Development and validation of a host-dependent, PDL1-independent, biomarker to predict 6-month progression-free survival in metastatic non-small cell lung cancer (mNSCLC) patients treated with anti-PD1 immune checkpoint inhibitors (ICI) in the CERTIM Cohort: The ELY study

Routine assessment of nutritional, functional and inflammatory criteria in patients with cancer: A systematic review

BACKGROUND

The review discusses the significant impact of cancer on patients, particularly focusing on cachexia - a condition marked by weight and lean tissue loss. This condition critically affects the nutritional status, quality of life, and treatment outcomes of cancer patients.

RESEARCH QUESTION

The review seeks to understand the effectiveness and necessity of routine clinical monitoring of cancer cachexia, and how it can aid in better therapeutic interventions.

METHODS

The systematic review followed a pre-defined protocol based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)statement. A systematic search using specific keywords was conducted in PubMed and EMBASE databases on October 24, 2023, supplemented by citations from the original papers. The selection process involved screening titles and abstracts for relevance.

RESULTS

The review finds varying levels of effectiveness in the different measurement criteria used for monitoring cachexia. It highlights the potential of the Global Leadership Initiative on Malnutrition (GLIM) framework in defining and managing cancer cachexia, though noting some challenges in standardisation and implementation of measurements.

CONCLUSION

The present systematic review highlights the variability and lack of standardization in the application of GLIM criteria for monitoring cachexia in cancer patients. Despite these challenges, it will be important to determine the most efficacious clinically routine nutritional and inflammation assessments in the routine application of GLIM criteria assessment.

Relationship between energetic gap and sensitivity to anti-programmed cell death 1 immune checkpoint inhibitors in non-small cell lung cancer patients: The ELY-2 study

BACKGROUND & AIMS

We previously reported in the ELY prospective study that increased resting energy expenditure (REE) - so-called hypermetabolism - worsened tumor response, 6-month progression-free (PFS) and overall survival (OS) in metastatic non-small cell lung cancer (mNSCLC) patients treated with immune checkpoint inhibitors (ICI). Here, we investigated the effect of caloric coverage on the sensitivity to ICI.

METHODS

We retrospectively analysed a multicentric database of mNSCLC patients treated with ICI. All patients had a baseline nutritional assessment including REE measured with indirect calorimetry and a dietitian estimation of food intakes. Measured/theoretical REE ≥110% defined hypermetabolism. Intakes ≥90% of estimated needs defined caloric coverage. The primary endpoint was PFS. Secondary endpoints included response rate and OS.

RESULTS

Among 162 patients, 84 (51.9%) were normometabolic, and 78 (48.1%) hypermetabolic. In hypermetabolic patients, 40 (51.3%) met their caloric needs (group A) while 38 (48.7%) did not (group B). Median PFS was 4.3 vs. 1.9 months in groups A and B, respectively (HR: 0.49, 95%CI [0.31-0.80], p = 0.004). The PFS achieved in the group A and in normometabolic patients were similar (HR: 0.99, 95%CI [0.65-1.51], p = 0.95). In multivariate analysis, caloric coverage was independently associated with improved PFS in hypermetabolic patients (HR: 0.56, 95%CI [0.31-0.99], p = 0.048). Among hypermetabolic patients, the median OS was higher in the group A (HR: 0.58, 95%CI [0.35-0.95], p = 0.03).

CONCLUSION

Energy supply is a critical determinant of the sensitivity to ICI in NSCLC patients. A randomized study to evaluate the benefit of early nutritional intervention is warranted.

A comprehensive supportive care program for fine-tuning cancer immunotherapy

Supportive care has become a new pilar of modern oncology, and a great deal of research is being conducted in that area, especially on immune checkpoint inhibitors (ICIs), to help fine-tune immunotherapy. Four major areas of supportive care can enhance responsiveness to cancer immunotherapy whilst minimizing adverse effects: diet (indirectly, by modulating the microbiota or directly, by modulating the immune system), physical activity (by modulating the immune system), electronic patient-reported outcomes (ePRO) (by detecting and treating immune-related adverse events early on), and co-medication management (to possibly suppress those drugs that negatively affect the efficacy of ICIs). Therefore, patients treated with ICIs could receive a systematic multimodal supportive care program encompassing regular nutritional counseling, regular physical activity under the supervision of a physical activity professional, ePRO follow-up, and regular pharmaceutical counseling. This type of approach needs to be evaluated in well-conducted randomized clinical trials.

Extending the dosing intervals of nivolumab: model-based simulations in unselected cancer patients

BACKGROUND

Reducing nivolumab dose intensity could increase patients' life quality and decrease the financial burden while maintaining efficacy. The aims of this study were to develop a population PK model of nivolumab based on data from unselected metastatic cancer patients and to simulate extended-interval regimens allowing to maintain minimal effective plasma concentrations (MEPC).

METHODS

Concentration-time data (992 plasma nivolumab concentrations, 364 patients) were modeled using a two-compartment model with linear elimination clearance in Monolix software. Extended-interval regimens allowing to maintain steady-state trough concentrations (Cmin,ss) above the MEPC of 2.5 mg/L or 1.5 mg/L in >90% of patients were simulated.

RESULTS

Increasing 3-times the dosing interval from 240 mg every two weeks (Q2W) to Q6W and 2-times from 480 mg Q4W to Q8W resulted in Cmin,ss above 2.5 mg/L in 95.8% and 95.4% of patients, respectively. 240 mg Q8W and 480 mg Q10W resulted in Cmin,ss above 1.5 mg/L in 91.0% and 91.8% of patients, respectively. Selection of a 240 mg Q6W regimen would decrease by 3-fold the annual treatment costs compared to standard regimen of 240 mg Q2W (from 78,744€ to 26,248€ in France).

CONCLUSIONS

Clinical trials are warranted to confirm the non-inferiority of extended-interval compared to standard regimen.

Effect of Cancer-Related Cachexia and Associated Changes in Nutritional Status, Inflammatory Status, and Muscle Mass on Immunotherapy Efficacy and Survival in Patients with Advanced Non-Small Cell Lung Cancer

Immune checkpoint inhibitor (ICI)-based immunotherapy has significantly improved the survival of patients with advanced non-small cell lung cancer (NSCLC); however, a significant percentage of patients do not benefit from this approach, and predictive biomarkers are needed. Increasing evidence demonstrates that cachexia, a complex syndrome driven by cancer-related chronic inflammation often encountered in patients with NSCLC, may impair the immune response and ICI efficacy. Herein, we carried out a prospective study aimed at evaluating the prognostic and predictive role of cachexia with the related changes in nutritional, metabolic, and inflammatory parameters (assessed by the multidimensional miniCASCO tool) on the survival and clinical response (i.e., disease control rate) to ICI-based immunotherapy in patients with advanced NSCLC. We included 74 consecutive patients. Upon multivariate regression analysis, we found a negative association between IL-6 levels (odds ratio (OR) = 0.9036; 95%CI = 0.8408-0.9711; p = 0.0025) and the miniCASCO score (OR = 0.9768; 95%CI = 0.9102-0.9999; p = 0.0310) with the clinical response. As for survival outcomes, multivariate COX regression analysis found that IL-6 levels and miniCASCO-based cachexia severity significantly affected PFS (hazard ratio (HR) = 1.0388; 95%CI = 1.0230-1.0548; p < 0.001 and HR = 1.2587; 95%CI = 1.0850-1.4602; p = 0.0024, respectively) and OS (HR = 1.0404; 95%CI = 1.0221-1.0589; p < 0.0001 and HR = 2.3834; 95%CI = 1.1504-4.9378; p = 0.0194, respectively). A comparison of the survival curves by Kaplan-Meier analysis showed a significantly lower OS in patients with cachexia versus those without cachexia (p = 0.0323), as well as higher miniCASCO-based cachexia severity (p = 0.0428), an mGPS of 2 versus those with a lower mGPS (p = 0.0074), and higher IL-6 levels (>6 ng/mL) versus those with lower IL-6 levels (≤6 ng/mL) (p = 0.0120). In conclusion, our study supports the evidence that cachexia, with its related changes in inflammatory, body composition, and nutritional parameters, is a key prognostic and predictive factor for ICIs. Further larger studies are needed to confirm these findings and to explore the potential benefit of counteracting cachexia to improve immunotherapy efficacy.

Prognostic score and sex-specific nomograms to predict survival in resectable lung cancer: A French nationwide study from the Epithor cohort database

Background

Prognostic assessment in patients undergoing cancer treatments is of paramount importance to plan subsequent management. In resectable lung cancer availability of an easy-to use nomogram to predict long-term outcome would be extremely useful to identify high-risk patients in the era of perioperative targeted and immune therapies.

Methods

We retrieved clinical, surgical and pathological data of all consecutive patients included in Epithor, the database of French Society of Thoracic and Cardiovascular Surgery, and operated on between 2003 and 2020 for non-small cell lung cancer in a curative intent. The primary endpoint was overall survival up to 5 years. We assessed prognostic significance of available variables using Cox modelling, in the whole dataset, and in men and in women separately, and performed temporal validation. Finally, we constructed two sex-specific nomograms. Survivals by fifths of score were assessed in the development and temporal validation sets.

Findings

The study included 62,633 patients (43,551 men and 19,082 women). Median survival time was 9.2 years. Nine factors had strong prognostic impact and were used to construct nomograms. The optimism-corrected c statistic for the prognostic score was 0.689 in the development sample, and 0.726 (95% CI 0.718-0.735) in the temporal validation sample. All differences between adjacent fifths of score were significant (P < 0.0001). Figures of 3-year OS by fifths of score were 92.2%, 83.0%, 74.3%, 64.0%, and 43.4%, respectively, in the development set and 93.3%, 88.4%, 81.0%, 73.7%, 55.7% in the temporal validation set. Performance of score was maintained when stratifying by stage of diseases.

Interpretation

In the present work, we report evidence that long-term overall survival after resection of NSCLC can be predicted by an easy to construct and use composite score taking into account both host and tumour related factors.

Funding

Epithor is funded by FSTCVS.

Construction and validation of a novel web-based nomogram for patients with lung cancer with bone metastasis: A real-world analysis based on the SEER database

Purpose

Patients with lung cancer with bone metastasis (LCBM) often have a very poor prognosis. The purpose of this study is to characterize the prevalence and associated factors and to develop a prognostic nomogram to predict the overall survival (OS) and cancer-specific survival (CSS) for patients with LCBM using multicenter population-based data.

Methods

Patients with LCBM at the time of diagnosis were identified using the Surveillance, Epidemiology, and End Results (SEER) Program database of the National Cancer Institute (NCI) from 2010 to 2015. Multivariable and univariate logistic regression analyses were performed to identify factors associated with all-cause mortality and lung cancer (LC)-specific mortality. The performance of the nomograms was evaluated with the calibration curves, area under the curve (AUC), and decision curve analysis (DCA). Kaplan-Meier analysis and log-rank tests were used to estimate the survival times of patients with LCBM.

Results

We finally identified 26,367 patients with LCBM who were selected for survival analysis. Multivariate analysis demonstrated age, sex, T stage, N stage, grade, histology, radiation therapy, chemotherapy, primary site, primary surgery, liver metastasis, and brain metastasis as independent predictors for LCBM. The AUC values of the nomogram for the OS prediction were 0.755, 0.746, and 0.775 in the training cohort; 0.757, 0.763, and 0.765 in the internal validation cohort; and 0.769, 0.781, and 0.867 in the external validation cohort. For CSS, the values were 0.753, 0.753, and 0.757 in the training cohort; 0.753, 0.753, and 0.757 in the internal validation cohort; and 0.767, 0.774, and 0.872 in the external validation cohort.

Conclusions

Our study constructs a new prognostic model and clearly presents the clinicopathological features and survival analysis of patients with LCBM. The result indicated that the nomograms had favorable discrimination, good consistency, and clinical benefits in patients. In addition, our constructed nomogram prediction models may assist physicians in evaluating individualized prognosis and deciding on treatment for patients.

A Profile of Avelumab Plus Axitinib in the Treatment of Renal Cell Carcinoma

Until recently, the approved first-line treatment for metastatic RCC (mRCC) consisted of tyrosine kinase inhibitors (TKI) targeting the vascular endothelial growth factor receptors (VEGFR) monotherapy. The landscape of first-line treatment has been transformed in the last few years with the advent of immune checkpoint inhibitors (ICI) or VEGFR TKI plus ICI combinations. This article focuses on the profile of one of these ICI plus VEGFR TKI combination, avelumab plus axitinib. We detail the characteristics of each drug separately, and then we explore the rationale for their association, its efficacy and the resulting toxicity. Finally, we examine the factors associated with avelumab plus axitinib outcomes, and their impact on therapeutic strategy.

Association of Energy Expenditure and Efficacy in Metastatic Renal Cell Carcinoma Patients Treated with Nivolumab

Background: Nivolumab improved patients’ survival in metastatic renal cell carcinoma (mRCC). We aimed to evaluate resting energy expenditure (REE) (i.e., patients’ basal metabolism) to predict efficacy. Methods: We conducted a monocentric, observational study of mRCC patients receiving nivolumab between October 2015 and May 2020. REE was measured prior to initiating immunotherapy using indirect calorimetry to determine hypo, normo and hypermetabolism. Primary endpoint was 6-month, progression-free survival (PFS), and secondary endpoints were response rate, PFS and overall survival (OS). Results: Of the 51 consecutive patients, 15 (29%) were hypermetabolic, 24 (47%) normometabolic, and 12 (24%) hypometabolic. The 6-month PFS was 15% for hypermetabolic patients and 65% for non-hypermetabolic patients (p < 0.01). In the multivariate analysis, hypermetabolism was the only baseline factor predicting 6-month PFS (OR 9.91, 95%CI [1.62−60.55], p = 0.01). Disease progression was noted as the best response in 73% of hypermetabolic patients and 26% of non-hypermetabolic patients (p = 0.02). Median PFS was 2.8 and 8.7 months (p < 0.01), and median OS was 20.2 and 35.1 months (p = 0.13) in the hypermetabolic and non-hypermetabolic groups, respectively. Conclusions: Our study identifies an association between mRCC patients’ energy expenditure and nivolumab efficacy. The measurement of REE by indirect calorimetry in routine practice could help identify patients at risk of nivolumab failure.