Association of Performance Status With Survival in Patients With Advanced Non-Small Cell Lung Cancer Treated With Pembrolizumab Monotherapy

Dissecting the global leadership initiative on malnutrition criteria in advanced cancer: Reduced intake vs. inflammation

BACKGROUND & AIMS

The Global Leadership Initiative on Malnutrition (GLIM) criteria have been recommended for the diagnosis of malnutrition. It requires that the patient meets at least one phenotypic criterion and at least one aetiological criterion. For the latter, the patient must either demonstrate reduced food intake or have evidence of systemic inflammation. As both are common in advanced cancer, the aim of the present study was to determine, in patients who met the GLIM phenotypical criteria, which GLIM aetiological criteria (reduced food intake or systemic inflammation) is most useful in predicting overall survival (OS).

METHODS

Data from two cancer biobanks were combined. Inclusion criteria were: ≥18 years, advanced cancer (stage III or IV) and ability to provide written consent. Weight loss (WL) was selected as the phenotypic criterion of choice, as preliminary analysis demonstrated it to be a superior predictor of OS compared to body mass index. Malnutrition type 1 was defined as >5 % WL over 6 months and a C reactive protein (CRP) ≥3 mg/l. Further analysis was performed with a CRP >10 mg/l cut-off. Malnutrition type 2 was defined as >5 % WL over 6 months and reduced food intake, as reported in the Patient Generated Subjective Global Assessment. Survival was assessed using Kaplan-Meier methodology, log-rank tests and Cox proportional hazards models, with hazard ratios (HR) and confidence intervals (CI) reported.

RESULTS

In total, 176 patients were studied, with 147 events observed. The 3-month mortality rate was 32.4 % (CI: 25.1 to 39.0) and the 1-year mortality rate was 71.8 % (CI: 63.8 to 78.0). Malnutrition type 1 and malnutrition type 2 were observed in 37.8 % (HR: 2.27 [CI: 1.54 to 3.33], p < 0.001) and 26.3 % (HR: 1.74 [CI: 1.19 to 2.54], p = 0.005) of patients respectively, with both significantly increasing the risk of death. Following adjustment for relevant confounders both malnutrition type 1 (HR: 1.92 [CI: 1.25 to 2.94], p = 0.003) and malnutrition type 2 (HR: 1.61 [CI: 1.09 to 2.38], p = 0.019) remained significant predictors of OS. Median survival for patients with malnutrition type 1 was 2.14 (CI: 1.74 to 4.90) months compared to 9.5 (6.94-13.64) months for those without (p < 0.001). For malnutrition type 2, this was 2.37 (CI: 1.64 to 5.46) vs. 7.40 months (CI: 6.08 to 10.16), p = 0.004. When the CRP threshold was increased to >10 mg/l, malnutrition type 1 was observed in fewer patients (30.4%), median survival was shorter (1.91 [CI: 1.25 to 2.99] vs. 9.86 months [CI: 7.27 to 14.7], p < 0.001) and in both univariable (HR: 2.91 [CI: 1.94 to 4.63], p < 0.001) and multivariable (HR: 2.32 [CI: 1.50 to 3.60], p < 0.001) analyses, the risk of death increased.

CONCLUSION

The results suggest that the inflammatory component of GLIM appears superior compared to reduced intake in predicting OS and notably, a higher CRP threshold correlates with shorter OS. Therefore, whilst GLIM has multiple potential combinations, all treated with equal regard, these data suggest that the inflammatory aetiological component should be hierarchical to others.

Risk Factors for Progressive Disease After Immune Checkpoint Inhibitor Therapy in Head and Neck Squamous Cell Carcinoma

BACKGROUND

This study analyzed the clinical features of patients with recurrent or metastatic (R/M) head and neck squamous cell carcinoma (HNSCC), who developed progressive disease (PD) after immune checkpoint inhibitor (ICI) therapy.

METHODS

We retrospectively analyzed 256 patients with R/M HNSCC treated with ICIs at 11 medical centers. Associations between the treatment outcomes-best response, overall survival, and progression-free survival-and various clinical factors were analyzed.

RESULTS

The objective response rate was 19.5% and PD was observed in 50.4% of the patients. A high neutrophil-to-lymphocyte ratio (NLR > 4; HR, 2.20 [1.28-3.78]) and large tumor size (sum of the target lesions > 40 mm; HR, 1.74 [1.03-2.94]) were significant risk factors for PD. High NLR (HR, 2.00 [1.42-2.82]), poor performance status (ECOG PS 2-3; HR, 3.51 [2.04-6.05]), and large tumor size (HR. 1.63 [1.19-2.24]) were independently associated with poor overall survival.

CONCLUSIONS

Patients with high NLR and large tumor size are at higher risk of PD during ICI therapy.

Impact of metabolic and nutritional disorders on the synergy between radiotherapy and immunotherapy in non-small-cell lung cancer

BACKGROUND

Patient conditions including metabolic and nutritional status were reported to be prognostic or predictive biomarkers of anti-cancer treatment, while little attention has been paid to its association with the synergistic effect of radiotherapy (RT) and immune checkpoint inhibitors (ICIs).

METHODS

Metastatic non-small-cell lung cancer (mNSCLC) patients who received concurrent RT and ICIs between 2018 and 2023 were included in this study. In addition, mNSCLC patients treated with ICIs alone were enrolled to confirm the synergetic effect of RT and ICIs. Clinicopathological, metabolic and nutritional factors were collected to analyze their influence on progression-free survival (PFS), overall survival and abscopal control time. Abdominal CT was used to obtain body composition data including abdominal obesity and muscle mass.

RESULTS

A total of 96 mNSCLC patients who received RT concurrent with ICIs were included, and a synergistic effect of significantly improved PFS was observed when compared with patients treated with ICIs alone. Among patients undergoing concurrent RT and ICIs, both total adipose area(HR = 2.81,P = 0.029) and prognosis nutritional index (HR = 0.24, P<0.001) were confirmed as independent positive prognostic markers for PFS. Later-line of immunotherapy (HR = 3.67, P = 0.006), low visceral-to-subcutaneous ratio (VSR, HR = 5.53, P = 0.002), high total adipose area (HR = 5.21, P = 0.0016) and high prognostic nutritional index (HR = 0.24, P = 0.002) were independent risk factors for abscopal progression. Then, we established a scoring system consisting of metabolic and nutritional factors to stratify patients into three groups. Patients with non-visceral obesity and good nutrition status have the longest PFS and abscopal control survival, while patients with poor nutritional status regardless of body composition represent the worst prognosis.

CONCLUSION

Metabolic and nutritional status, particularly the combined assessment of body composition and nutritional index, serves as a valuable predictor for the synergistic efficacy of concurrent RT and ICIs.

Spatial analysis identifies DC niches as predictors of pembrolizumab therapy in head and neck squamous cell cancer

Head and neck squamous cell carcinoma (HNSCC) shows variable response to anti-programmed cell death protein 1 (PD-1) therapy, which can be partially explained by a combined positive score (CPS) of tumor and immune cell expression of programmed death-ligand 1 (PD-L1) within the local tumor microenvironment (TME). To better define TME immune determinants associated with treatment efficacy, we conduct a study of n = 48 HNSCC tumors from patients prior to pembrolizumab therapy. Our investigation combines a rapid bioorthogonal multiplex staining method with computational analysis of whole-slide imaging to capture the single-cell spatial heterogeneity and complexity of the TME. Analyzing 6,316 fields of view (FOVs), we provide comprehensive PD-L1 phenotyping and cell proximity assays across the entirety of tissue sections. While none of the PD-L1 metrics adequately predict response, we find that the spatial organization of CCR7+ dendritic cells (DCs) in niches better predicts overall patient survival than CPS alone. This study highlights the importance of understanding the spatial context of immune networks for immunotherapy.

We Need to Talk About Quality of Life with Cancer Patients: Primum Non Nocere in Oncology

The Hippocratic principle primum non nocere, or "first, do no harm", serves as a vital lens through which to re-evaluate modern oncology practices. While recent advances such as immunotherapy, targeted agents, and precision medicine have transformed cancer care, these treatments are not without risk. Even with improved tolerability, they may still lead to substantial toxicities, particularly in frail patients with advanced cancer. The pursuit of survival often overshadows the patient's quality of life, with aggressive interventions frequently continuing beyond the point of meaningful benefit. This perspective article argues for a more individualized and ethically grounded approach to cancer treatment, emphasizing the careful assessment of each patient's clinical status, values, and goals. By integrating geriatric and palliative assessments, improving shared decision making, and moving away from a default treatment-at-all-costs mindset, clinicians can better align care with what truly matters to patients. Honoring primum non nocere in oncology means not only extending life when appropriate but ensuring that life remains worth living.

Real-World Outcomes of First-Line Pembrolizumab Monotherapy in Metastatic NSCLC with High PD-L1 Expression (TPS ≥ 50%): A Multicenter Study from Serbia

Background: Pembrolizumab monotherapy is the standard first-line treatment for metastatic non-small cell lung cancer (NSCLC) patients whose tumors express a PD-L1 tumor proportion score (TPS) of ≥50%. However, real-world data regarding its effectiveness outside of clinical trials, particularly in Eastern European populations, are limited. Methods: We conducted a retrospective, multicenter study including 225 patients with metastatic NSCLC and PD-L1 TPS ≥ 50% who received first-line pembrolizumab monotherapy in Serbia between 2019 and 2022. Patient demographics, clinical characteristics, and treatment outcomes were collected. Progression-free survival (PFS) and overall survival (OS) were estimated using the Kaplan-Meier method, and multivariable Cox proportional hazards regression was performed to identify predictors of outcomes. Results: The median PFS was 9.7 months (95% CI: 7.979-11.421), and the median OS was 17.0 months (95% CI: 12.813-20.187) at a median follow-up of 18.1 months. The overall response rate (ORR) was 36.4%, and the disease control rate (DCR) was 73.4%. Multivariable analysis identified good performance status (ECOG PS 0-1), PD-L1 TPS ≥ 90%, and the occurrence of immune-related adverse events (irAEs) as independent predictors of improved PFS and OS. Conclusions: Our study highlights the efficacy and safety of first-line pembrolizumab monotherapy in a real-world Serbian population with metastatic NSCLC and high PD-L1 expression. Furthermore, it confirms the prognostic value of ECOG PS, high PD-L1 expression, and the development of irAEs in predicting favorable clinical outcomes.

Recovery of quality of life in 574 patients with inoperable lung cancer undergoing (chemo)radiotherapy

Introduction

Quality of life (QoL) of patients with inoperable lung cancer can be negatively affected by both the disease and its treatment, generally consisting of (chemo)radiotherapy. The aim of this study was to prospectively assess QoL in patients with inoperable lung cancer, treated with (chemo)radiotherapy and to assess whether patient- and/or treatment-related characteristics were associated with poorer QoL.

Methods

This prospective cohort study evaluated QoL and patient-, tumor-, and treatment characteristics from inoperable lung cancer patients, treated with fractionated (≥40 Gy) (chemo)radiotherapy. Patients were evaluated at baseline, upon finishing radiotherapy, and 3 months, 6 months, 1 year, and yearly thereafter up to 5 years after radiotherapy. The QoL assessment consisted of questionnaires evaluating lung cancer-specific and treatment-related complaints using scale scores.

Results

Compliance rates of the 574 analyzed patients ranged from 87 to 97 % during follow-up. Complaints increased after radiotherapy, as the QoL scale scores increased from median 8 (interquartile range, IQR 4-14) to 17 (IQR 4-25) after completing radiotherapy (P < 0.0004), indicating more complaints. From 3 months to 24 months of follow-up, scale scores returned to a median of 13, but were significantly higher compared to baseline (P < 0.0004). However, no clinically relevant differences compared to baseline were observed. Patients with pulmonary comorbidity and WHO scores ≥ 2 generally reported more complaints.

Conclusion

Patients experienced a temporary increase in complaints after finishing (chemo)radiotherapy, QoL returned to baseline level and remained stable up to five years of follow-up.

On-treatment dynamics of circulating extracellular vesicles in the first-line setting of patients with advanced non-small cell lung cancer: the LEXOVE prospective study

Extracellular vesicle (EV) monitoring can complement clinical assessment of cancer response. In this study, patients with advanced non-small cell lung cancer (NSCLC) undergoing osimertinib, alectinib, pembrolizumab or platinum-based chemotherapy ± pembrolizumab were enrolled. EVs were characterized using Bradford assay to quantify the circulating cell-free EV protein content (cfEV), and dynamic light scattering to assess Rayleigh ratio excess at 90°, z-averaged hydrodynamic diameter and polydispersity index. A total of 135 plasma samples from 27 patients were collected at baseline (T0) and at the first radiological restaging (T1). A ∆cfEV < 20% was associated with improved median progression-free survival (mPFS) in responders versus non-responders. Specifically, cfEV responders on pembrolizumab had a significantly better mPFS (25.2 months) compared to those on chemotherapy plus pembrolizumab (6.1 months). EGFR-positive cfEV responders also experienced longer mPFS compared to cfEV non-responders (35.1 months, 95% CI: 14.9-35.5 vs. 20.8 months, 95% CI: 11.2-30.4). This study suggested that monitoring circulating EV could provide valuable insights into treatment efficacy in NSCLC, particularly for patients receiving pembrolizumab or osimertinib.

Real-world data of immune-related adverse events in lung cancer patients receiving immune-checkpoint inhibitors

BACKGROUND

Immune-checkpoint inhibitors (ICIs) have revolutionized lung cancer (LC) treatment; however, immune-related adverse effects (irAEs) may occur. The risk factors of irAEs and the impact of irAEs on patient outcomes in LC remain uncertain.

MATERIALS AND METHODS

irAEs within 12 months of ICI initiation in LC patients who initiated ICIs 2018-2021 were identified. Cause-specific Cox regression was used to assess risk factors for irAEs with the competing risk of death; a subset analysis was done among non-small cell lung cancer (NSCLC) group. Multivariable Cox regressions were used to evaluate the impact of irAEs on progression-free survival (PFS) and overall survival (OS).

RESULTS

Of 125 patients, 50 irAEs occurred in 39 patients. Small cell lung cancer (SCLC) histology was associated with a higher risk of irAEs (Hazard ratio (HR) = 2.73, 95% CI [1.17, 6.35], p = 0.020) than NSCLC. In NSCLC subset, programmed death-ligand 1 (PDL1) positivity (HR = 2.68, 95% CI [1.10. 6.53], p = 0.030) was identified as a risk factor. irAEs were not significantly associated with PFS (HR = 0.69, p = 0.204) or OS (HR = 0.72, p = 0.353).

CONCLUSION

SCLC histology and PDL1 positivity were associated with irAEs, and the occurrence of irAEs showed no impact on survival in LC patients. Future studies are required to validate the findings.

Immunotherapy in advanced non-small cell lung cancer: What to do for the 'Invisible' patients after IPSOS trial results?

BACKGROUND

Immune checkpoint inhibitors (ICIs) are currently included in the standard of care of the first-line treatment of advanced/metastatic non-small cell lung cancer (NSCLC). However, a relevant group of clinically unfit patients, including poor Performance Status, Elderly, and those with relevant comorbidities, are not represented in most pivotal clinical trials.

METHODS

An expert panel meeting commentary was virtually held to point out the key issues in treating such 'invisible' patients and to review the available evidence.

RESULTS

Overall, clinically unfit patients represent up to 50% of patients with diagnosis of advanced/metastatic NSCLC. Few dedicated studies with immunotherapy were conducted in this population. Among them, the IPSOS trial finally answers the issue of first line immunotherapy in platinum-unfit patients with advanced NSCLC, demonstrating atezolizumab improved OS and good tolerability compared to monochemotherapy.

CONCLUSIONS

Atezolizumab monotherapy can be considered a valid first-line treatment in patients with advanced NSCLC who are unfit to receive platinum-based chemotherapy, including elderly, those with poor PS and/or comorbidities.

Real-world effectiveness and tolerability of sotorasib in patients with KRAS G12C-mutated metastatic non-small cell lung cancer: The IFCT-2102 Lung KG12Ci study

INTRODUCTION

Sotorasib has shown efficacy in a phase 3 trial compared to docetaxel among previously treated non-small cell lung cancer (NSCLC) patients with a KRAS G12C mutation. However, its real-world effectiveness and tolerance, especially post-immunotherapy, remain debated.

METHODS

This French retrospective multicentre study analysed NSCLC patients receiving at least one dose of sotorasib as part of early access program The main objective was to assess real-world progression-free survival (rwPFS), and secondary objectives included assessment of overall survival (rwOS) and sotorasib-related hepatotoxicity.

RESULTS

458 patients from 76 centres were analysed, with a median age 65.8. Among them, 43.4 % were female, 28.3 % had performance status ≥ 2, 95.4 % were active/former smokers, and 38.0 % had brain metastases with 55.2 % in progression at sotorasib initiation. PD-L1 expression was < 1 %, ≥ 1-49 %, ≥ 50 %, and unknown in 35.1 %, 34.1 %, 23.4 %, and 7.4 % of patients, respectively. Most patients had received prior treatments (96.7 %), including immunotherapy (54.9 %). Median (95 % confidence interval [CI]) rwPFS and rwOS were 3.5 (3.1-4.2) and 8.3 (7.5-9.3) months, with a median (95 % CI) follow-up of 15.8 (13.9-17.3) and 16.4 (15.5-17.3) months, respectively. The real-world objective response rate (rwORR) was 33.2 % and disease control rate (rwDCR) was 63.2 %. In patients with brain metastases, cerebral rwORR and rwDCR were 20.1 % and 66.9 %, respectively. Grade 3-4 adverse events related to hepatotoxicity occurred in 5.2 % of patients. Sotorasib was discontinued for toxicity in 16.5 % of patients.

CONCLUSION

This study gave insights into effectiveness and safety of sotorasib in a real-world setting, in advanced or metastatic KRAS G12C-mutated non-squamous NSCLC.

The prognostic value of a laboratory cachexia score (LCAS) defined by LDH, CRP and albumin in patients with advanced lung cancer

BACKGROUND

Systemic inflammation has prognostic value in cancer and is considered aetiological of cachexia by the Global Leadership Initiative on Malnutrition (GLIM). Lactate dehydrogenase (LDH) also has recognized prognostic value. The present study aimed to evaluate the ability of a laboratory cachexia score (LCAS) defined by LDH, CRP and albumin, to identify cachexia and predict outcome in advanced lung cancer.

METHODS

Patients (n = 261) with serum LDH, CRP and albumin measurement receiving palliative radiotherapy for advanced lung cancer between 2009 and 2015 were identified. Subjects were stratified by LDH and LCAS. This was compared to GRIm and LIPI, two previously described LDH based prognostic scores, which do not incorporate CRP.

RESULTS

On follow up there were 201 deaths. LDH and LCAS were associated with 1-year survival independent of ECOG-PS, MUST, weight loss, BMI, SMI, SMD, metastases, mGPS or NLR (all p < 0.001). On multivariate analysis LCAS (1.36, 1.13-1.63, p = 0.001), LIPI (1.50, 1.17-1.92, p = 0.02), metastases (1.53, 1.15-2.04, p = 0.004) and ECOG-PS (1.28, 1.04-1.57, p = 0.019) were independently associated with poorer overall survival.

CONCLUSION

LCAS appears to identify cachexia and stratify survival. This may represent a useful aetiological criterion within the GLIM framework and a more powerful prognostic tool than the phenotypic criteria.

Deterioration of performance status before administration of chemotherapy as a prognostic factor in untreated advanced non-small cell lung cancer

INTRODUCTION

The prognostic impact of changes in performance status (PS) of untreated patients with advanced non-small cell lung cancer (NSCLC) are not clear. This study aimed to evaluate the prognostic impact of acute PS deterioration in patients with untreated advanced NSCLC.

METHODS

This study is a single center, retrospective, observational study. Patients with Stage IV NSCLC who were referred to our institution between January 2018 and March 2023 were retrospectively reviewed. Patients were divided into three groups: 1) patients with PS 0 or 1 at referral and the start of chemotherapy; 2) patients with PS 2 or worse at initial referral and the start of chemotherapy; and 3) patients with PS 0 or 1 at referral that deteriorated to PS 2 or worse at the start of chemotherapy. The prognoses of Groups 2 and 3 were compared with those of Group 1.

RESULTS

A total of 373 patients were included: 321 in Group 1, 20 in Group 2, and 32 in Group 3. The median overall survival (OS) of Group 3 was shorter than that of Group 1 (9.3 vs. 27.1 months, hazard ratio [HR] 2.56, p < 0.01). The median OS of Group 2 was also shorter than that of Group 1, although not as significant as in Group 3 (20.2 vs. 27.1 months, HR 1.68, p = 0.06). After adjusting for symptoms, liver and pericardial metastases were associated with PS deterioration in multivariate analysis.

CONCLUSION

Among patients with untreated advanced NSCLC, acute PS deterioration before chemotherapy administration was associated with poor prognosis.

Improving Risk Stratification in pT3 Upper Tract Urothelial Carcinoma: A Focus on Invasion Patterns

Purpose: Existing T3 subclassifications for upper tract urothelial cancer (UTUC) are limited by heterogeneity and a primary focus on renal pelvis tumors. Our study aimed to propose a novel pT3 subclassification system specifically tailored to pT3 UTUC patients. Materials and Methods: This study analyzed 120 pT3 UTUC cases from a Taiwanese multicenter registry, using a standardized pathology report and a single pathologist for evaluation. Results: Univariate analysis revealed survival differences based on existing subclassifications. Multivariate analysis identified concurrent fat and parenchyma invasion as an independent predictor of worse overall survival (OS), cancer-specific survival (CSS), and disease-free survival (DFS). Conclusions: This study proposes a novel pT3 subclassification incorporating fat and parenchyma invasion, applicable to all UTUC sites. This subclassification may improve risk stratification, guide treatment decisions, and ultimately enhance patient outcomes.

Quantitative Bias Analysis for Single-Arm Trials With External Control Arms

Importance

Unmeasured confounding is a key concern for decision-makers when observational datasets are used to assemble external control arms (ECAs) for single-arm trials.

Objective

To investigate the utility of quantitative bias analysis (QBA) for exploring the sensitivity to unmeasured confounding of nonrandomized analyses using ECAs.

Design, Setting, and Participants

This study emulated 15 treatment comparisons using experimental arms from existing randomized trials in advanced non-small cell lung cancer (aNSCLC) conducted after 2011 and ECAs derived from observational data. Participants were eligible individuals diagnosed with aNSCLC between January 1, 2011, and March 1, 2020. After adjustment for measured baseline confounders, a prespecified QBA was conducted to address potential bias by known unmeasured and mismeasured confounders. The QBA relied on a synthesis of external evidence from a targeted literature search, randomized trial data, and clinician input. Hazard ratios from the original randomized trials were compared with those from their emulation based on ECA analyses. Analyses were completed from February 2022 to October 2023.

Exposure

Initiation of systemic therapies for aNSCLC.

Main outcomes and measures

Hazard ratios for all-cause death.

Results

Sample sizes varied from 52 to 830 depending on the treatment group. The mean difference in the log hazard ratio estimates when using the original control arm vs the ECA for each trial was 0.247 in unadjusted analyses (ratio of hazard ratios, 1.36), 0.139 when adjusted for measured confounders (ratio of hazard ratios, 1.22), and 0.098 when adding external adjustment for unmeasured and mismeasured confounders (ratio of hazard ratios, 1.17).

Conclusions and Relevance

QBA was feasible and informative in ECA analyses in which residual confounding was expected to be the most important source of bias. These findings encourage further exploration of how QBA can help quantify the impact of bias in other settings and when using other data sources.

Role of dasatinib in the management of lung cancer: A meta-analysis of clinical trials

Lung cancer, particularly non-small cell lung cancer (NSCLC), the leading cause of cancer-related deaths worldwide, has prompted extensive research into innovative treatments, including targeted therapies. The present meta-analysis aims to evaluate the efficacy of dasatinib, both as monotherapy and in combination with other therapies, for the treatment of lung cancer. Adhering to the PRISMA guidelines, a meticulous, thorough review of clinical trials was conducted across reputable databases, including Google Scholar, PubMed/MEDLINE, and EMBASE, focusing on studies published in English up to May 5th, 2024. Inclusion criteria were restricted to randomized clinical trials (RCTs) assessing the efficacy of dasatinib, either as a standalone therapy or in combination with other treatments. The search identified 55 studies, of which nine RCTs met the inclusion criteria: four phase II, three phase I, and two phase I/II. A total of 234 patients participated, with 107 receiving dasatinib alone and 127 undergoing combination therapy. Histological analyses revealed that 79.1% of patients had non-small cell lung cancer, with adenocarcinoma being the predominant subtype (63.8%), followed by squamous cell carcinoma (22.1%). Treatment responses varied, with 52.4% of the patients in the dasatinib alone group experiencing progressive disease, while 38.3% achieved stable disease; by contrast, 29.6% of patients in the combination therapy showed progressive disease. Adverse events, including anemia and fatigue, were more prevalent with combination therapies. Dasatinib treatment shows potential for improving overall survival with fewer adverse events compared with combination therapies in patients with lung cancer; however, large-scale clinical trials are essential to confirm its efficacy as a standalone treatment.

Effects of cannabinoids on immune checkpoint inhibitor response: CCTG pooled analysis of individual patient data

BACKGROUND

Immune checkpoint inhibitors (ICIs) benefit patients across various tumor types. ICIs block cancer and T-cell interactions whereas cannabinoids may inhibit T-cell activation, reducing lysis of tumor cells. Interactions between cannabinoid use and dual ICI treatment remain unknown.

METHODS

Individual patient data from 4 Canadian Cancer Trials Group (CCTG) trials of patients treated with dual ICI ± chemotherapy (n = 684) were pooled. Cochran - Mantel - Haenszel and log-rank tests (stratified by trial/treatment arms) correlated cannabinoid use with clinicopathologic characteristics, Best Overall Response (BOR)/iBOR per RECIST 1.1/iRECIST, Progression-Free Survival (PFS)/iPFS, Overall Survival (OS) and immune-related adverse events (irAEs).

RESULTS

Sixty-five (9.5%) patients took cannabinoids at any time on trial, 32 (4.7%) of which were using cannabinoids at baseline. By multivariate analysis, cannabinoid use at baseline was significantly associated with improved iPFS (0.05), but not iBOR (p = 0.15), PFS (p = 0.12), OS (p = 0.35) or incidence of grade 1/2 or 3/4 irAEs (p = 0.96 and 0.65 respectively). Results were not significantly different with cannabinoid use at any time on trial.

CONCLUSION

Improved iPFS with cannabinoid use in patients treated with durvalumab plus tremelimumab ± chemotherapy did not translate into OS benefits. This study supports the safe use of cannabinoids in the context of combination ICI therapy.

Immunotherapy for Elderly Patients with Advanced Non-Small Cell Lung Cancer: Challenges and Perspectives

Lung cancer, a leading cause of cancer-related mortality, disproportionately affects the elderly, who face unique challenges due to comorbidities and reduced organ function. Immune checkpoint inhibitors (ICIs) offer a more tolerable alternative to chemotherapy, but their efficacy and safety in elderly non-small cell lung cancer (NSCLC) patients remain underexplored due to limited representation in clinical trials. A narrative literature review was conducted using PubMed, Embase, and the Cochrane Library to evaluate studies on elderly NSCLC patients (≥65 years) treated with ICIs. Key outcomes assessed included overall survival, progression-free survival, response rates, treatment-related adverse events, and the influence of immunosenescence on treatment efficacy. The review highlighted evidence supporting the efficacy and safety of ICIs in elderly NSCLC patients, particularly those with good performance status. Age-related immunosenescence may affect outcomes, emphasizing the need for individualized treatment. Limited data suggest ICIs alone may be preferable to chemo-immunotherapy for patients over 75 years. However, the exclusion of elderly patients from clinical trials and methodological limitations reduces the generalizability of these findings. ICIs hold promise for advanced NSCLC in older adults, but tailored approaches and greater elderly inclusion in trials are needed to optimize outcomes.

Utilization of Immune Checkpoint Inhibitors in Human Epidermal Growth Factor Receptor 2-Negative, Advanced Metastatic, or Unresectable Gastric Cancer Under All Combined Positive Score Grading: Evaluation of Efficacy Based on Individual Patient Data Reconstruction and Secondary Analyses

PURPOSE

The efficacy of several novel combinations of anti-programmed cell death protein 1 or its ligand antibodies with chemotherapy, which have become the new standard first-line combination therapy with favorable outcomes, was still not certain in patients with different combined positive score (CPS) grades. This research aimed to evaluate the efficacy of immune checkpoint inhibitor immunotherapy or immunochemotherapy at different CPS grades, compared with chemotherapy.

METHODS

Kaplan-Meier (KM) curve reconstruction was employed to assess the overall survival (OS) and progression-free survival (PFS) of patients with gastric cancer. The graphical reconstruction algorithm was used to estimate the time-to-event outcomes from Kaplan-Meier curves of the overall cohort or reported subgroups (depending on CPS). KMSubtraction was used to derive the unreported survival data by matching participants in the overall cohort and known subgroups.

FINDINGS

This analysis included 5072 patients in 5 trials (CheckMate 649, KEYNOTE-859, ORIENT-16, KEYNOTE-062, and JAVELIN Gastric 100). Immunochemotherapy exhibited more effectiveness than chemotherapy in most cases. For the overall cohort, sintilimab + chemotherapy exhibited the best effect in OS (hazard ratio [HR], 0.65; 95% CI, 0.55-0.76). Nivolumab + chemotherapy (HR, 0.75; 95% CI, 0.67-0.84), sintilimab + chemotherapy (HR, 0.52; 95% CI, 0.41-0.65), and pembrolizumab + chemotherapy (HR, 0.68; 95% CI, 0.58-0.81) exhibited favorable outcomes in OS in patients with a CPS ≥1, 5, and 10, respectively, and similarly in PFS. Avelumab + chemotherapy performed similarly to chemotherapy in OS but had poor PFS in the reported subgroup.

IMPLICATIONS

Finding suggests that immune checkpoint inhibitors combined with chemotherapy could enrich patients with benefits regardless of CPS grades, though subtle efficacy in low CPS subgroups. This study compared the efficacy of different immunotherapies combined with chemotherapy in patients with gastric cancer, but we acknowledge some differences between reconstructed and original data. Hopefully there will be more research investigating comparisons between current therapies rather than with chemotherapy only in the future.

Nivolumab plus ipilimumab versus carboplatin-based doublet as first-line treatment for patients with advanced non-small-cell lung cancer aged ≥70 years or with an ECOG performance status of 2 (GFPC 08-2015 ENERGY): a randomised, open-label, phase 3 study

BACKGROUND

Combined treatment with anti-PD-1 and anti-CTLA-4 antibodies has shown superiority over chemotherapy in patients with advanced non-small-cell lung cancer (NSCLC), but data for older patients (aged ≥70 years) with an Eastern Cooperative Oncology Group (ECOG) performance status of 0-1 or those with an ECOG performance status of 2 are scarce. We aimed to test the superiority of the PD-1 antibody nivolumab and the CTLA-4 antibody ipilimumab over platinum-based doublet chemotherapy as first-line treatment in patients with NSCLC aged 70 years or older or with an ECOG performance status of 2.

METHODS

This open-label, multicentre, randomised, controlled, phase 3 trial was done at 30 hospitals and cancer centres in France. Eligible patients had stage IV histologically proven NSCLC, with no known oncogenic alterations, and were either aged 70 years or older with ECOG performance status of 0-2 or younger than 70 years with an ECOG performance status of 2. Patients were randomly assigned (1:1) centrally, using a computer-generated algorithm stratified by age (<70 vs ≥70 years), ECOG performance status (0-1 vs 2), and histology (squamous vs non-squamous) to receive nivolumab plus ipilimumab or platinum-based doublet chemotherapy (carboplatin [area under the curve ≤700 mg] plus pemetrexed [500 mg/m2 intravenous infusion every 3 weeks] or carboplatin [on day 1; area under the curve ≤700 mg] plus paclitaxel [90 mg/m2 as intravenous infusion on days 1, 5, and 15, every 4 weeks]). The primary endpoint was overall survival; secondary endpoints included progression-free survival and safety. All efficacy analyses were performed in the intention-to-treat population, which included all randomly assigned patients. Safety was analysed in the safety analysis set, which included all randomly assigned patients who received at least one dose of study treatment and who had at least one safety follow-up. The trial is registered with ClinicalTrials.gov, NCT03351361.

FINDINGS

The trial was stopped early for futility on the basis of a pre-planned interim analysis after 33% of the expected events had occurred. Between Feb 12, 2018, and Dec 15, 2020, 217 patients were randomly assigned, of whom 216 patients were included in the final analysis, with 109 patients in the nivolumab plus ipilimumab group and 107 in the chemotherapy group; median age was 74 years (IQR 70-78). Median overall survival was 14·7 months (95% CI 8·0-19·7) in the nivolumab plus ipilimumab group and 9·9 months (7·7-12·3) in chemotherapy group (hazard ratio [HR] 0·85 [95% CI 0·62-1·16]). Among patients aged 70 years or older with an ECOG performance status of 0-1 (median age 76 years [IQR 73-79]), median overall survival was longer in the nivolumab plus ipilimumab group than the chemotherapy group: 22·6 months (95% CI 18·1-36·0) versus 11·8 months (8·9-20·5; HR 0·64 [95% CI 0·46-0·96]). Among patients with an ECOG performance status of 2 (median age 69 years [IQR 63-75]), median overall survival was 2·9 months (95% CI 1·4-4·8) in the nivolumab plus ipilimumab group versus 6·1 months (3·5-10·4) in the chemotherapy group (HR 1·32 [95% CI 0·82-2·11]). No new safety signals were reported. The most frequent grade 3 or worse adverse events were neutropenia (28 [27%] of 103 patients) in the chemotherapy group and endocrine disorders (five [5%] of 105 patients), cardiac disorders (ten [10%] patients), and gastrointestinal disorders (11 [11%] patients) in the nivolumab plus ipilimumab group.

INTERPRETATION

The study showed no benefit of nivolumab plus ipilimumab combination in the overall study population. As a result of early stopping, the trial was underpowered for primary and secondary endpoints; however, the finding of better survival with nivolumab plus ipilimumab compared with platinum doublet in the subgroup of older patients with NSCLC with an ECOG performance status of 0-1 warrants further study.

FUNDING

Bristol-Myers Squibb.

Metastatic Lung Adenocarcinomas: Development and Evaluation of Radiomic-Based Methods to Measure Baseline Intra-Patient Inter-Tumor Lesion Heterogeneity

Radiomics has traditionally focused on individual tumors, often neglecting the integration of metastatic disease, particularly in patients with non-small cell lung cancer. This study sought to examine intra-patient inter-tumor lesion heterogeneity indices using radiomics, exploring their relevance in metastatic lung adenocarcinoma. Consecutive adults newly diagnosed with metastatic lung adenocarcinoma underwent contrast-enhanced CT scans for lesion segmentation and radiomic feature extraction. Three methods were devised to measure distances between tumor lesion profiles within the same patient in radiomic space: centroid to lesion, lesion to lesion, and primitive to lesion, with subsequent calculation of mean, range, and standard deviation of these distances. Associations between HIs, disease control rate, objective response rate to first-line treatment, and overall survival were explored. The study included 167 patients (median age 62.3 years) between 2016 and 2019, divided randomly into experimental (N = 117,546 lesions) and validation (N = 50,232 tumor lesions) cohorts. Patients without disease control/objective response and with poorer survival consistently systematically exhibited values of all heterogeneity indices. Multivariable analyses revealed that the range of primitive-to-lesion distances was associated with disease control in both cohorts and with objective response in the validation cohort. This metrics showed univariable associations with overall survival in the experimental. In conclusion, we proposed original methods to estimate the intra-patient inter-tumor lesion heterogeneity using radiomics that demonstrated correlations with patient outcomes, shedding light on the clinical implications of inter-metastases heterogeneity. This underscores the potential of radiomics in understanding and potentially predicting treatment response and prognosis in metastatic lung adenocarcinoma patients.

Bayesian design of clinical trials with multiple time-to-event outcomes subject to functional cure

With the continuous advancement of medical treatments, there is an increasing demand for clinical trial designs and analyses using cure rate models to accommodate a plateau in the survival curve. This is especially pertinent in oncology, where high proportions of patients, such as those with melanoma, lung cancer, and endometrial cancer, exhibit usual life spans post-cancer detection. A Bayesian clinical trial design methodology for multivariate time-to-event outcomes with cured fractions is developed. This approach employs a copula to jointly model the multivariate time-to-event outcomes. We propose a model that uses a Gaussian copula on the population survival function, irrespective of cure status. The minimum sample size required to achieve high statistical power while maintaining reasonable control over the type I error rate from a Bayesian perspective is identified using point-mass sampling priors. The methodology is demonstrated in simulation studies inspired by an endometrial cancer trial.

Utility of ursodiol prophylaxis against sinusoidal obstruction syndrome (SOS)/ veno-occlusive disease (VOD) in acute leukemia patients receiving gemtuzumab-ozogamicin (GO) or inotuzumab-ozogamicin (InO)

PURPOSE

Sinusoidal obstructive syndrome (SOS)/veno-occlusive disease (VOD) is a serious complication in hematopoietic stem-cell transplant (HSCT) patients. Gemtuzumab-ozogamicin (GO) and InO are known to cause SOS/VOD in leukemic and transplant populations. Due to limited data on ursodiol prophylaxis in non-HSCT patients, we aimed to assess hepatotoxicity, SOS/VOD incidences, time to hepatotoxicity, and confirmed SOS/VOD in adults receiving GO or InO ± ursodiol.

METHODS

A multicenter, retrospective chart review of adult acute leukemia patients who received ≥1 dose of GO or InO at DFCI/some of the Harvard Cancer Centers during 4-year period (9/1/2017-9/1/2021). Acute promyelocytic leukemia patients and post-GO or InO HSCT-recipients (100-day follow-up period) were excluded. Descriptive summaries are provided, direct comparisons were made using Student T-test (continuous variables) and Fisher's exact test (categorical variables).

RESULTS

In our population (N = 82), 87.8% received ursodiol and 12.2% did not. There were no significant differences in baseline to peak hepatic labs. The No-Ursodiol Group had higher incidence of Grade 3 aspartate aminotransferase (AST) transaminitis vs. the Ursodiol Group (60% vs. 20.8%; p = 0.015), and a trend towards shorter mean time to Grade 3 AST transaminitis (18.5 vs. 23.8 days; p = 0.30). Moreover, 4.2% of Ursodiol Group developed SOS/VOD vs. 0% in the No-Ursodiol Group (NS). Three patients developed SOS/VOD: 2 received GO, 1 received InO, and 2 were alive by the end of the follow-up period.

CONCLUSION

In our cohort, ursodiol prophylaxis in adults receiving GO/InO is not associated with lower incidences of hepatotoxicity, SOS/VOD, or time to Grade 3 AST transaminitis, but is associated with decreased incidence of AST elevations.

Functional status, lymphocyte-to-monocyte ratio, and platelet-to-lymphocyte ratio as prognostic factors of one-year survival rate in elderly patients with advanced-stage non-small cell lung cancer

BACKGROUND AND AIM

Non-small cell lung cancer (NSCLC) is the most common lung cancer found in elderly patients. Aging and chronic inflammation are related to its pathogenesis. Functional status, lymphocyte-to-monocyte ratio and platelet-to-lymphocyte ratio describe a chronic inflammation and correlate to the survival of older adults with advanced-stage (IIIB-IV) NSCLC. This study aims to determine functional status, lymphocyte-to-monocyte ratio and platelet-to-lymphocyte ratio as prognostic factors to 1-year survival in elderly patients with NSCLC stage IIIB-IV.

METHODS

Survival analysis with a cohort retrospective study is conducted on elderly patients with NSCLC stage IIIB-IV in Dharmais National Cancer Center Hospital between January 2020 and June 2022. Medical records were collected, comprising complete blood count prior to chemotherapy or radiotherapy, assessment of functional status through the Barthel Index for Activities of Daily Living (ADL), and 1-year survival post-diagnosis. Factors potentially influencing outcomes included diabetes mellitus, anemia, chronic obstructive pulmonary disease, and chronic kidney disease. Statistical analyses were performed using SPSS 20.0, employing the log-rank method for bivariate analysis and Cox regression for multivariate analysis.

RESULTS

In a cohort of 108 patients, the majority were aged 60-69 years (74.1 %), male (66.7 %), diagnosed at stage IV (80.5 %), and with adenocarcinoma subtype (75.0 %). Significant correlations were observed between the lymphocyte-to-monocyte ratio and platelet-to-lymphocyte ratio with the 1-year survival rate in elderly patients with stage IIIB-IV NSCLC (p = 0.015 and p = 0.001, respectively). Functional status did not show a significant correlation with 1-year survival overall (p = 0.540), but significant correlations were noted in patients receiving chemotherapy (p = 0.044) and radiotherapy (p = 0.009).

CONCLUSION

The lymphocyte-to-monocyte ratio and platelet-to-lymphocyte ratio provide significant prognostic insights regarding 1-year survival in elderly patients diagnosed with stage IIIB-IV non-small cell lung cancer (NSCLC). In contrast, the functional status of these patients does not demonstrate a significant correlation with one-year survival.

Association between higher glucose levels and reduced survival in patients with non-small cell lung cancer treated with immune checkpoint inhibitors

BACKGROUND

Obesity and hypercholesterolemia have been associated with better responses to ICIs in NSCLC, while type 2 diabetes (T2D) has been associated with a worse response. However, the association between glucose levels and outcomes remains unknown. This study investigated the impact of mean baseline glucose levels, T2D, dyslipidemia, and obesity on overall survival (OS) in NSCLC patients undergoing ICI therapy.

METHODS

A multicenter retrospective cohort study was conducted using data from three medical centers, with locally advanced or metastatic NSCLC patients receiving ICI, regardless of treatment line or concurrent therapy. Random venous glucose levels within 4 weeks prior to ICI initiation, BMI, history of dyslipidemia, and T2D, along with OS, were assessed. Patients with BMI < 18.5 were excluded.

RESULTS

Among 438 patients, those with the highest quartile of baseline glucose levels had significantly shorter OS compared to those in the lowest quartile (HR, 1.53; 95 % CI, 1.08 - 2.15; p-value = 0.016). This association remind consistent after adjusting for steroid use, diabetes, performance status and glucose-lowering medication use. These effects were consistently observed in subsets of patients treated with ICI monotherapy and with PD-L1 TPS ≥ 1 %.

CONCLUSION

Higher mean baseline glucose levels correlated with shorter survival in patients with NSCLC treated with ICIs. The divergent effects of individual metabolic syndrome components on ICI response in patients with NSCLC underscore the complexity of metabolic influences on treatment outcomes.

Depression, performance status, and discontinued treatment mediate an association of curability belief with prognosis in advanced cancer patients

Individuals diagnosed with advanced cancer often experience stress and depression, factors linked to worse survival. Curability belief-defined as the hope and expectation of cure through treatment, based on affective forecasting-may differ from the patient's actual life expectancy (i.e., likelihood estimation) and has shown variable associations with cancer survival. In this study, multivariate Cox regression analyses were used to examine the effect of curability belief and depression on 1-year survival after adjustment for physical factors. Additionally, regularized partial correlations among physical and psychological factors were assessed using mixed graphical models to elucidate their roles in mediating the relationship between curability belief and 1-year survival. This multi-center cohort study, conducted across 13 tertiary hospitals (including four ranked among the 'World's Best Specialized Hospitals 2025' in oncology), involved 382 adults with stage IV advanced cancer and an oncologist-estimated survival of more than 6 months. Baseline data included demographics, primary tumor site, number of metastatic sites, symptom burdens (EORTC QLQ-C15-PAL), performance status (ECOG-PS), depression levels (PHQ-9), anti-cancer treatment type, patient's life expectancy estimation, and curability belief. Follow-up data included 1-year survival and end-of-life care (place of death) for deceased patients. Multivariate Cox proportional hazards models were used to assess adjusted hazard ratios (aHRs) for curability belief, depression, and their interaction on 1-year survival, adjusting for significant demographic and clinical factors from univariate Cox regressions. The Kaplan-Meier method was used to plot survival probability by curability belief and depression interaction. Mixed graphical models estimated regularized partial correlations among 1-year survival, curability belief, patient's life expectancy, depression, primary tumor site, anti-cancer treatment type, performance status, and symptom burden. In terms of healthcare utilization, patients with curability belief were more likely to receive standard or advanced anti-cancer therapy, while those without curability belief tended to suspend or discontinue therapy (P < 0.001). Among patients who did not survive the 1-year follow-up (N = 161), end-of-life care settings differed significantly between those with curability belief (predominantly nursing homes and home settings) and those without (primarily hospice and tertiary/secondary hospitals; P = 0.036). In multivariate Cox regression, curability belief (P = 0.003), depression (PHQ-9 score ≥ 10; P = 0.003), and their interaction (P = 0.040) were significantly associated with 1-year survival, after adjusting for sex, residential area, primary tumor site, performance status, anti-cancer treatment type, and symptom burdens (fatigue and appetite loss). The relationship between curability belief and 1-year survival was significant only in patients without depression [PHQ-9 score < 10; aHR (95% CI) = 2.20 (1.31-3.70); P = 0.003]. In the mixed graphical model, node predictability values for curability belief, depression, and 1-year survival were 0.68, 0.50, and 0.70, respectively, with curability belief showing partial correlations with depression (r = 0.30) and patients' life expectancy (r = 0.20); depression correlated with fatigue (r = 0.53), anorexia (r = 0.16), life expectancy (r = 0.24), performance status (r = 0.23), and curability belief; and 1-year survival correlated with suspended/stopped anti-cancer treatment (r = 0.45), primary tumor site (r = 0.24), and performance status (r = 0.15). Partial correlations of performance status with depression and discontinued treatment mediated the association between curability belief and 1-year survival. Curability belief among stage IV advanced cancer patients with an oncologist-estimated survival of over 6 months was associated with depression levels and patients' perceived life expectancy estimations. Performance status, depression, and anti-cancer treatment status mediate the relationship between curability belief and improved 1-year survival in patients without depression. Further research using longitudinal modeling of depression, performance status, and healthcare utilization, with curability belief and primary tumor site as covariates, is warranted.Trial registration: Clinical Trial Number (ClinicalTrials.gov): NCT03222258; Study Registration Dates (First submitted: 2017-06-05; First submitted following the QC criteria: 2017-07-16; First posted: 2017-07-19).

Single- and multi-site radiomics may improve overall survival prediction for patients with metastatic lung adenocarcinoma

PURPOSE

The purpose of this study was to assess whether single-site and multi-site radiomics could improve the prediction of overall survival (OS) of patients with metastatic lung adenocarcinoma compared to clinicopathological model.

MATERIALS AND METHODS

Adults with metastatic lung adenocarcinoma, pretreatment whole-body contrast-enhanced computed tomography examinations, and performance status (WHO-PS) ≤ 2 were included in this retrospective single-center study, and randomly assigned to training and testing cohorts. Radiomics features (RFs) were extracted from all measurable lesions with volume ≥ 1 cm3. Radiomics prognostic scores based on the largest tumor (RPSlargest) and the average RF values across all tumors per patient (RPSaverage) were developed in the training cohort using 5-fold cross-validated LASSO-penalized Cox regression. Intra-patient inter-tumor heterogeneity (IPITH) metrics were calculated to quantify the radiophenotypic dissimilarities among all tumors within each patient. A clinicopathological model was built in the training cohort using stepwise Cox regression and enriched with combinations of RPSaverage, RPSlargest and IPITH. Models were compared with the concordance index in the independent testing cohort.

RESULTS

A total of 300 patients (median age: 63.7 years; 40.7% women; median OS, 16.3 months) with 1359 lesions were included (200 and 100 patients in the training and testing cohorts, respectively). The clinicopathological model included WHO-PS = 2 (hazard ratio [HR] = 3.26; P < 0.0001), EGFR, ALK, ROS1 or RET mutations (HR = 0.57; P = 0.0347), IVB stage (HR = 1.65; P = 0.0211), and liver metastases (HR = 1.47; P = 0.0670). In the testing cohort, RPSaverage, RPSlargest and IPITH were associated with OS (HR = 85.50, P = 0.0038; HR = 18.83, P = 0.0082 and HR = 8.00, P = 0.0327, respectively). The highest concordance index was achieved with the combination of clinicopathological variables and RPSaverage, significantly better than that of the clinicopathological model (concordance index = 0.7150 vs. 0.695, respectively; P = 0.0049) CONCLUSION: Single-site and multi-site radiomics-based scores are associated with OS in patients with metastatic lung adenocarcinoma. RPSaverage improves the clinicopathological model.

Patient- and Areal-Level Risk Factors Associated With Lung Cancer Mortality in Victoria, Australia: A Bayesian Spatial Survival Analysis

BACKGROUND

In Australia, lung cancer is the leading cause of cancer-related deaths. In Victoria, the mortality risk is assumed to vary across Local Government Areas (LGAs) due to variations in socioeconomic advantage, remoteness, and healthcare accessibility. Thus, we applied Bayesian spatial survival models to examine the geographic variation in lung cancer survival in Victoria.

METHODS

Data on lung cancer cases were extracted from the Victorian Lung Cancer Registry (VLCR). To account for spatial dependence and risk factors of survival in lung cancer patients, we employed a Bayesian spatial survival model. Conditional Autoregressive (CAR) prior was assigned to model the spatial dependence. Deviance Information Criterion (DIC), Watanabe Akaike Information Criterion (WAIC), and Log Pseudo Marginal Likelihood (LPML) were used for model comparison. In the final best-fitted model, the Adjusted Hazard Ratio (AHR) with the 95% Credible Interval (CrI) was reported. The outcome variable was the survival status of lung cancer patients, defined as whether they survived or died during the follow-up period (death was our interest).

RESULTS

Our study revealed substantial variations in lung cancer mortality in Victoria. Poor Eastern Cooperative Oncology Group (ECOG) performance status, diagnosed at a regional hospital, Small Cell Lung Cancer (SCLC), advanced age, and advanced clinical stage were associated with a higher risk of mortality, whereas being female, presented at Multidisciplinary Team (MDT) meeting, and diagnosed at a metropolitan private hospital were significantly associated with a lower risk of mortality.

CONCLUSION

Identifying geographical disparities in lung cancer survival may help shape healthcare policy to implement more targeted and effective lung cancer care services.

Immunotherapy in Patients with Advanced Non-Small-Cell Lung Cancer Under-Represented by Clinical Trials

Since the initial US FDA approval of an immune checkpoint inhibitor (ICI) for the treatment of non-oncogene-driven non-small-cell lung cancer (NSCLC) nine years ago, this therapeutic strategy has been cemented as a crucial component of treatment for most of these patients. However, there is a clear efficacy-effectiveness gap whereby patients in the 'real world' seem to have more modest clinical outcomes compared to those enrolled in landmark clinical trials. This gap may be driven by the under-representation of important patient populations, including populations defined by clinical or molecular characteristics. In this review, we summarize the data outlining the evidence of ICIs in patients with poor Eastern Cooperative Oncology Group performance status (ECOG PS), underlying autoimmune disease (AID), older age, active brain metastases (BMs), and molecular aberrations such as EGFR mutations, ALK fusions, BRAF mutations and ROS1 fusions.

The impact of the expression level of growth differentiation factor 15 in tumor tissue on the response to immunotherapy in non-small cell lung cancer

BACKGROUND

Growth differentiation factor-15 (GDF-15), a member of the TGF-β superfamily, is overexpressed in various cancers and facilitates immune evasion by inhibiting T-cell activation. GDFATHER-TRIAL's phase 2a results demonstrated promising outcomes when combining the GDF-15 neutralizing antibody visugromab (CTL002) with nivolumab, enhancing the response to immunotherapy. This study evaluated the prognostic significance of GDF-15 expression in non-small cell lung cancer (NSCLC) tumor tissues in terms of immunotherapy response.

METHODS

This retrospective study included 50 patients with metastatic NSCLC treated with nivolumab at Gazi University Hospital between January 2021 and July 2023. GDF-15 expression was evaluated using immunochemistry staining and categorized based on the intensity of cytoplasmic or membranous staining. Samples were divided into a low expression group (scores 0 and 1) and a high expression group (scores 2 and 3). The primary outcomes were progression-free survival (PFS) and overall survival (OS), which were analyzed using Kaplan‒Meier and Cox proportional hazards models. Objective response rates were assessed in secondary outcomes.

RESULTS

Of the 50 patients, 43 were men (86%), with a median age of 63.9 years. Half of the patients exhibited low GDF-15 expression. High GDF-15 expression correlated with shorter PFS and OS. The median PFS was 7.8 months for the low-expression group versus 4.4 months for the high-expression group (HR, 0.41; 95% CI, 0.20-0.83; p = 0.013). The median OS was 18.1 months for the low-expression group compared to 11.8 months for the high-expression group (HR, 0.36; 95% CI, 0.16-0.78; p = 0.007). The objective response rate was significantly greater in the low GDF-15 group (52%) than in the high GDF-15 group (24%) (p = 0.040).

CONCLUSION

Elevated GDF-15 expression in NSCLC tumor tissues is associated with poorer response to nivolumab, suggesting that GDF-15 is a potential prognostic biomarker for immunotherapy efficacy. These findings warrant further validation through prospective studies to optimize treatment strategies for NSCLC patients.

The performance status gap in immunotherapy for frail patients with advanced non-small cell lung cancer

PURPOSE

In advanced non-small cell lung cancer (NSCLC), immune checkpoint inhibitor (ICI) monotherapy is often preferred over intensive ICI treatment for frail patients and those with poor performance status (PS). Among those with poor PS, the additional effect of frailty on treatment selection and mortality is unknown.

METHODS

Patients in the veterans affairs national precision oncology program from 1/2019-12/2021 who received first-line ICI for advanced NSCLC were followed until death or study end 6/2022. Association of an electronic frailty index with treatment selection was examined using logistic regression stratified by PS. We also examined overall survival (OS) on intensive treatment using Cox regression stratified by PS. Intensive treatment was defined as concurrent use of platinum-doublet chemotherapy and/or dual checkpoint blockade and non-intensive as ICI monotherapy.

RESULTS

Of 1547 patients receiving any ICI, 66.2% were frail, 33.8% had poor PS (≥ 2), and 25.8% were both. Frail patients received less intensive treatment than non-frail patients in both PS subgroups (Good PS: odds ratio [OR] 0.67, 95% confidence interval [CI] 0.51 - 0.88; Poor PS: OR 0.69, 95% CI 0.44 - 1.10). Among 731 patients receiving intensive treatment, frailty was associated with lower OS for those with good PS (hazard ratio [HR] 1.53, 95% CI 1.2 - 1.96), but no association was observed with poor PS (HR 1.03, 95% CI 0.67 - 1.58).

CONCLUSION

Frail patients with both good and poor PS received less intensive treatment. However, frailty has a limited effect on survival among those with poor PS. These findings suggest that PS, not frailty, drives survival on intensive treatment.

Risk factors for severe immune-related pneumonitis after nivolumab plus ipilimumab therapy for non-small cell lung cancer

BACKGROUND

The efficacy of anti-CTLA-4 antibody (ipilimumab) plus anti-programmed cell death 1 antibody (nivolumab) in treating advanced non-small cell lung cancer (NSCLC) is impeded by an elevated risk of severe immune-related adverse events. However, our understanding of associations among pre-existing fibrosis, emphysematous changes, and objective indicators as predictive factors is limited for severe pneumonitis in NSCLC patients receiving this combination therapy. Thus, we retrospectively investigated these associations, including overall tumor burden, before treatment initiation in the Japanese population.

METHODS

We focused on patients (n = 76) with pre-existing interstitial lung disease (ILD) to identify predictors of severe pneumonitis. Variables included age, sex, smoking status, programmed cell death ligand 1 expression, overall tumor burden, chest computed tomography-confirmed fibrosis, serum markers, and respiratory function test results.

RESULTS

Severe pneumonitis was more frequent in patients with squamous cell carcinoma, fibrosis, low diffusing capacity for carbon monoxide (%DLCO), and high surfactant protein D (SP-D) level. Notably, squamous cell carcinoma, baseline %DLCO, and SP-D level were significant risk factors. Our findings revealed the nonsignificance of tumor burden (≥85 mm) in predicting severe pneumonitis, emphasizing the importance of pre-existing ILD. Conversely, in cases without pre-existing fibrosis, severe pneumonitis was not associated with %DLCO or SP-D level (93.2% vs. 91.9%, and 63.3 vs. 40.9 ng/mL, respectively) and was more common in patients with a large overall tumor burden (97.5 vs. 70.0 mm).

CONCLUSION

Vigilant monitoring and early intervention are crucial for patients with squamous cell carcinoma, high SP-D level, or low %DLCO undergoing ipilimumab plus nivolumab therapy.

DUX4 is a common driver of immune evasion and immunotherapy failure in metastatic cancers

Cancer immune evasion contributes to checkpoint immunotherapy failure in many patients with metastatic cancers. The embryonic transcription factor DUX4 was recently characterized as a suppressor of interferon-γ signaling and antigen presentation that is aberrantly expressed in a small subset of primary tumors. Here, we report that DUX4 expression is a common feature of metastatic tumors, with ~10-50% of advanced bladder, breast, kidney, prostate, and skin cancers expressing DUX4. DUX4 expression is significantly associated with immune cell exclusion and decreased objective response to PD-L1 blockade in a large cohort of urothelial carcinoma patients. DUX4 expression is a significant predictor of survival even after accounting for tumor mutational burden and other molecular and clinical features in this cohort, with DUX4 expression associated with a median reduction in survival of over 1 year. Our data motivate future attempts to develop DUX4 as a biomarker and therapeutic target for checkpoint immunotherapy resistance.

Beyond the Barrier: Unraveling the Mechanisms of Immunotherapy Resistance

Immune checkpoint blockade (ICB) induces a remarkable and durable response in a subset of cancer patients. However, most patients exhibit either primary or acquired resistance to ICB. This resistance arises from a complex interplay of diverse dynamic mechanisms within the tumor microenvironment (TME). These mechanisms include genetic, epigenetic, and metabolic alterations that prevent T cell trafficking to the tumor site, induce immune cell dysfunction, interfere with antigen presentation, drive heightened expression of coinhibitory molecules, and promote tumor survival after immune attack. The TME worsens ICB resistance through the formation of immunosuppressive networks via immune inhibition, regulatory metabolites, and abnormal resource consumption. Finally, patient lifestyle factors, including obesity and microbiome composition, influence ICB resistance. Understanding the heterogeneity of cellular, molecular, and environmental factors contributing to ICB resistance is crucial to develop targeted therapeutic interventions that enhance the clinical response. This comprehensive overview highlights key mechanisms of ICB resistance that may be clinically translatable.

Checkpoint Inhibitor Monotherapy in Potentially Trial-Eligible or Trial-Ineligible Patients With Metastatic NSCLC in the German Prospective CRISP Registry Real-World Cohort (AIO-TRK-0315)

Introduction

Patients with metastatic NSCLC (mNSCLC) treated with immune checkpoint inhibitors in clinical practice may often not meet the strict inclusion criteria of clinical trials. Our aim was to assess the trial eligibility of patients with mNSCLC treated with pembrolizumab monotherapy in real-world and to compare the outcome of "trial-ineligible" and "potentially trial-eligible" patients.

Methods

Data from the prospective, clinical research platform CRISP were used to compare patient characteristics, treatment, and outcome of patients with programmed cell death-ligand 1 tumor proportion score greater than or equal to 50% tumors treated with pembrolizumab monotherapy who are deemed either "potentially trial-eligible" or "trial-ineligible" according to inclusion and exclusion criteria of the registrational studies (KEYNOTE-024 and -042).

Results

Of 746 patients included, 343 patients (46.0%) were classified as "trial-ineligible" and had significantly worse outcomes compared with "potentially trial-eligible" patients (n = 403, 54.0%): median progression-free survival: 6.2 (95% confidence interval [CI]: 5.2-8.4) versus 10.3 (95% CI: 8.4-13.8) months, hazard ratio (trial-ineligible versus potentially trial-eligible) of 1.43 (95% CI: 1.19-1.72), p less than 0.001; median overall survival: 15.9 (95% CI: 11.4-20.3) versus 25.3 (95% CI: 19.8-30.4) months, hazard ratio of 1.36 (95% CI: 1.10-1.67), p equals 0.004.

Conclusions

Our data reveal that a considerable proportion of patients with mNSCLC are not eligible to participate in a clinical trial and were found to have worse outcomes than potentially trial-eligible patients, whose outcomes were comparable with those obtained from pivotal clinical trials. This is of substantial clinical relevance for physicians discussing outcomes to be expected with their patients and stresses the need for real-world effectiveness analyses.

Impact of lymph node dissection on the efficacy of immune checkpoint inhibitors in patients with postoperative recurrence of non-small cell lung cancer

Background

The effect of lymph node dissection (LND) on the efficacy of immune checkpoint inhibitor (ICI) remains unclear. The purpose of this study was to examine the difference in the effect of ICI between patients with non-small cell lung cancer (NSCLC) according to the extent of LND performed in surgery prior to postoperative recurrence.

Methods

A total of 134 patients with postoperative recurrence (surgery group, n=26) or unresectable advanced lung cancer (non-surgery group, n=108) who were treated with ICIs between January 2016 and December 2022 were included for analysis. In the surgery group, 16 patients underwent systematic LND, whereas the remaining 10 patients underwent selective LND. Progression-free survival with ICI treatment (ICI-PFS) and overall survival (OS) were compared between the surgery and non-surgery groups and between the systematic and selective LND groups using the inverse probability of treatment weighting (IPTW) method to adjust for patient background characteristics.

Results

In the IPTW-adjusted analysis, the 2-year PFS rate with ICI treatment was 31.2% in the surgery group and 27.3% in the non-surgery group (P=0.19); the corresponding 2-year OS rates were 69.6% and 62.2%, respectively (P=0.10). In the surgery group, the 2-year PFS rates under ICI were 20.0% in the systematic LND group and 45.7% in the selective LND group (P=0.03).

Conclusions

IPTW-adjusted analysis indicated no difference in prognosis between patients with postoperative recurrence and those with advanced unresectable lung cancer. However, in patients with postoperative recurrence, the extent of LND was a significant predictor of ICI-PFS. These findings suggest that systematic LND may reduce the efficacy of ICI, indicating that preoperative ICI administration may be warranted.

Effect of autologous dendritic cell cytokine-induced killer on refractory metastatic colorectal cancer: a matched case-control comparative study

Background

Patients with metastatic colorectal cancer (mCRC) who are refractory to two or more lines of systemic chemotherapy have limited therapeutic options. The aim of this study was to evaluate the effect of autologous dendritic cell cytokine-induced killer (DC-CIK) transfer on the survival of patients with mCRC who are refractory or intolerant to at least two lines of systemic chemotherapies.

Methods

A matched case-control comparative study was conducted with patients who received DC-CIK immunotherapy in addition to standard chemotherapy (cases) and those with standard chemotherapy alone (controls). The primary objective was to compare the duration of oncologic survival, including overall survival (OS) and progression-free survival (PFS), between the two groups.

Results

A total of 27 cases and 27 controls were included. The median OS in the DC-CIK case group was 18.73 ± 5.48 months, which was significantly longer than that in the control group (14.23 ± 1.90 months, p = 0.045). However, there was no significant difference in PFS between the two groups (p = 0.086). Subgroup analysis showed that in patients with liver or extra-regional lymph node metastasis, DC-CIK cases had longer OS than controls (17.0 vs. 11.87 months, p = 0.019; not match vs. 6.93 months, p = 0.002, respectively). In patients with Eastern Cooperative Oncology Group (ECOG) scale 0 or wild RAS/BRAF, DC-CIK cases showed a significant increase in OS duration compared to controls (28.03 vs. 14.53 months, p = 0.038; 18.73 vs. 11.87 months, p = 0.013, respectively).

Conclusions

The addition of autologous DC-CIK to standard chemotherapy had a positive effect on OS of patients with refractory mCRC, especially those with liver or extra-regional lymph node metastasis, ECOG = 0, and wild RAS/BRAF status.

The role of microbiomes in gastrointestinal cancers: new insights

Gastrointestinal (GI) cancers constitute more than 33% of new cancer cases worldwide and pose a considerable burden on public health. There exists a growing body of evidence that has systematically recorded an upward trajectory in GI malignancies within the last 5 to 10 years, thus presenting a formidable menace to the health of the human population. The perturbations in GI microbiota may have a noteworthy influence on the advancement of GI cancers; however, the precise mechanisms behind this association are still not comprehensively understood. Some bacteria have been observed to support cancer development, while others seem to provide a safeguard against it. Recent studies have indicated that alterations in the composition and abundance of microbiomes could be associated with the progression of various GI cancers, such as colorectal, gastric, hepatic, and esophageal cancers. Within this comprehensive analysis, we examine the significance of microbiomes, particularly those located in the intestines, in GI cancers. Furthermore, we explore the impact of microbiomes on various treatment modalities for GI cancer, including chemotherapy, immunotherapy, and radiotherapy. Additionally, we delve into the intricate mechanisms through which intestinal microbes influence the efficacy of GI cancer treatments.

A Multi-Institutional Natural Language Processing Pipeline to Extract Performance Status From Electronic Health Records

PURPOSE

Performance status (PS), an essential indicator of patients' functional abilities, is often documented in clinical notes of patients with cancer. The use of natural language processing (NLP) in extracting PS from electronic medical records (EMRs) has shown promise in enhancing clinical decision-making, patient monitoring, and research studies. We designed and validated a multi-institute NLP pipeline to automatically extract performance status from free-text patient notes.

PATIENTS AND METHODS

We collected data from 19,481 patients in Harris Health System (HHS) and 333,862 patients from veteran affair's corporate data warehouse (VA-CDW) and randomly selected 400 patients from each data source to train and validate (50%) and test (50%) the proposed pipeline. We designed an NLP pipeline using an expert-derived rule-based approach in conjunction with extensive post-processing to solidify its proficiency. To demonstrate the pipeline's application, we tested the compliance of PS documentation suggested by the American Society of Clinical Oncology (ASCO) Quality Metric and investigated the potential disparity in PS reporting for stage IV non-small cell lung cancer (NSCLC). We used a logistic regression test, considering patients in terms of race/ethnicity, conversing language, marital status, and gender.

RESULTS

The test results on the HHS cohort showed 92% accuracy, and on VA data demonstrated 98.5% accuracy. For stage IV NSCLC patients, the proposed pipeline achieved an accuracy of 98.5%. Furthermore, our analysis revealed a documentation rate of over 85% for PS among NSCLC patients, surpassing the ASCO Quality Metrics. No disparities were observed in the documentation of PS.

CONCLUSION

Our proposed NLP pipeline shows promising results in extracting PS from free-text notes from various health institutions. It may be used in longitudinal cancer data registries.

DUX4 is a common driver of immune evasion and immunotherapy failure in metastatic cancers

Cancer immune evasion contributes to checkpoint immunotherapy failure in many patients with metastatic cancers. The embryonic transcription factor DUX4 was recently characterized as a suppressor of interferon-γ signaling and antigen presentation that is aberrantly expressed in a small subset of primary tumors. Here, we report that DUX4 expression is a common feature of metastatic tumors, with ~10-50% of advanced bladder, breast, kidney, prostate, and skin cancers expressing DUX4. DUX4 expression is significantly associated with immune cell exclusion and decreased objective response to PD-L1 blockade in a large cohort of urothelial carcinoma patients. DUX4 expression is a significant predictor of survival even after accounting for tumor mutational burden and other molecular and clinical features in this cohort, with DUX4 expression associated with a median reduction in survival of over one year. Our data motivate future attempts to develop DUX4 as a biomarker and therapeutic target for checkpoint immunotherapy resistance.

Combination of immunotherapy, radiotherapy and denosumab as the best approach even for NSCLC poor prognosis patients: a case report with strong response, prolonged survival and a review of literature

Non-Small Cell Lung Cancer (NSCLC) with bone metastasis and poor performance status has the worst prognosis even in strong PD-L1 expression patients. Treatment approach includes immuno- or chemo-immunotherapy, Radiotherapy (RT) and Bone-Targeted Therapy (BTT) but there is insufficient data to suggest the best time to use each of them, alone or in combination. Using an integrated and synergistic treatment strategy with immunotherapy, radiotherapy, and Denosumab as BTT is probably the best treatment planning for metastatic NSCLC for both good and poor performance status patients, although more data are needed to confirm this approach. Here we describe an interesting case report on patient with extensive bone involvement from NSCLC and PS >2 treated simultaneously with radiotherapy, immunotherapy and BTT, achieving an excellent clinical benefit, radiological and metabolic complete response, as a sort of Lazarus effect. We analyzed our result comparing with currently published data about radio-immunotherapy or immunotherapy and BTT combination even though there is no published experience about integration of all 3 treatments. Approval studies often do not represent real-world experience (RWE), so we analyzed data from both RWE and clinical trials.

The landscape of immune therapy in vulnerable patients with advanced non-small cell lung cancer: a narrative review

BACKGROUND AND OBJECTIVE

The clinical development of immune checkpoint inhibitors (ICIs) has led to substantial advances in the treatment of lung cancer. In particular, the contribution of ICIs to the long-term survival of certain patients with non-small cell lung cancer (NSCLC) has been reported. With the accumulated experience in the use of ICIs, numerous studies have documented the efficacy and safety of ICIs in patients with diverse backgrounds, including those with problematic indications for drug therapy. In the current review, we summarize the most recent literature-based findings on ICI administration in vulnerable patients with NSCLC and provide an overview of the current status and prospects of ICIs.

METHODS

Herein, we defined vulnerable as the group of patients with NSCLC and performance status (PS) ≥2 (poor PS), advanced age (≥75 years), or cancer cachexia. We conducted a narrative review of the literature on the efficacy and safety of ICIs in vulnerable patients with advanced NSCLC.

KEY CONTENT AND FINDINGS

Among the vulnerable patient group, poor PS was a strong, poor prognostic factor, even in patients undergoing ICI therapy. ICI therapy in older patients can be effective, although adverse events (AEs) should be carefully monitored. The efficacy of ICI therapy in patients with cancer cachexia is poor, with further therapeutic development warranted.

CONCLUSIONS

Although prior studies have evaluated lung cancer pharmacotherapy in various vulnerable populations, clinical studies on the application of ICIs in patients with vulnerable NSCLC are lacking in both number and quality. Further development of these therapeutic agents, with the emergence of additional evidence regarding their appropriate use in this population, is expected.

Pembrolizumab monotherapy for non-small cell lung cancer (NSCLC): can patient stratification be improved in the UK Tayside population? A retrospective cohort study

OBJECTIVE

Pembrolizumab is a programmed cell death protein-1 (PD-1) inhibitor used to treat advanced patients with non-small cell lung cancer (NSCLC) with a programmed cell death ligand-1 (PD-L1) tumour proportion score (TPS) ≥50. Further sub-division of TPS-based stratification has not been evaluated in the UK, although smoking-induced tumour mutational burden and the immunogenic effects of prior radiotherapy are suggested to improve response.

AIMS

To investigate if PD-L1 TPS ≥80%, smoking status or radiotherapy before or within 2 months of treatment influenced progression-free survival (PFS) in patients with NSCLC treated with pembrolizumab monotherapy.

METHODS

PD-L1 TPS, smoking status and radiotherapy exposure were compared in patients with NSCLC in National Health Service (NHS) Tayside (n=100) treated with pembrolizumab monotherapy between 1 November 2017 and 18 February 2022. Survival estimates were compared using log-rank analysis, and Cox proportional hazards analysis was used to investigate the influence of potential confounding factors, including tumour stage and performance status.

RESULTS

PFS was not significantly different (log-rank HR=0.330, p=0.566) comparing patients with PD-L1 TPS 50-79% and PD-L1 TPS ≥80%. Smokers had significantly improved PFS (log-rank HR=4.867, p=0.027), while patients receiving radiotherapy had significantly decreased PFS (log-rank HR=6.649, p=0.012). A Cox regression model confirmed that both radiotherapy (p=0.022) and performance status (p=0.009) were independent negative predictors of PFS.

CONCLUSIONS

More rigorous PD-L1 TPS stratification did not influence survival outcomes. Smoking history improved PFS, although it was not an independent response predictor, while radiotherapy and performance status independently influenced clinical response. We suggest that further stratification of PD-L1 TPS is not warranted, while performance status and radiotherapy treatment may be additional clinically useful biomarkers of response to pembrolizumab in patients with NSCLC.

IPSOS trial: A "game changer" redefining first-line immunotherapy in platinum-ineligible NSCLC

First-line therapy for advanced non-small cell lung cancer (NSCLC) involves immunotherapy with or without platinum-based chemotherapy; however, not all patients are fit enough. In the IPSOS trial, atezolizumab monotherapy demonstrated a clinical benefit in platinum-ineligible patients with advanced NSCLC, redefining first-line immunotherapy, and breaking barriers for unfit population in NSCLC.

Mean Platelet Volume to Lymphocyte Ratio: A New Biomarker Predicting Response in Patients with Solid Tumors Treated with Nivolumab

Introduction

Although immune checkpoint inhibitors (ICIs) are widely used in cancer treatment, identifying factors that predict treatment response remains a challenge in clinical practice. There is a need for biomarkers to identify patients who may not benefit from these treatments. It is crucial to identify a simple and cost-effective biomarker that can be easily incorporated into clinical practice. This study aims to investigate the mean platelet volume to lymphocyte ratio (MPVLR), as measured by a hemogram test, and median overall survival (mOS) in patients with cancer treated with nivolumab.

Methods

A total of 131 adult patients with metastatic cancer, including malignant melanoma (MM), renal cell carcinoma (RCC), non-small cell lung cancer (NSCLC), and head and neck cancer (HNC), were included in this study. Baseline demographics, ECOG (Eastern Cooperative Oncology Group) performance status, tumor type, and blood count parameters were recorded. Univariate and multivariate analyses were conducted to evaluate potential risk factors.

Results

The median age of the patients was 59.87 ± 11.97 years, and the median follow-up period was 20.20 months (IQR, 12.80-27.60). RCC (43.5%) and MM (25.9%) were the most common diagnoses. Patients with ECOG scores of 0-1 had a longer mOS than those with scores of 2-3 (mOS: 20.60 months [95% CI, 14.94-25.29] vs. 5.24 months [95% CI, 0-16.42], p < 0.001). Additionally, patients with lactate dehydrogenase (LDH) levels within the normal range had a longer mOS than those with high LDH levels (mOS: 24.54 months [95% CI, 14.13-34.96] vs. 13.10 months [95% CI, 4.49-21.72], p = 0.038). Patients with low MPVLR also had a longer mOS than those with high MPVLR (mOS: 33.70 months [95% CI, 25.99-41.42] vs. 11.07 months [95% CI, 6.89-15.24], p < 0.001). In the multivariate Cox regression analysis, high MPVLR, ECOG score of 2-3, and high LDH level were associated with shorter mOS (p < 0.001, p = 0.001, and p = 0.046, respectively).

Conclusion

This study demonstrates that MPVLR could serve as a novel biomarker for predicting response to nivolumab treatment. Incorporating MPVLR into clinical practice may aid in identifying patients who are less likely to benefit from the treatment.

Real-world outcomes of 18,186 metastatic solid tumor outpatients: Baseline blood cell counts correlate with survival after immune checkpoint inhibitor therapy

BACKGROUND

Patient survival in advanced/metastatic melanoma, non-small cell lung cancer (NSCLC), and renal cell carcinoma (RCC) has improved with immune checkpoint inhibitors (ICI). Biomarkers' role in prognosis and treatment has been limited by conflicting trial results.

METHODS

This retrospective, observational study analyzed baseline demographic, clinical, laboratory, and treatment data versus outcomes of The US Oncology Network adult outpatients. Patients with advanced/metastatic melanoma, NSCLC, or RCC treated between January 1, 2015 and November 30, 2020 were given ICI monotherapy or combination therapy with ipilimumab, pembrolizumab, nivolumab, or atezolizumab. Treatment outcomes (overall survival [OS], time to treatment discontinuation, time to next treatment) were followed longitudinally until May 31, 2021, last patient record, or date of death. Baseline blood cell counts, including absolute monocyte count (AMC), absolute lymphocyte count (ALC), monocyte-to-lymphocyte ratio (MLR), absolute neutrophil count (ANC), and eosinophil count, were subdivided into quintiles for univariate and multivariable Cox regression analyses.

RESULTS

Data from 18,186 patients with advanced/metastatic melanoma (n = 3314), NSCLC (n = 12,416), and RCC (n = 2456) were analyzed. Better OS correlated with increased baseline serum albumin concentration, increased eosinophil and lymphocyte counts, and Western United States physician practice location. Decreased OS correlated with increased AMC, MLR, ANC, age, and worse Eastern Cooperative Oncology Group performance status.

CONCLUSIONS

To our knowledge, this study is the largest to date to associate baseline survival indicators and outcomes in outpatients with advanced/metastatic melanoma, NSCLC, or RCC and receiving ICIs. Results may inform disease-specific prognostic models and help providers identify patients most likely to benefit from ICI therapy.

Comparative efficacy & safety of buparlisib plus fulvestrant, fulvestrant plus dalpiciclib, and ribociclib plus letrozole for postmenopausal, hormone receptor-positive, and HER2-negative breast cancer

OBJECTIVES

This study aimed to compare progression-free survival, overall survival, clinical benefits, and adverse effects in postmenopausal women with hormone receptor-positive and HER2-negative breast cancer who received buparlisib plus fulvestrant against those of women who received dalpiciclib plus fulvestrant, considering ribociclib plus letrozole treatment as the reference standard.

METHODS

Women received buparlisib plus fulvestrant (BF cohort, n = 108), dalpiciclib plus fulvestrant (DF cohort, n = 132), or ribociclib plus letrozole (RL cohort, n = 150) until unacceptable toxicity was observed.

RESULTS

A total of 117 (89 %), 80 (74 %), and 84 (56 %) women in the BF, DF, and RL cohorts, respectively, had clinical benefits. After treatment, the clinical benefits for women and after 42 months of follow-up progression-free survival and overall survival were higher in the DF cohort than in the BF and RL cohorts (p < 0.05 for all). Neutropenia, vomiting, constipation, nausea, diarrhea, and anorexia were reported higher in women of the DF and BF cohorts than in women of the RL cohort. Leukopenia and increased levels of alanine aminotransferase and aspartate aminotransferase were reported to be higher in women in the RL cohort than in women in the DF and BF cohorts. Depression, anxiety, and increased levels of alanine aminotransferase and aspartate aminotransferase were reported to be higher in women in the BF cohort than in women in the DF and RL cohorts.

CONCLUSIONS

Dalpiciclib plus fulvestrant is effective and comparatively safe in postmenopausal women with hormone receptor-positive and HER2-negative breast cancers. Dalpiciclib, buparlisib, fulvestrant, and ribociclib cause neutropenia, severe depression, adverse gastroenterological effects, and adverse hepatological effects, respectively.