 4-anaplastic lymphoma kinase (EML4-ALK) gene rearrangement. The primary endpoint was overall survival (OS). SPSS 16.0 statistical analysis software was used for univariate analysis. The expression of TS was detected by immunohistochemistry (IHC). Fluorescence in situ hybridization (FISH) was performed to detect EML4-ALK gene rearrangement. Efficacy of the chemotherapy regimen including pemetrexed was analyzed with these molecular biomarkers.

RESULTS

The median survival time (MST) of all patients was 15.5 months (95% CI: 10.6 - 20.4). Univariate survival analysis revealed that treatment factors including receiving operation, systemic chemotherapy, pemetrexed-based chemotherapy and capability of receiving second (or above) line chemotherapy were significantly related with OS. The MST of patients receiving operation was 5.4 months (95% CI: 3.6 - 7.3), significantly shorter than the 17.7months (95% CI: 11.8 - 23.5) in those who didn't receive operation (P = 0.030). Patients receiving systemic chemotherapy had a longer MST of 18.0 months (95% CI: 12.3 - 23.8) as compared to the 7.9 months (95% CI: 1.1 - 14.7) in those who didn't (P = 0.001). The MST of pemetrexed-based chemotherapy was 21.9 months (95% CI: 14.1-29.7) compared with 8.8 months (95% CI: 4.2 - 13.4) of regimens without pemetrexed (P = 0.000). For patients capable of receiving second (or above) line chemotherapy the MST was longer (21.0 months, 95% CI: 12.7 - 29.3) than those who could not (12.1 month, 95% CI: 6.4 - 17.8 month), P = 0.022. For the 42 patients treated with pemetrexed-based chemotherapy, the objective response rate (ORR) was 33.3% (14/42), the disease control rate (DCR) was 78.6% (33/42), the median progression-free survival (PFS) was 4.8 months (95% CI: 3.6 - 6.0) and MST was 21.9 months (95% CI: 14.1 - 29.7). Twenty-nine patients provided adequate specimens for detection of TS expression and 6 cases (20.7%) were positive. EML4-ALK gene rearrangement was studied in 32 patients and 6 (18.8%) were positive. TS expression was found to be inversely related to PFS of pemetrexed-based chemotherapy (P = 0.041). The MST was 19.6 months (95% CI: 6.0 - 7.9) in EML4-ALK-positive patients and 9.57 months (95% CI: 2.7 - 4.3) in negative ones (P = 0.159).

CONCLUSIONS

Systemic chemotherapy especially pemetrexed-based regimen was proved to be a superior option for MPM with a significantly prolonged OS. Correlation between TS expression or EML4-ALK rearrangement and outcome of pemetrexed-based chemotherapy for MPM may contribute to future individualized treatment, which needs further validation from large-scale prospective studies.

Genetically predicted blood metabolites mediate the association between circulating immune cells and pancreatic cancer: A Mendelian randomization study

BACKGROUND

Pancreatic cancer is characterized by metabolic dysregulation and unique immunological profiles. Nevertheless, the comprehensive understanding of immune and metabolic dysregulation of pancreatic cancer remains unclear. In the present study, we aimed to investigate the causal relationship of circulating immune cells and pancreatic cancer and identify the blood metabolites as potential mediators.

METHODS

The exposure and outcome genome-wide association studies (GWAS) data used in the present study were obtained from the GWAS open-access database (https://gwas.mrcieu.ac.uk). The study used 731 circulating immune cell features, 1400 types of blood metabolites and pancreatic cancer from GWAS. We then performed bidirectional Mendelian randomization (MR) analyses to explore the causal relationships between the circulating immune cells and pancreatic cancer, and two-step MR to discover potential mediating blood metabolites in this process. All statistical analyses were performed in R software. The STROBE-MR (i.e. Strengthening the Reporting of Observational Studies in Epidemiology using Mendelian Randomization) checklist for the reporting of MR studies was also used.

RESULTS

MR analysis identified seven types of circulating immune cells causally associated with pancreatic cancer. Furthermore, there was no strong evidence that genetically predicted pancreatic cancer had an effect on these seven types of circulating immune cells. Further two-step MR analysis found 10 types of blood metabolites were causally associated with pancreatic cancer and the associations between circulating CD39+CD8+ T cells and pancreatic cancer were mediated by blood orotates with proportions of 5.18% (p = 0.016).

CONCLUSIONS

The present study provides evidence supporting the causal relationships between various circulating immune cells, especially CD39+CD8+ T cells, and pancreatic cancer, with a potential effect mediated by blood orotates. Further research is needed on additional risk factors as potential mediators and establish a comprehensive immunity-metabolism network in pancreatic cancer.

Nanoparticle drug delivery system for the treatment of brain tumors: Breaching the blood-brain barrier

The current status of clinical trials utilizing nanoparticle drug delivery system (NDDS) for brain tumors was summarized.Image 1.

Bridging the gap: unlocking the potential of emerging drug therapies for brain metastasis

Brain metastasis remains an unmet clinical need in advanced cancers with an increasing incidence and poor prognosis. The limited response to various treatments is mainly derived from the presence of the substantive barrier, blood-brain barrier (BBB) and brain-tumour barrier (BTB), which hinders the access of potentially effective therapeutics to the metastatic tumour of the brain. Recently, the understanding of the structural and molecular features of the BBB/BTB has led to the development of efficient strategies to enhance BBB/BTB permeability and deliver drugs across the BBB/BTB to elicit the anti-tumour response against brain metastasis. Meanwhile, novel agents capable of penetrating the BBB have rapidly developed and been evaluated in preclinical studies and clinical trials, with both targeted therapies and immunotherapies demonstrating impressive intracranial activity against brain metastasis. In this review, we summarize the recent advances in the biological properties of the BBB/BTB and the emerging strategies for BBB/BTB permeabilization and drug delivery across the BBB/BTB. We also discuss the emerging targeted therapies and immunotherapies against brain metastasis tested in clinical trials. Additionally, we provide our viewpoints on accelerating clinical translation of novel drugs into clinic for patients of brain metastasis. Although still challenging, we expect this review to benefit the future development of novel therapeutics, specifically from a clinical perspective.

Toward a comprehensive solution for treating solid tumors using T-cell receptor therapy: A review

T-cell receptor therapy (TCR-T) has demonstrated efficacy, durability, and safety advantages in certain solid tumors (such as human papillomavirus-related tumors, synovial sarcoma, and melanoma). This study aimed to provide careful considerations for developing TCR-T for solid tumors. Therefore, in this review, we have summarized the current clinical application, advantage of TCR-T modalities and explored efficacy/safety-related parameters, particularly avidity, pharmacokinetics/pharmacodynamics, and indications, for solid tumors. Furthermore, we have investigated critical factors related to avidity, including antigen selection, T-cell receptor acquisition, optimization, and co-receptor engagement. Moreover, we have re-examined the expression of tumor antigens for a potentially higher coverage rate of solid tumors based on the current RNA-seq datasets. Finally, we have discussed the current limitations and future directions of TCR-Ts.

[A review of immune-related adverse events associated with immunotherapy]

Immune checkpoint inhibitors have been approved for clinical application in China. However, the increased immune-related adverse event (irAE) needs more attention. This review summarized the incidence, characteristic clinical manifestation and treatment of irAEs associated with programmed cell death protein-1(PD-1) and programmed cell death ligand-1(PD-L1) inhibitors. To have a deep insight into irAE, the potential mechanisms, the different incidences of cancer types, influencing factors and the direction of future research were also discussed here to provide guidance for clinical oncologist to identify and monitor irAE.

The reliability and integrity of overall survival data based on follow-up records only and potential solutions to the challenges

Overall survival (OS) is considered the standard clinical endpoint to support effectiveness claims in new drug applications globally, particularly for lethal conditions such as cancer. However, the source and reliability of OS in the setting of clinical trials have seldom been doubted and discussed. This study first raised the common issue that data integrity and reliability are doubtful when we collect OS information or other time-to-event endpoints based solely on simple follow-up records by investigators without supporting material, especially since the 2019 COVID-19 pandemic. Then, two rounds of discussions with 30 Chinese experts were held and 12 potential source scenarios of three methods for obtaining the time of death of participants, including death certificate, death record and follow-up record, were sorted out and analysed. With a comprehensive assessment of the 12 scenarios by legitimacy, data reliability, data acquisition efficiency, difficulty of data acquisition, and coverage of participants, both short-term and long-term recommended sources, overall strategies and detailed measures for improving the integrity and reliability of death date are presented. In the short term, we suggest integrated sources such as public security systems made available to drug inspection centres appropriately as soon as possible to strengthen supervision. Death certificates provided by participants' family members and detailed standard follow-up records are recommended to investigators as the two channels of mutual compensation, and the acquisition of supporting materials is encouraged as long as it is not prohibited legally. Moreover, we expect that the sharing of electronic medical records and the legal disclosure of death records in established health registries can be realized with the joint efforts of the whole industry in the long-term. The above proposed solutions are mainly based on the context of China and can also provide reference for other countries in the world.

[Clinical and chest CT features of immune checkpoint inhibitor-related pneumonitis]

Objective: To explore the clinical and chest computed tomography (CT) features and the outcome of immune checkpoint inhibitor-related pneumonitis (CIP). Methods: Clinical and chest CT data of 38 CIP patients with malignant tumors from the Cancer Hospital, Chinese Academy of Medical Sciences between August 2017 and April 2021 were retrospectively reviewed, and the outcomes of pneumonitis were followed up. Results: The median time from the administration of immune checkpoint inhibitors (ICIs) to the onset of CIP was 72.5 days in 38 patients with CIP, and 22 patients developed CIP within 3 months after the administration of ICIs. The median occurrence time of CIP in 24 lung cancer patients was 54.5 days, earlier than 119.0 days of non-lung cancer patients (P=0.138), with no significant statistical difference. 34 patients (89.5%) were accompanied by symptoms when CIP occurred. The common clinical symptoms were cough (29 cases) and dyspnea (27 cases). The distribution of CIP on chest CT was asymmetric in 31 cases and symmetrical in 7 cases. Among the 24 lung cancer patients, inflammation was mainly distributed ipsilateral to the primary lung cancer site in 16 cases and diffusely distributed throughout the lung in 8 cases. Ground glass opacities (37 cases) and consolidation (30 cases) were the common imaging manifestations, and organizing pneumonia (OP) pattern (15 cases) was the most common pattern. In 30 CIP patients who were followed up for longer than one month, 17 cases had complete absorption (complete absorption group), and 13 cases had partial absorption or kept stable (incomplete absorption group). The median occurrence time of CIP in the complete absorption group was 55 days, shorter than 128 days of the incomplete absorption group (P=0.022). Compared with the incomplete absorption group, there were less consolidation(P=0.010) and CIP were all classified as hypersensitivity pneumonitis (HP) pattern (P=0.004) in the complete absorption group. Conclusions: CIP often occurs within 3 months after ICIs treatment, and the clinical and CT findings are lack of specificity. Radiologic features may have a profound value in predicting the outcome of CIP.

Predictive value of longitudinal systemic inflammatory markers for pathologic response to neoadjuvant PD-1 blockade in resectable non-small cell lung cancer

BACKGROUND

Identifying biomarkers to predict responses for neoadjuvant immunotherapy in resectable non-small cell lung cancer (NSCLC) is under intensive study. Considering the interplay between cancer, inflammation, and immunosuppression, we hypothesized that circulating and imaging inflammatory markers could serve as indicators of anti-tumor immune responses, and thus conducting an exploratory study to reveal the predictive value of combining longitudinal systemic inflammatory markers in stratifying pathologic response to neoadjuvant sintilimab.

METHODS

We retrospectively reviewed 36 patients (29 male and seven female) with NSCLC (stage IA-IIIB) who underwent pre- and post-treatment peripheral blood tests and 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) scans before and after two cycles of neoadjuvant sintilimab (registration number: ChiCTR-OIC-17013726). The neutrophil-to-lymphocyte ratio (NLR), immune-related adverse events (irAEs) on imaging, and lymphoid organ metabolism [spleen-to-liver ratio (SLR) and bone marrow-to-liver ratio (BLR)] were evaluated to examine their predictive value for the major pathologic response (MPR). Significant variables were used to classify patients into low, intermediate, and high inflammatory burden groups for stratifying pathologic regression and tumor-infiltrating immune cells abundance in the tumor microenvironment. Spearman's correlation analysis was performed to explore the correlation between systemic inflammatory markers, primary tumor metabolism, and tumor-infiltrating immune cells abundance at various time points.

RESULTS

Of the 36 enrolled patients, 13 (36.1%) exhibited MPR. ΔNLR% was a significant negative predictor of MPR (P=0.047) and negatively correlated with pathologic regression (r=-0.34, P=0.045). Pre- and post-treatment SLRs were potential negative predictors of MPR (P=0.06; P=0.055) and negatively correlated with pathologic regression (r=-0.30, P=0.07; r=-0.31, P=0.06). The high inflammatory burden group (pre-treatment SLR >0.83 and ΔNLR% >-17%) had the lowest pathologic regression (P=0.01) and the highest infiltration abundance of pre-treatment CD68+ macrophage (P=0.01-0.04). irAEs on imaging did not have significant effects on MPR and pathologic regression in overall and per-organ analyses.

CONCLUSIONS

The combination of pre-treatment SLR and ΔNLR% demonstrates predictive value in stratifying pathologic response to neoadjuvant immunotherapy in resectable NSCLC. The high inflammatory burden group had the lowest pathologic regression and the pre-treatment immunosuppressive microenvironment with macrophage enrichment.