1
|
Verheijden RJ, Burgers FH, Janssen JC, Putker AE, Veenstra SPGR, Hospers GAP, Aarts MJB, Hehenkamp KW, Doornebosch VLE, Verhaert M, van den Berkmortel FWPJ, Chatzidionysiou K, Llobell A, Barros M, Maria ATJ, Takeji A, García Morillo JS, Lidar M, van Eijs MJM, Blank CU, Aspeslagh S, Piersma D, Kapiteijn E, Labots M, Boers-Sonderen MJ, van der Veldt AAM, Haanen JBAG, May AM, Suijkerbuijk KPM. Corticosteroids and other immunosuppressants for immune-related adverse events and checkpoint inhibitor effectiveness in melanoma. Eur J Cancer 2024; 207:114172. [PMID: 38905818 DOI: 10.1016/j.ejca.2024.114172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Accepted: 05/30/2024] [Indexed: 06/23/2024]
Abstract
BACKGROUND Recent studies indicate an association between immunosuppression for immune-related adverse events (irAEs) and impaired survival in patients who received immune checkpoint inhibitors. Whether this is related to corticosteroids or second-line immunosuppressants is unknown. In the largest cohort thus far, we assessed the association of immunosuppressant type and dose with survival in melanoma patients with irAEs. METHODS Patients with advanced melanoma who received immunosuppressants for irAEs induced by first-line anti-PD-1 ± anti-CTLA-4 were included from 18 hospitals worldwide. Associations of cumulative and peak dose corticosteroids and use of second-line immunosuppression with survival from start of immunosuppression were assessed using multivariable Cox proportional hazard regression. RESULTS Among 606 patients, 404 had anti-PD-1 + anti-CTLA-4-related irAEs and 202 had anti-PD-1-related irAEs. 425 patients (70 %) received corticosteroids only; 181 patients (30 %) additionally received second-line immunosuppressants. Median PFS and OS from starting immunosuppression were 4.5 (95 %CI 3.4-8.1) and 31 (95 %CI 15-not reached) months in patients who received second-line immunosuppressants, and 11 (95 %CI 9.4-14) and 55 (95 %CI 41-not reached) months in patients who did not. High corticosteroid peak dose was associated with worse PFS and OS (HRadj 1.14; 95 %CI 1.01-1.29; HRadj 1.29; 95 %CI 1.12-1.49 for 80vs40mg), while cumulative dose was not. Second-line immunosuppression was associated with worse PFS (HRadj 1.32; 95 %CI 1.02-1.72) and OS (HRadj 1.34; 95 %CI 0.99-1.82) compared with corticosteroids alone. CONCLUSIONS High corticosteroid peak dose and second-line immunosuppressants to treat irAEs are both associated with impaired survival. While immunosuppression is indispensable for treatment of severe irAEs, clinicians should weigh possible detrimental effects on survival against potential disadvantages of undertreatment.
Collapse
Affiliation(s)
- Rik J Verheijden
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584CX Utrecht, the Netherlands; Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Heidelberglaan 100, 3584CX Utrecht, the Netherlands
| | - Femke H Burgers
- Divisions of Medical Oncology & Molecular Oncology & Immunology, Netherlands Cancer Institute, Plesmanlaan 121, 1066CX Amsterdam, the Netherlands
| | - Josephine C Janssen
- Department of Medical Oncology and Surgical Oncology, Erasmus Medical Centre, 's Gravendijkwal 230, 3015CE Rotterdam, the Netherlands
| | - Anouk E Putker
- Department of Medical Oncology, Radboud University Medical Centre, Geert Grooteplein Zuid 10, 6525GA Nijmegen, the Netherlands
| | - Sophie P G R Veenstra
- Department of Medical Oncology, Amsterdam UMC location VUmc, Cancer Center Amsterdam, De Boelelaan 1117, 1081HV Amsterdam, the Netherlands
| | - Geke A P Hospers
- Department of Medical Oncology, University Medical Centre Groningen, University of Groningen, Hanzeplein 1, 9713GZ Groningen, the Netherlands
| | - Maureen J B Aarts
- Department of Medical Oncology, GROW-School for Oncology and Reproduction, Maastricht University Medical Centre+, P. Debyelaan 25, 6229HX Maastricht, the Netherlands
| | - Karel W Hehenkamp
- Department of Medical Oncology, Leiden University Medical Centre, Albinusdreef 2, 2333ZA Leiden, the Netherlands
| | - Veerle L E Doornebosch
- Department of Internal Medicine, Medisch Spectrum Twente, Koningsplein 1, 7512KZ Enschede, the Netherlands
| | - Marthe Verhaert
- Department of Medical Oncology, Laboratory of Medical and Molecular Oncology (LMM0), Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090 Jette, Belgium
| | | | | | - Arturo Llobell
- R3 Rheumatology, Parc Taulí University Hospital, Sabadell, Barcelona 1-08208, Spain
| | - Milton Barros
- Department of Clinical Oncology, AC Camargo Cancer Center, R. Professor Antônio Prudente, 211 Liberdade, Sao Paulo, Brazil
| | - Alexandre T J Maria
- Department of Internal Medicine, CHRU de Montpellier, 371 avenue du Doyen Gaston Giraud, 34090 Montpellier, France
| | - Akari Takeji
- Division of Rheumatology, Kanazawa University Hospital, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa 920-8640, Japan
| | - José-Salvador García Morillo
- Unidad de Enfermedades Autoinmunes Sistemicas y Raras del Adulto, UGC Medicina Interna, Hospital Universitario Virgen del Rocío, Avda de Manuel Siurot s/n., 41013 Sevilla, Spain
| | - Merav Lidar
- Rheumatology Unit, Sheba Medical Center, Derech Sheba 2, Tel HaShomer, Israel
| | - Mick J M van Eijs
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584CX Utrecht, the Netherlands; Center for Translational Immunology, University Medical Center Utrecht, Utrecht University, Lundlaan 6, 3584EA Utrecht, the Netherlands
| | - Christian U Blank
- Department of Medical Oncology & Immunology, Netherlands Cancer Institute, Plesmanlaan 121, 1066CX Amsterdam, the Netherlands
| | - Sandrine Aspeslagh
- Department of Medical Oncology, Laboratory of Medical and Molecular Oncology (LMM0), Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090 Jette, Belgium
| | - Djura Piersma
- Department of Internal Medicine, Medisch Spectrum Twente, Koningsplein 1, 7512KZ Enschede, the Netherlands
| | - Ellen Kapiteijn
- Department of Medical Oncology, Leiden University Medical Centre, Albinusdreef 2, 2333ZA Leiden, the Netherlands
| | - Mariette Labots
- Department of Medical Oncology, Amsterdam UMC location VUmc, Cancer Center Amsterdam, De Boelelaan 1117, 1081HV Amsterdam, the Netherlands
| | - Marye J Boers-Sonderen
- Department of Medical Oncology, Radboud University Medical Centre, Geert Grooteplein Zuid 10, 6525GA Nijmegen, the Netherlands
| | - Astrid A M van der Veldt
- Department of Medical Oncology and Radiology & Nuclear Medicine, Erasmus Medical Centre, 's Gravendijkwal 230, 3015CE Rotterdam, the Netherlands
| | - John B A G Haanen
- Divisions of Medical Oncology & Molecular Oncology & Immunology, Netherlands Cancer Institute, Plesmanlaan 121, 1066CX Amsterdam, the Netherlands; Department of Medical Oncology, Leiden University Medical Centre, Albinusdreef 2, 2333ZA Leiden, the Netherlands; Melanoma clinic, Centre Hospitalier Universitaire Vaudois, Rue du Bugnon 23, 1011 Lausanne, Switzerland
| | - Anne M May
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Heidelberglaan 100, 3584CX Utrecht, the Netherlands
| | - Karijn P M Suijkerbuijk
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584CX Utrecht, the Netherlands.
| |
Collapse
|
2
|
Syed S, Hines J, Baccile R, Rouhani S, Reid P. Studying Outcomes after Steroid-Sparing Immunosuppressive Agent vs. Steroid-Only Treatment for Immune-Related Adverse Events in Non-Small-Cell Lung Cancer (NSCLC) and Melanoma: A Retrospective Case-Control Study. Cancers (Basel) 2024; 16:1892. [PMID: 38791970 PMCID: PMC11119129 DOI: 10.3390/cancers16101892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 05/06/2024] [Accepted: 05/11/2024] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND The effects of steroid-sparing immunosuppressive agents (SSIAs), used for the treatment of immune-related adverse events (irAEs), on immune checkpoint inhibitor (ICI) antitumor activity is not well known. We compared tumor outcomes of patients who received corticosteroid monotherapy (CS) versus a corticosteroid plus SSIA (CS-SSIA) for irAE treatment, using statistical methods to address immortal time bias. METHODS We conducted a retrospective case-control study on patients ≥ 18 years with melanoma or non-small-cell lung cancer (NSCLC) treated with ≥1 ICI at a quaternary care center between 1 January 2016 and 11 January 2021. Patients were divided into two cohorts: CS or CS-SSIA. We used propensity score nearest-neighbor matching to match on tumor type, stage, and prior lines of therapy. Primary outcomes were progression-free survival (PFS) and overall survival (OS). Secondary outcomes included the time from the start of the irAE treatment to the irAE resolution. Hazard ratios (HRs) for PFS and OS were calculated using the Cox proportional hazard regression method with both (1) the time to the steroid and SSIA as time-varying covariates and (2) a binary exposure classification not accounting for the time to the treatment. RESULTS A total of 167 patients were included after matching (132 in the CS cohort and 35 in the CS-SSIA cohort). Sixty-six percent of all the patients had melanoma. The most common irAEs requiring treatment were gastroenterocolitis and hepatitis. In an adjusted analysis not accounting for immortal time bias, there were no significant differences in PFS (HR 0.75, 95% CI [0.46-1.23]) or OS (HR 0.82, 95% CI [0.46-1.47]). In analyses using a time-varying treatment indicator, there was a trend toward improved PFS in patients treated with SSIAs (HR 0.54, CI 0.26-1.10). There was no difference in OS (HR 1.11, CI 0.55-2.23). Patients with melanoma who specifically received infliximab had improved PFS compared to patients with CS only, after adjusting for immortal time bias (HR 0.32, CI 0.24-0.43). CONCLUSIONS The use of SSIAs with CS did not have worse outcomes than CS monotherapy. In melanoma, our findings showed improved PFS for the use of infliximab versus steroid monotherapy for irAEs. Large, prospective, randomized controlled trials are needed to confirm these findings and guide the optimal treatment of irAEs.
Collapse
Affiliation(s)
- Sharjeel Syed
- Department of Medicine, University of Chicago, Chicago, IL 60637, USA;
| | - Jacobi Hines
- Division of Hematology-Oncology, Department of Medicine, University of Chicago, Chicago, IL 60637, USA
| | - Rachel Baccile
- Center for Health and The Social Sciences, University of Chicago, Chicago, IL 60637, USA
| | - Sherin Rouhani
- Mass General Cancer Center, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Pankti Reid
- Division of Rheumatology, Department of Medicine, University of Chicago, Chicago, IL 60637, USA
| |
Collapse
|
4
|
McCarter KR, Arabelovic S, Wang X, Wolfgang T, Yoshida K, Qian G, Kowalski EN, Vanni KMM, LeBoeuf NR, Buchbinder EI, Gedmintas L, MacFarlane LA, Rao DA, Shadick NA, Gravallese EM, Sparks JA. Immunomodulator use, risk factors and management of flares, and mortality for patients with pre-existing rheumatoid arthritis after immune checkpoint inhibitors for cancer. Semin Arthritis Rheum 2024; 64:152335. [PMID: 38100899 PMCID: PMC10842881 DOI: 10.1016/j.semarthrit.2023.152335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 11/17/2023] [Accepted: 11/28/2023] [Indexed: 12/17/2023]
Abstract
OBJECTIVE To investigate immunomodulator use, risk factors and management for rheumatoid arthritis (RA) flares, and mortality for patients with pre-existing RA initiating immune checkpoint inhibitors (ICI) for cancer. METHODS We performed a retrospective cohort study of all patients with RA meeting 2010 ACR/EULAR criteria that initiated ICI for cancer at Mass General Brigham or Dana-Farber Cancer Institute in Boston, MA (2011-2022). We described immunomodulator use and changes at baseline of ICI initiation. We identified RA flares after baseline, categorized the severity, and described the management. Baseline factors were examined for RA flare risk using Fine and Gray competing risk models. We performed a landmark analysis to limit the potential for immortal time bias, where the analysis started 3 months after ICI initiation. Among those who survived at least 3 months, we examined whether RA flare within 3 months after ICI initiation was associated with mortality using Cox regression. RESULTS Among 11,901 patients who initiated ICI for cancer treatment, we analyzed 100 pre-existing RA patients (mean age 70.3 years, 63 % female, 89 % on PD-1 monotherapy, 50 % lung cancer). At ICI initiation, 71 % were seropositive, 82 % had remission/low RA disease activity, 24 % were on glucocorticoids, 35 % were on conventional synthetic disease-modifying antirheumatic drugs (DMARDs), and 10 % were on biologic or targeted synthetic DMARDs. None discontinued glucocorticoids and 3/35 (9 %) discontinued DMARDs in anticipation of starting ICI. RA flares occurred in 46 % (incidence rate 1.84 per 1000 person-months, 95 % CI 1.30, 2.37); 31/100 flared within 3 months of baseline. RA flares were grade 1 in 16/46 (35 %), grade 2 in 25/46 (54 %), and grade 3 in 5/46 (11 %); 2/46 (4 %) required hospitalization for RA flare. Concomitant immune-related adverse events occurred in 15/46 (33 %) that flared. A total of 72/100 died during follow-up; 21 died within 3 months of baseline. Seropositivity had an age-adjusted sdHR of 1.95 (95 % CI 1.02, 3.71) for RA flare compared to seronegativity, accounting for competing risk of death. Otherwise, no baseline factors were associated with RA flare, including cancer type, disease activity, RA duration, and deformities. 9/46 (20 %) patients had their ICI discontinued/paused due to RA flares. In the landmark analysis among 79 patients who survived at least 3 months, RA flare in the first 3 months was not associated with lower mortality (adjusted HR 1.24, 95 % CI 0.71, 2.16) compared to no RA flare. CONCLUSION Among patients with pre-existing RA, few changed immunomodulator medications in anticipation of starting ICI, but RA flares occurred in nearly half. RA flares were mostly mild and treated with typical therapies. Seropositivity was associated with RA flare risk. A minority had severe RA flares requiring disruption of ICI, and RA flares were not associated with mortality.
Collapse
Affiliation(s)
- Kaitlin R McCarter
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, Massachusetts, United States of America
| | - Senada Arabelovic
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, Massachusetts, United States of America; Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
| | - Xiaosong Wang
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, United States of America; Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
| | - Taylor Wolfgang
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, Massachusetts, United States of America; Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
| | - Kazuki Yoshida
- Harvard Medical School, Boston, Massachusetts, United States of America; Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
| | - Grace Qian
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, United States of America; Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
| | - Emily N Kowalski
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, United States of America; Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
| | - Kathleen M M Vanni
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, United States of America; Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
| | - Nicole R LeBoeuf
- Harvard Medical School, Boston, Massachusetts, United States of America; Department of Dermatology, Brigham and Women's Hospital, Boston, Massachusetts, United States of America; Dana-Farber Cancer Institute, Boston, Massachusetts, United States of America
| | - Elizabeth I Buchbinder
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, Massachusetts, United States of America; Dana-Farber Cancer Institute, Boston, Massachusetts, United States of America
| | - Lydia Gedmintas
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, Massachusetts, United States of America; Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
| | - Lindsey A MacFarlane
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, Massachusetts, United States of America; Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
| | - Deepak A Rao
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, Massachusetts, United States of America; Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
| | - Nancy A Shadick
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, Massachusetts, United States of America; Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
| | - Ellen M Gravallese
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, Massachusetts, United States of America; Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
| | - Jeffrey A Sparks
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, Massachusetts, United States of America; Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, Massachusetts, United States of America.
| |
Collapse
|