DiM: Prognostic Score for Second- or Further-line Immunotherapy in Advanced Non–Small-Cell Lung Cancer: An External Validation

Nivolumab or Atezolizumab in the Second-Line Treatment of Advanced Non-Small Cell Lung Cancer? A Prognostic Index Based on Data from Daily Practice

BACKGROUND

The efficacy of nivolumab and atezolizumab in advanced pre-treated NSCLC was documented in prospective trials. We aim to confirm the benefits and indicate predictive factors for immunotherapy in daily practice.

METHODS

This study was a retrospective analysis. The median PFS and OS were estimated using the Kaplan-Meier method. The log-rank test was used for comparisons. Multivariate analyses were performed using the Cox regression method.

RESULTS

A total of 260 patients (ECOG 0-1) with advanced NSCLC (CS III-IV) were eligible to receive nivolumab or atezolizumab as second-line treatment. Median PFS and OS were three months (95% confidence interval [CI] 2.57-3.42) and 10 months (95% CI 8.03-11.96), respectively, for the overall population. The median OS for the atezolizumab arm was eight months (95% CI 5.89-10.1), while for the nivolumab group, it was 14 months (95% CI 10.02-17.97) (p = 0.018). The sum of all measurable changes >100.5 mm (p = 0.007; HR = 1.003, 95% CI 1.001-1.005), PLT > 281.5 G/l (p < 0.001; HR = 1.003, 95% CI 1.001-1.003) and bone metastases (p < 0.004; HR = 1.58, 95% CI 1.04-2.38) were independent negative prognostic factors for OS in multivariate analysis. Based on preliminary analyses, a prognostic index was constructed to obtain three prognostic groups. Median OS in the subgroups was 16 months (95% CI 13.3-18.7), seven months (95% CI 4.83-9.17) and four months (95% CI 2.88-5.13), respectively (p < 0.001).

CONCLUSIONS

Nivolumab and atezolizumab provided clinical benefit in real life. Clinical and laboratory factors may help to identify subgroups likely to benefit. The use of prognostic indices may be valuable in clinical practice.

Biological Rationale for Peripheral Blood Cell-Derived Inflammatory Indices and Related Prognostic Scores in Patients with Advanced Non-Small-Cell Lung Cancer

PURPOSE OF REVIEW

To describe the biological rationale of peripheral blood cells (PBC)-derived inflammatory indexes and assess the related prognostic scores for patients with advanced non-small cell lung cancer (aNSCLC) treated with immune-checkpoint inhibitors (ICI).

RECENT FINDINGS

Inflammatory indexes based on PBC may indicate a pro-inflammatory condition affecting the immune response to cancer. The lung immune prognostic index (LIPI), consisting of derived neutrophils-to-lymphocyte ratio (NLR) and lactate dehydrogenase, is a validated prognostic tool, especially for pretreated aNSCLC patients, where the combination of NLR and PD-L1 tumour expression might also be predictive of immunotherapy benefit. In untreated high-PD-L1 aNSCLC patients, the Lung-Immune-Prognostic score (LIPS), including NLR, ECOG PS and concomitant steroids, is prognostic, and its modified version might indicate patients with favourable outcomes despite an ECOG PS of 2. NLR times platelets (i.e., SII), included in the NHS-Lung score, might improve the prognostication for combined chemoimmunotherapy. PBC-derived inflammatory indexes and related scores represent accurate, reproducible and non-expensive prognostic tools with clinical and research utility.

Prognostic scores including peripheral blood-derived inflammatory indices in patients with advanced non-small-cell lung cancer treated with immune checkpoint inhibitors

Peripheral blood inflammatory indices, like the neutrophil-to-lymphocyte ratio (NLR), may reflect the host's pro-inflammatory status and systemic immune response to cancer-related inflammation. We reviewed 22 combined prognostic scores based on peripheral blood-derived inflammatory indices for aNSCLC patients treated with single-agent or combination immune-checkpoint inhibitors (ICI) as first-line or subsequent therapy lines and attempted evidence strength assessment and scoring. The Lung Immune Prognostic Index (LIPI), consisting of derived NLR and LDH, was the most studied score with validated prognostic value in over five thousand aNSCLC ICI-naïve or pretreated patients. The combination of NLR and tumour programmed-cell-death-ligand1 (PD-L1) expression showed a predictive value. The Lung-Immune-Prognostic score (LIPS) might help identify patients with poor performance status but a favourable outcome following first-line ICI. These non-expensive scores can help clinicians discuss the prognosis with aNSCLC patients approaching ICI, identify those less likely to benefit from single-agent ICI and orient future clinical research.

Current state of knowledge on immunotherapy in ECOG PS 2 patients. A systematic review

BACKGROUND

Patients with Eastern Cooperative Oncology Group Performance Status 2 (ECOG PS 2) are not included in most randomized clinical trials and registry studies. Nevertheless, immune checkpoint inhibitors are registered in the USA and Europe regardless of the performance status. Evidence regarding the effectiveness and safety of such treatment in this cohort is sparse.

METHODS

Using PubMed (to July 2020), the relevant literature on the effect of ECOG PS 2 on the efficacy and safety of immunotherapy in patients with advanced non-small cell lung cancer (NSCLC) with ECOG PS 2 was searched.

RESULTS

A database search conducted using an international repository (PubMed) identified 191 records. Additional 3 records were identified through other sources. After pre-selection, 92 records were excluded, and 102 full-text articles were assessed for eligibility. With further exclusion of articles not meeting the inclusion criteria, 44 studies were entered into the qualitative synthesis.

CONCLUSIONS

Immunotherapy seems to be justified in PS 2 patients with NSCLC. This method of treatment has been proven to be safe and tolerable. However, outcomes in this population remain suboptimal and the impact of immunotherapy in this cohort is less dramatic. Multiple scales evaluating many factors beyond PS scores have been suggested to help stratify the PS 2 to reinforce the chance of achieving better treatment outcomes. Randomized trials are needed to determine the benefits of immune checkpoint inhibitors (ICIs) for patients with poor ECOG PS.

Immunotherapy in patients with non-small cell lung cancer with ECOG PS 2

Immunotherapy is a new and very promising method of anti-cancer treatment. Unfortunately, not every patient can benefit from this treatment. The Polish drug program determines the selection of patients based on PD-L1 expression and the performance status assessed with the use of Eastern Cooperative Oncology Group Performance Status (ECOG PS) score. Patients with ECOG PS 2 represent a significant proportion of the cancer population, one which is overlooked in most clinical trials of immunotherapy. Often, a reduced performance status is the only factor that excludes the patient from treatment with immunotherapy. Choosing the optimal method of treatment in patients with a worse general condition and with multiple diseases may be a significant problem for the doctor. Assessment of performance status may be a particular problem because not every patient has a worse PS score for the same reasons. In this study, we analyse the results of treatment of patients with a poorer performance status to date, and we present tools that improve the precise assessment of the degree of the performance status, which may enable more patients to access novel lung cancer treatments.

Immunotherapy in advanced Non-Small Cell Lung Cancer patients with poor performance status: The role of clinical-pathological variables and inflammatory biomarkers

BACKGROUND

The introduction of immunotherapy has improved the prognosis of patients with Non-Small Cell Lung Cancer (NSCLC). However, data in poor ECOG Performance Status (PS) patients remain scant due to their exclusion from randomized trials.

MATERIAL AND METHODS

We analyzed data of patients with advanced NSCLC treated with immunotherapy in two Italian Centers, to evaluate the impact of PS (0-1 vs 2) on disease control rate (DCR), progression free survival (PFS) and overall survival (OS). Chi-square test was used to compare clinical-pathological variables, their impact on survival was evaluated through Cox proportional hazard models.

RESULTS

Among 404 patients included, PS was 0 in 137 (33.9 %), 1 in 208 (51.5 %) and 2 in 59 (14.6 %) patients; 143 were female and 90 had squamous NSCLC. Clinical-pathological variables were uniformly distributed except for higher prevalence of liver metastases in patients with poor PS. We found that PS2 patients showed worse outcomes in terms of DCR (21.8 % vs 50.3 %, p = 0.001), PFS [2.0 (95 % CI 1.6-3.0) vs 3.0 (95 % CI 2.7-4.0) months, p < 0.0001] and OS [4.0 (95 % CI 2.8-5.7) vs 13.2 (95 % CI 11.0-15.8) months, p < 0.0001]. PS2 status, negative PDL1 expression and early corticosteroids exposure as well as higher Neutrophil to Lymphocyte Ratio and LDH at baseline were associated with worse outcomes at univariate and multivariable analysis. Subgroup analysis confirmed poor outcomes in PS2 patients with high LDH and concomitant corticosteroid therapies. The incidence of Grade 3/4 adverse events was 11.3 % in PS 0-1 and 10.2 % in PS 2 patients (p = 0.81).

CONCLUSION

Our data confirm reduced efficacy of immunotherapy in patients with poor PS even though a good safety. Despite PS remains the most powerful independent prognostic factor for NSCLC, LDH levels and steroids exposure could support the decision making in PS2 patients.