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Olivier T, Haslam A, Prasad V. Postrecurrence Treatment in Neoadjuvant or Adjuvant FDA Registration Trials: A Systematic Review. JAMA Oncol 2024; 10:1055-1059. [PMID: 38900419 PMCID: PMC11190827 DOI: 10.1001/jamaoncol.2024.1569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 12/28/2023] [Indexed: 06/21/2024]
Abstract
Importance In oncology randomized clinical trials, suboptimal access to best available care at recurrence (or relapse) may affect overall survival results. Objective To assess the proportion and the quality of postrecurrence treatment received by patients enrolled in US Food and Drug Administration (FDA) registration trials of systemic therapy in the adjuvant or neoadjuvant setting. Evidence Review For this systematic review, all trials leading to an FDA approval from January 2018 through May 2023 were obtained from the FDA website and drug announcements. Randomized clinical trials of an anticancer drug in the neoadjuvant or the adjuvant setting were included. Trials of supportive care treatment and treatments given in combination with radiotherapy were excluded. Information abstracted for each trial included tumor type, setting, phase, type of sponsor, reporting and assessment of postrecurrence, and overall survival data. Findings A total of 14 FDA trials met the inclusion criteria. Postrecurrence data were not available in 6 of 14 registration trials (43%). Of the 8 remaining trials, postrecurrence treatment was assessed as suboptimal in 6 (75%). Overall, only 2 of 14 trials (14%) had data assessed as appropriate. Conclusions and Relevance This systematic review found that 43% of randomized clinical trials of anticancer treatment in the adjuvant or neoadjuvant context failed to present any assessable postrecurrence treatment data. In instances in which these data were shared, postrecurrence treatment was suboptimal 75% of the time. The findings suggest that regulatory bodies should enforce rules stipulating that patients have access to the best standard of care at recurrence.
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Affiliation(s)
- Timothée Olivier
- Department of Oncology, Geneva University Hospital, Geneva, Switzerland
| | - Alyson Haslam
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Vinay Prasad
- Department of Epidemiology and Biostatistics, University of California, San Francisco
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Mountzios G, Remon J, Hendriks LEL, García-Campelo R, Rolfo C, Van Schil P, Forde PM, Besse B, Subbiah V, Reck M, Soria JC, Peters S. Immune-checkpoint inhibition for resectable non-small-cell lung cancer - opportunities and challenges. Nat Rev Clin Oncol 2023; 20:664-677. [PMID: 37488229 DOI: 10.1038/s41571-023-00794-7] [Citation(s) in RCA: 53] [Impact Index Per Article: 53.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2023] [Indexed: 07/26/2023]
Abstract
Therapeutic strategies harnessing the immune system to eliminate tumour cells have been successfully used for several cancer types, including in patients with advanced-stage non-small-cell lung cancer (NSCLC). In these patients, immune-checkpoint inhibitors (ICIs) can provide durable responses and improve overall survival either as monotherapy, or combined with chemotherapy or other immunotherapeutic agents. However, the implementation of ICIs in early stage NSCLC has been hampered by the continuous struggle to develop robust end points to assess their efficacy in this setting, especially those enabling a fast and reproducible evaluation of the clinical activity of neoadjuvant strategies. Several trials are testing ICIs, alone or in combination with chemotherapy, in early stage NSCLC as an adjuvant, neoadjuvant or perioperative approach. As a novelty, most trials in the neoadjuvant setting have adopted pathological response as a primary end point. ICIs have been approved for use in the neoadjuvant and adjuvant settings on the basis of event-free survival and disease-free survival benefit, respectively; however, the correlation of these end points with overall survival remains unclear in these settings. Unresolved challenges for the optimal use of ICIs with curative intent include concerns about their applicability in daily clinical practice and about improving patient selection based on predictive biomarkers or assessment of pathological response and minimal residual disease. In this Review, we discuss the rationale, available strategies and current trial landscape for the implementation of ICIs in patients with resectable NSCLC, and we further elaborate on future approaches to optimize their clinical benefit.
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Affiliation(s)
- Giannis Mountzios
- Fourth Department of Medical Oncology and Clinical Trials Unit, Henry Dunant Hospital Center, Athens, Greece.
| | - Jordi Remon
- Department of Cancer Medicine, Gustave Roussy, Villejuif, France
| | - Lizza E L Hendriks
- Department of Respiratory Medicine, Maastricht University Medical Centre, GROW School for Oncology and Reproduction, Maastricht, Netherlands
| | | | - Christian Rolfo
- Center for Thoracic Oncology, The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Paul Van Schil
- Department of Thoracic and Vascular Surgery, University Hospital of Antwerp, Antwerp, Belgium
| | - Patrick M Forde
- Bloomberg~Kimmel Institute for Cancer Immunotherapy, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | - Benjamin Besse
- Department of Cancer Medicine, Gustave Roussy, Villejuif, France
- Department of Cancer Medicine, Université Paris-Saclay, Orsay, France
| | - Vivek Subbiah
- Department of Cancer Medicine, Sarah Cannon Research Institute, Nashville, TN, USA
| | - Martin Reck
- Department of Thoracic Oncology, Airway Research Center North, German Center of Lung Research, Lung Clinic, Grosshansdorf, Germany
| | | | - Solange Peters
- Oncology Department, CHUV, Lausanne University, Lausanne, Switzerland
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Sharma R, Ogale S, Smith NJ, Lee JS. Estimating recurrences prevented and costs avoided with atezolizumab in early non-small cell lung cancer in the United States. Cancer Med 2023; 12:7450-7458. [PMID: 36420712 PMCID: PMC10067035 DOI: 10.1002/cam4.5462] [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: 08/22/2022] [Revised: 10/12/2022] [Accepted: 11/11/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Recurrence of early-stage non-small cell lung cancer (eNSCLC) is associated with significant mortality and costs. Atezolizumab (ATZ) was recently approved as adjuvant treatment following resection and platinum-based chemotherapy for adults with stage II-IIIA NSCLC with PD-L1 expression ≥1% after demonstrating significant improvement in disease-free survival (DFS) relative to best supportive care (BSC) in the IMpower010 trial (NCT02486718). This study evaluated the population-level impact of ATZ as adjuvant treatment for eNSCLC in the United States by estimating the number and costs of recurrences avoided. METHODS A Monte Carlo simulation model estimated the cumulative number of recurrences and deaths prevented, along with direct, indirect, and terminal care costs, by treating eNSCLC patients with ATZ compared to BSC. The model included eligible patients treated in any given year and followed over a 5-year period. Recurrence and mortality rates and costs were based on the IMpower010 data and supplemented by estimates from published literature. RESULTS An estimated 4400 eNSCLC patients in the United States were eligible for adjuvant ATZ in any given year, of whom 2387 would experience recurrence within 5 years with BSC. Following the introduction of ATZ, 1030 (95% confidence interval [CI]: 1023, 1036) recurrences and 369 (95% CI: 362, 376) deaths would be avoided with estimated reductions in cumulative recurrence-related direct, indirect, and terminal care costs of $785 million, $15 million, and $32 million, respectively, over a 5-year time horizon. CONCLUSIONS Adjuvant ATZ is estimated to prevent a significant number of recurrences and reduce the economic burden of eNSCLC.
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Abboud K, Umoru G, Esmail A, Abudayyeh A, Murakami N, Al-Shamsi HO, Javle M, Saharia A, Connor AA, Kodali S, Ghobrial RM, Abdelrahim M. Immune Checkpoint Inhibitors for Solid Tumors in the Adjuvant Setting: Current Progress, Future Directions, and Role in Transplant Oncology. Cancers (Basel) 2023; 15:1433. [PMID: 36900226 PMCID: PMC10000896 DOI: 10.3390/cancers15051433] [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: 01/20/2023] [Revised: 02/16/2023] [Accepted: 02/20/2023] [Indexed: 02/26/2023] Open
Abstract
The rationale for administering immune checkpoint inhibitors (ICIs) in the adjuvant setting is to eradicate micro-metastases and, ultimately, prolong survival. Thus far, clinical trials have demonstrated that 1-year adjuvant courses of ICIs reduce the risk of recurrence in melanoma, urothelial cancer, renal cell carcinoma, non-small cell lung cancer, and esophageal and gastroesophageal junction cancers. Overall survival benefit has been shown in melanoma while survival data are still not mature in other malignancies. Emerging data also show the feasibility of utilizing ICIs in the peri-transplant setting for hepatobiliary malignancies. While ICIs are generally well-tolerated, the development of chronic immune-related adverse events, typically endocrinopathies or neurotoxicities, as well as delayed immune-related adverse events, warrants further scrutiny regarding the optimal duration of adjuvant therapy and requires a thorough risk-benefit determination. The advent of blood-based, dynamic biomarkers such as circulating tumor DNA (ctDNA) can help detect minimal residual disease and identify the subset of patients who would likely benefit from adjuvant treatment. In addition, the characterization of tumor-infiltrating lymphocytes, neutrophil-to-lymphocyte ratio, and ctDNA-adjusted blood tumor mutation burden (bTMB) has also shown promise in predicting response to immunotherapy. Until additional, prospective studies delineate the magnitude of overall survival benefit and validate the use of predictive biomarkers, a tailored, patient-centered approach to adjuvant ICIs that includes extensive patient counseling on potentially irreversible adverse effects should be routinely incorporated into clinical practice.
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Affiliation(s)
- Karen Abboud
- Department of Pharmacy, Houston Methodist Hospital, Houston, TX 77030, USA
| | - Godsfavour Umoru
- Department of Pharmacy, Houston Methodist Hospital, Houston, TX 77030, USA
| | - Abdullah Esmail
- Section of GI Oncology, Department of Medical Oncology, Houston Methodist Cancer Center, Houston, TX 77030, USA
| | - Ala Abudayyeh
- Section of Nephrology, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Naoka Murakami
- Division of Renal Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Humaid O. Al-Shamsi
- Department of Oncology, Burjeel Cancer Institute, Burjeel Medical City, Abu Dhabi P.O. Box 92510, United Arab Emirates
| | - Milind Javle
- Department of Gastrointestinal Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Ashish Saharia
- JC Walter Jr Center for Transplantation and Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston, TX 77030, USA
| | - Ashton A. Connor
- JC Walter Jr Center for Transplantation and Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston, TX 77030, USA
| | - Sudha Kodali
- JC Walter Jr Center for Transplantation and Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston, TX 77030, USA
| | - Rafik M. Ghobrial
- JC Walter Jr Center for Transplantation and Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston, TX 77030, USA
| | - Maen Abdelrahim
- Section of GI Oncology, Department of Medical Oncology, Houston Methodist Cancer Center, Houston, TX 77030, USA
- Cockrell Center of Advanced Therapeutics Phase I Program, Houston Methodist Research Institute, Houston, TX 77030, USA
- Department of Internal Medicine, Weill Cornell Medical College, New York, NY 14853, USA
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Chen P, Liu Y, Wen Y, Zhou C. Non-small cell lung cancer in China. Cancer Commun (Lond) 2022; 42:937-970. [PMID: 36075878 PMCID: PMC9558689 DOI: 10.1002/cac2.12359] [Citation(s) in RCA: 182] [Impact Index Per Article: 91.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 07/21/2022] [Accepted: 08/24/2022] [Indexed: 04/08/2023] Open
Abstract
In China, lung cancer is a primary cancer type with high incidence and mortality. Risk factors for lung cancer include tobacco use, family history, radiation exposure, and the presence of chronic lung diseases. Most early-stage non-small cell lung cancer (NSCLC) patients miss the optimal timing for treatment due to the lack of clinical presentations. Population-based nationwide screening programs are of significant help in increasing the early detection and survival rates of NSCLC in China. The understanding of molecular carcinogenesis and the identification of oncogenic drivers dramatically facilitate the development of targeted therapy for NSCLC, thus prolonging survival in patients with positive drivers. In the exploration of immune escape mechanisms, programmed cell death protein 1 (PD-1)/programmed death-ligand 1 (PD-L1) inhibitor monotherapy and PD-1/PD-L1 inhibitor plus chemotherapy have become a standard of care for advanced NSCLC in China. In the Chinese Society of Clinical Oncology's guidelines for NSCLC, maintenance immunotherapy is recommended for locally advanced NSCLC after chemoradiotherapy. Adjuvant immunotherapy and neoadjuvant chemoimmunotherapy will be approved for resectable NSCLC. In this review, we summarized recent advances in NSCLC in China in terms of epidemiology, biology, molecular pathology, pathogenesis, screening, diagnosis, targeted therapy, and immunotherapy.
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Affiliation(s)
- Peixin Chen
- School of MedicineTongji UniversityShanghai200092P. R. China
- Department of Medical OncologyShanghai Pulmonary HospitalSchool of MedicineTongji UniversityShanghai200433P. R. China
| | - Yunhuan Liu
- Department of Respiratory and Critical Care MedicineHuadong HospitalFudan UniversityShanghai200040P. R. China
| | - Yaokai Wen
- School of MedicineTongji UniversityShanghai200092P. R. China
- Department of Medical OncologyShanghai Pulmonary HospitalSchool of MedicineTongji UniversityShanghai200433P. R. China
| | - Caicun Zhou
- School of MedicineTongji UniversityShanghai200092P. R. China
- Department of Medical OncologyShanghai Pulmonary HospitalSchool of MedicineTongji UniversityShanghai200433P. R. China
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Effects of Tumor Mutational Burden and Gene Alterations Associated with Radiation Response on Outcomes of Postoperative Radiation Therapy in Non-Small Cell Lung Cancer. Int J Radiat Oncol Biol Phys 2022; 113:335-344. [PMID: 35157996 PMCID: PMC9976944 DOI: 10.1016/j.ijrobp.2022.02.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 01/31/2022] [Accepted: 02/06/2022] [Indexed: 01/19/2023]
Abstract
PURPOSE Postoperative radiation therapy (PORT) in resected non-small cell lung cancer (NSCLC) improves locoregional outcomes, but recent randomized data do not support its unselected use. We assessed if tumor mutational burden (TMB) and mutations in genes associated with radiation sensitivity can select patients for PORT. METHODS AND MATERIALS Patients with resected NSCLC treated with and without PORT who underwent tumor genomic profiling were examined. The incidence of locoregional failures (LRFs) in patients with deleterious mutations in DNA damage response and repair (DDR) genes and genes associated with radiation resistance (KEAP1/NFE2L2/STK11/PIK3CA) were investigated. Cox modeling and receiver operating characteristic curve (ROC) analysis assessed the relationship between TMB and locoregional control (LRC). RESULTS Eighty-nine patients with NSCLC treated with PORT were analyzed, with a 2-year LRF rate of 19% (95% confidence interval, 10%-27%). Among patients treated with PORT, those with mutations in radiation resistance genes (n = 16 [18%]) had significantly more LRFs than patients without mutations (2-year LRF rate: 60% vs 11%; P < .001). On multivariate analysis, radiation-resistance mutations were associated with LRF after PORT (hazard ratio, 7.42; P < .001). Patients with mutations identified in DDR genes (n = 15 [17%]) had significantly improved LRC (P = .048) and no LRF events after PORT. On multivariate analysis, a higher TMB was associated with improved LRC after PORT (hazard ratio, 0.86; P = .01), and TMB was associated with PORT outcomes (area under ROC curve, 0.67-0.77). These genomic markers were not similarly associated with LRF in patients not treated with PORT. CONCLUSIONS The data suggest that patients with radiation-resistance gene alterations may derive minimal benefit from PORT, whereas patients with high TMB and/or alterations in DDR genes may benefit from PORT and be suited for future precision-RT strategies. Prospective studies are necessary to validate these findings.
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Pan Y, Fu Y, Zeng Y, Liu X, Peng Y, Hu C, Deng C, Qiu Z, Zou J, Liu Y, Wu F. The key to immunotherapy: how to choose better therapeutic biomarkers for patients with non-small cell lung cancer. Biomark Res 2022; 10:9. [PMID: 35255999 PMCID: PMC8900392 DOI: 10.1186/s40364-022-00355-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 02/18/2022] [Indexed: 12/12/2022] Open
Abstract
Immunotherapy has become the standard of care for non-small cell lung cancer (NSCLC), either in combination or monotherapy. However, there are still some patients who cannot benefit from it. Immunization strategies for NSCLC are based on the expression of PD-L1 on tumor cells and TMB, and although these indicators have a certain predictive effect, their predictive performance is not good. Therefore, clinicians must make adjustments to recognize markers. This is a review article that summarized immunotherapeutic biomarkers according to the "seed-soil-environment", generalizes primary resistance to immunotherapy, and summarizes the integration of markers.
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Affiliation(s)
- Yue Pan
- Department of Oncology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China
| | - Yucheng Fu
- Hunan University of Chinese Medicine, Changsha, 410208, Hunan, People's Republic of China
| | - Yue Zeng
- Department of Oncology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China
| | - Xiaohan Liu
- Department of Oncology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China
| | - Yurong Peng
- Department of Oncology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China
| | - Chunhong Hu
- Department of Oncology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China
| | - Chao Deng
- Department of Oncology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China
| | - Zhenhua Qiu
- Department of Oncology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China
| | - Jian Zou
- Xiangya School of Medicine, Central South University, Changsha, 410013, Hunan, People's Republic of China
| | - Yuxuan Liu
- Xiangya School of Medicine, Central South University, Changsha, 410013, Hunan, People's Republic of China
| | - Fang Wu
- Department of Oncology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China.
- Hunan Cancer Mega-Data Intelligent Application and Engineering Research Centre, Hunan, China.
- Hunan Key Laboratory of Tumor Models and Individualized Medicine, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China.
- Hunan Key Laboratory of Early Diagnosis and Precision Therapy in Lung Cancer, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China.
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