Pembrolizumab for Persistent, Recurrent, or Metastatic Cervical Cancer

A new treatment approach of toripalimab in combination with concurrent platinum-based chemoradiotherapy for locally advanced cervical cancer: A phase II clinical trial

This study investigated the efficacy and safety of toripalimab in combination with concurrent platinum-based chemoradiation in patients with untreated locally advanced cervical cancer. Eligible patients received toripalimab 240 mg once every 3 weeks in combination with concurrent platinum-based chemoradiotherapy, followed by the maintenance of toripalimab once every 6 weeks up to 1 year. The primary endpoint was objective response rate (ORR). Secondary endpoints included 2-year and 3-year progression-free survival (PFS) rates, 3-year overall survival (OS) rate, and safety. Biomarker analysis of PD-L1 expression and genomic mutational analysis by next-generation sequencing were conducted, as well as PD-L1 expression on tumor biopsies. A total of 82 patients were enrolled. The median follow-up was 21 months (range, 5.2-44.5 months). The ORR and disease control rate were both 87.8% among the 82 patients. Median PFS and OS were not reached. A trend toward longer PFS was observed in the populations with a PD-L1 combined positive score ≥10, low tumor mutation burden and loss of heterozygosity in human leukocyte antigen (HLA LOH) detected populations. A total of 37 patients experienced treatment-related adverse events, of which 17 (20.7%) patients experienced grade 3 or higher adverse events. Collectively, toripalimab plus concurrent platinum-based chemoradiotherapy showed promising antitumor efficacy with acceptable safety profiles in patients with untreated locally advanced cervical cancer.

Germline variants of homology-directed repair or mismatch repair genes in cervical cancer

While cervical cancer is associated with a persistent human papillomavirus (HPV) infection, the progression to cancer is influenced by genomic risk factors that have remained largely obscure. Pathogenic variants in genes of the homology-directed repair (HDR) or mismatch repair (MMR) are known to predispose to diverse tumour entities including breast and ovarian cancer (HDR) or colon and endometrial cancer (MMR). We here investigate the spectrum of HDR and MMR germline variants in cervical cancer, with particular focus on the HPV status and histological subgroups. We performed targeted next-generation sequencing for 5 MMR genes and 12 HDR genes on 728 German patients with cervical dysplasia or invasive cancer. In total, 4% of our patients carried a pathogenic germline variant, based on ClinVar classifications and additional ESM1b and AlphaMissense predictions. These included 15 patients with truncating variants in HDR genes (BARD1, BRCA1, BRCA2, BRIP1, FANCM, RAD51D and SLX4). MMR-related gene variants were less prevalent and mainly of the missense type. While MMR-related gene variants tended to associate with adenocarcinomas, HDR gene variants were commonly observed in squamous cancers. While one patient with HPV-negative cancer carried a pathogenic MMR gene variant (in MSH6), the HDR germline variants were found in patients with HPV-positive cancers and tended to associate with HPV18. Taken together, our study supports a potentially risk-modifying role of MMR and HDR germline variants in cervical cancer but no association with HPV-negative status. These variants may be exploitable in future therapeutic managements.

Chimeric antigen receptor macrophages (CAR-M) sensitize HER2+ solid tumors to PD1 blockade in pre-clinical models

We previously developed human CAR macrophages (CAR-M) and demonstrated redirection of macrophage anti-tumor function leading to tumor control in immunodeficient xenograft models. Here, we develop clinically relevant fully immunocompetent syngeneic models to evaluate the potential for CAR-M to remodel the tumor microenvironment (TME), induce T cell anti-tumor immunity, and sensitize solid tumors to PD1/PDL1 checkpoint inhibition. In vivo, anti-HER2 CAR-M significantly reduce tumor burden, prolong survival, remodel the TME, increase intratumoral T cell and natural killer (NK) cell infiltration, and induce antigen spreading. CAR-M therapy protects against antigen-negative relapses in a T cell dependent fashion, confirming long-term anti-tumor immunity. In HER2+ solid tumors with limited sensitivity to anti-PD1 (aPD1) monotherapy, the combination of CAR-M and aPD1 significantly improves tumor growth control, survival, and remodeling of the TME in pre-clinical models. These results demonstrate synergy between CAR-M and T cell checkpoint blockade and provide a strategy to potentially enhance response to aPD1 therapy for patients with non-responsive tumors.

Investigating the delivery of PD-L1-targeted immunoliposomes in a dynamic cervical cancer-on-a-chip model

The recent approval of pembrolizumab in recurrent or metastatic cervical cancer warrants further investigations into the usefulness of immunotherapies for more durable and less radical interventions. In this study, the targeting potential of anti-PD-L1-functionalized immunoliposomes was tested in a 3D in vitro cervical cancer-on-a-chip model. Immunolipsomes were synthesized and decorated externally with monovalent anti-PD-L1 Fab' fragments of commercially available atezolizumab. Cervical cancer cell lines with varying levels of PD-L1 expression were cultured as spheroids embedded in a collagen I matrix, and treated under flow of culture media. Flow cytometry and live-cell confocal imaging were used to measure the interactions and uptake of untargeted liposomes and immunoliposomes in this panel of cell lines. The immunoliposomes retained specific functionality regardless of protein corona formation in high serum environments. As such, spheroids expressing high levels of PD-L1 preferentially internalized immunoliposomes in a 3D environment with extracellular matrix present, while low PD-L1-expressing cell lines showed no preference for either formulation. Importantly, treatments performed in monolayer cultures (on plastic) showed no differences between immuno- and untargeted liposome uptake, including the way in which the endocytosed liposomes are trafficked subcellularly. This study demonstrates the importance of both active and passive accumulation strategies to achieve nanoparticle targeting. Immunoliposomes remain a promising platform for the development of targeted nanotherapies against cervical cancers. However, initial functional tests did not translate directly to biological performance and this should be kept in mind for future formulations. Furthermore, the in vitro model developed appeared useful for visualizing liposome uptake in a 3D, live tissue environment and represents a cost-effective and reproducible model for future studies.

Cemiplimab in recurrent cervical cancer: Final analysis of overall survival in the phase III EMPOWER-Cervical 1/GOG-3016/ENGOT-cx9 trial

AIM

Cemiplimab has demonstrated significantly longer survival than physician's choice of chemotherapy in patients with recurrent cervical cancer after first-line platinum-containing chemotherapy. We report the final survival analysis from the phase III randomized study (EMPOWER-Cervical 1/GOG-3016/ENGOT-cx9).

METHODS

Cemiplimab (n = 304) or chemotherapy (n = 304) were administered every 3 weeks. The primary endpoint was overall survival (OS). Patients were included regardless of programmed cell death-ligand 1 (PD-L1) status.

RESULTS

At a median follow-up of 47.3 months (data cut-off: April 20, 2023), median OS was 11.7 versus 8.5 months for patients treated with cemiplimab and chemotherapy, respectively (hazard ratio 0.67, 95 % confidence interval 0.56-0.80, p < .00001). OS benefit was seen in PD-L1 positive and negative populations, even though more patients with PD-L1 < 1 % (n = 92), had poor performance status in the cemiplimab arm than the chemotherapy arm (61.4 % vs 47.9 %).

CONCLUSION

This final analysis confirms that cemiplimab maintains survival benefit compared with chemotherapy in recurrent cervical cancer after progression on first-line platinum therapy, regardless of PD-L1 expression. The safety profile was consistent with published data; incidences of adverse events were similar between cemiplimab and chemotherapy groups. These results support the use of second-line cemiplimab for patients with recurrent cervical cancer.

PD-L1-Expression in in primary and recurrent vulvar squamous cell cancer

BACKGROUND

Squamous cell vulvar carcinoma is a rare malignant disease of women. In higher tumor stages survival rates are poor. Therapy options are limited. Immunoncology plays an increasing role in the treatment of gynecology cancers. Data on the expression of PD-L1 in vulvar cancer are rare and contradictory. We sought to describe the expression of PD-L1 in VSCC in respect to the clinicopathologic characteristics of the tumor.

STUDY DESIGN

We conducted a retrospective analysis including women with primary and recurrent vulvar cancer between 2000 and 2021. A next generation tissue micro array (ngTMA) was constructed for the analysis of PD-L1 expression.

RESULTS

In total 238 women with primary VSCC and 66 cases of local or distant recurrent vulvar cancer were included. 80 women with primary VSCC (33.6 %) had tumors with common positive score (CPS) <1 and 63 women (26.5 %) had tumors with CPS 1- < 10 and 95 women with CPS ≥10 (39.9 %). In the PD-L1 positive group the rates of p53+, groin metastasis, lymphatic invasion and tumor infiltration lymphocytes were higher as compared to PD-L1 negative (CPS <1). There was no significant influence of CPS in overall survival in addition to other prognostic factors (P = 0.13, likelihood ratio test).

CONCLUSION

PD-L1 expression in primary vulvar cancer is associated with poorer prognosis. Hence, PD-L1 is a possible target for immune checkpoint inhibitors and women might benefit from special treatment options.

Integrating CTLA-4/PD-1 blockade into cervical cancer management: Results of COMPASSION-16

Although there is anti-tumor efficacy of dual CTLA-4/PD-1 blockade in advanced/recurrent cervical cancer, it is unclear whether combination with chemotherapy is synergistic. In COMPASSION-16, Wu et al. demonstrated improved survival outcomes of cadolinimab plus chemotherapy compared to chemotherapy alone for first-line systemic therapy for advanced/recurrent cervical cancer, suggesting a potential role of bispecific CTLA-4/PD-1 inhibitors in the frontline setting.1.

Pembrolizumab plus chemotherapy in frontline treatment of advanced ovarian cancer: Clinical and translational results from a phase 2 trial

BACKGROUND

The efficacy and feasibility of pembrolizumab combined with chemotherapy in frontline management of advanced high-grade epithelial ovarian cancer (EOC) is unknown. Additionally, modification of the tumor microenvironment following neoadjuvant therapy is not well understood.

METHODS

In this single-arm phase 2 trial (this study was registered at ClinicalTrials.gov: NCT02520154), eligible patients received up to 4 cycles of neoadjuvant chemotherapy followed by interval cytoreduction, 3 cycles of adjuvant intravenous carboplatin/weekly paclitaxel/pembrolizumab, and finally maintenance pembrolizumab until progression or toxicity (maximum 20 cycles). The primary endpoint was progression-free survival (PFS). Secondary endpoints included feasibility, toxicity, and overall survival (OS). PD-L1 staining, multiplex immunofluorescence staining, RNA sequencing, reverse-phase protein array analyses were performed on pre- and post-chemotherapy samples.

FINDINGS

Thirty-one eligible patients were enrolled. Median PFS and OS was 14.88 (95% CI 12.39-23.00) and 57.43 months (95% CI 30.88-not reached), respectively. Among those with PD-L1 combined positive score (CPS) ≥10, the median PFS and OS were not reached compared to those with CPS <10 (10.50 and 30.90 months, respectively). Feasibility was met, with all patients completing their planned adjuvant cycles. Treatment discontinuation due to immune-related toxicity occurred in 6 patients (20%). Chemotherapy resulted in an infiltration of anti-tumor immune cells in the tumor microenvironment. Samples of patients with the best PFS demonstrated increased expression of NF-κB, TGF-β, and β-catenin signaling.

CONCLUSIONS

Pembrolizumab with chemotherapy was feasible and resulted in PFS within the historical range for this EOC population. Patients with CPS ≥10 may benefit more from this regimen, and future studies should investigate this potential biomarker.

FUNDING

This investigator-initiated trial was funded by Merck.

Neoadjuvant or concurrent atezolizumab with chemoradiation for locally advanced cervical cancer: a randomized phase I trial

Combined immune checkpoint blockade (ICB) and chemoradiation (CRT) is approved in patients with locally advanced cervical cancer (LACC) but optimal sequencing of CRT and ICB is unknown. NRG-GY017 (NCT03738228) was a randomized phase I trial of atezolizumab (anti-PD-L1) neoadjuvant and concurrent with CRT (Arm A) vs. concurrent with CRT (Arm B) in patients with high-risk node-positive LACC. The primary endpoint was the fraction of expanded tumor-associated T-cell receptor (TCR) clones in blood at day 21 as a surrogate measure of anti-tumor immune response. Secondary objectives were safety and feasibility, 2-year disease-free survival (DFS), and predictive value of PD-L1 expression. Forty patients were randomized, 36 received treatment, and 25 were evaluable for the primary endpoint. After cycle 1, there was peripheral expansion of higher proportion of tumor-associated TCR clones in Arm A than in Arm B (p = 0.0025) that remained higher at day 21, meeting the pre-specified endpoint on two-sample T-test (p = 0.052), but not on sensitivity analysis by Wilcoxon test (p = 0.13). At the median follow up of 25.8 months, 2-year DFS was 76% in Arm A and 56% in Arm B (p = 0.28). There were no new safety signals. In conclusion, neoadjuvant ICB prior to CRT was safe and was associated with immunologically and clinically favorable outcomes, warranting larger confirmatory studies.

Safety and efficacy of the therapeutic DNA-based vaccine VB10.16 in combination with atezolizumab in persistent, recurrent or metastatic HPV16-positive cervical cancer: a multicenter, single-arm phase 2a study

BACKGROUND

Second-line treatment options for persistent, recurrent or metastatic (r/m) cervical cancer are limited. We investigated the safety, efficacy, and immunogenicity of the therapeutic DNA-based vaccine VB10.16 combined with the immune checkpoint inhibitor atezolizumab in patients with human papillomavirus (HPV)16-positive r/m cervical cancer.

PATIENTS AND METHODS

This multicenter, single-arm, phase 2a study (NCT04405349, registered 26 May 2020) enrolled adult patients with persistent, r/m HPV16-positive cervical cancer. Patients received 3 mg VB10.16 (every 3 weeks (Q3W) for 12 weeks, hereafter every 6 weeks) combined with 1,200 mg atezolizumab (Q3W) for 48 weeks in total with a 12-month follow-up. The primary endpoints were incidence and severity of adverse events (AEs) and objective response rate (ORR; Response Evaluation Criteria in Solid Tumor V.1.1). ORR was assessed in the efficacy population, being all response-evaluable patients who received any administration of VB10.16 and atezolizumab and had at least one post-baseline imaging assessment.

RESULTS

Between June 16, 2020, and January 25, 2022, 52 patients received at least one administration of study treatment. Of these, 47 patients had a minimum of one post-baseline tumor assessment. The median follow-up time for survival was 11.7 months. AEs related to VB10.16 were non-serious and mainly mild injection site reactions (9 of 52 patients). There were no signs of new toxicities other than what was already described with atezolizumab. ORR was 19.1% (95% CI 9.1% to 33.3%). Median duration of response was not reached (n.r.) (95% CI 2.2 to n.r.), median progression-free survival was 4.1 months (95% CI 2.1 to 6.2), and median overall survival was 21.3 months (95% CI 8.5 to n.r.). In programmed death-ligand 1 (PD-L1)-positive patients (n=24), ORR was 29.2% (95% CI 12.6 to 51.1). HPV16-specific T-cell responses were analyzed in 36 of 47 patients with an increase observed in 22/36 (61%).

CONCLUSIONS

The therapeutic DNA-based vaccine VB10.16 combined with atezolizumab was safe and well tolerated showing a promising clinically meaningful efficacy with durable responses in patients with persistent, r/m HPV16-positive cervical cancer, especially if PD-L1-positive.

Pembrolizumab plus chemotherapy for advanced and recurrent cervical cancer: final analysis according to bevacizumab use in the randomized KEYNOTE-826 study

BACKGROUND

In KEYNOTE-826 (NCT03635567), pembrolizumab plus chemotherapy (±bevacizumab) significantly improved overall survival (OS) and progression-free survival (PFS) in patients with persistent, recurrent, or metastatic cervical cancer. This exploratory analysis examined outcomes in patient subgroups defined by bevacizumab use.

PATIENTS AND METHODS

Eligible adult patients had persistent, recurrent, or metastatic squamous cell carcinoma, adenosquamous carcinoma, or adenocarcinoma of the cervix not previously treated with chemotherapy and not amenable to curative treatment; measurable disease per RECIST v1.1; and an Eastern Cooperative Oncology Group performance status ≤1. Patients were randomly allocated 1 : 1 to pembrolizumab 200 mg every 3 weeks or placebo for up to 35 cycles plus chemotherapy (±bevacizumab 15 mg/kg). Dual primary endpoints were OS and PFS per RECIST v1.1 by investigator assessment. Outcomes were assessed in subgroups defined by bevacizumab use. Hazard ratios (HRs) and 95% confidence intervals (CIs) were based on a stratified Cox regression model.

RESULTS

A total of 617 patients were randomly assigned [pembrolizumab arm, n = 308 (63.6% with bevacizumab); placebo arm, n = 309 (62.5% with bevacizumab)]. The most common reason for bevacizumab exclusion was medical contraindication (75.9%). Among patients who received bevacizumab, HRs (95% CIs) for PFS favored the pembrolizumab arm in the programmed cell death-ligand 1 combined positive score ≥1 [0.56 (0.43-0.73)] and all-comer [0.57 (0.45-0.73)] populations; OS results were 0.60 (0.45-0.79) and 0.61 (0.47-0.80), respectively. Among patients who did not receive bevacizumab, HRs (95% CIs) for PFS also favored the pembrolizumab arm in the programmed cell death-ligand 1 combined positive score ≥1 [0.61 (0.44-0.85)] and all-comer [0.69 (0.50-0.94)] populations; OS results were 0.61 (0.44-0.85) and 0.67 (0.49-0.91), respectively. Among patients who received bevacizumab, grade ≥3 treatment-related adverse events occurred in 74.0% of patients in the pembrolizumab arm and 66.8% in the placebo arm.

CONCLUSION

Pembrolizumab plus chemotherapy prolonged PFS and OS and had manageable safety compared with placebo plus chemotherapy in patient subgroups defined by bevacizumab use.

Cancer immunotherapy in elderly patients: The concept of immune senescence challenged by clinical experience

Cancer immunotherapy, including immune checkpoint inhibitors, chimeric antigen receptor T-cell therapy and bispecific antibodies, has led to major improvements in the treatment of a wide range of hematologic malignancies and solid tumors. However, age-mediated immune system modifications, known as immunosenescence, may preclude its efficacy in elderly patients. In this review, we assessed the efficacy of these different cancer immunotherapies in elderly patients compared to young patients to revisit the concept of immunosenescence from a therapeutic perspective.

Advances in Vulvar Cancer Biology and Management

PURPOSE

Vulvar squamous cell carcinoma (VSCC), a rare gynecologic malignancy, has been rising in incidence. Molecular classification on the basis of human papilloma virus (HPV) and tumor protein 53 (p53) status has identified three clinically distinct subtypes, but we still treat all VSCCs the same. Here, we review molecular classification of VSCC, outline treatment landscape, and highlight potential for targeted therapies in advanced VSCC.

DESIGN

We conducted a comprehensive review of the literature on treatment of advanced VSCC with particular focus on the implications of molecular stratification on the basis of HPV and p53 status on the treatment landscape of advanced VSCC.

RESULTS

Incorporation of HPV and p53 status in locoregional treatment decision making has the potential to advise (de)escalation strategies. The role of immunotherapy, alone and in combination, requires further exploration particularly earlier in the course of the disease. In advanced stages, potential for targeted therapies in VSCCs include inhibitors of vascular endothelial growth factor, endothelial growth factor receptor, cell cycle, and DNA damage response, particularly in HPV-negative (HPV-) VSCCs. Targeting the phosphoinositide 3 kinase/mammalian target of rapamycin pathway is attractive in HPV-positive and HPV-/p53 wildtype VSCCs. Trials incorporating antibody-drug conjugates (eg, trophoblast cell-surface antigen 2, human epidermal growth factor receptor 2) should be considered, and basket trials in perineal squamous cell cancers are warranted. Preclinical models are limited and should be expanded to inform trial design.

CONCLUSION

Like other rare cancers, vulvar cancer lags behind in the identification and optimization of precision medicine strategies. Molecular-based preclinical models and rationally designed clinical trials, incorporating high-quality translational studies, are urgently required. These trials will require international collaboration to ensure feasibility and improvement of outcomes for women diagnosed with this disease.

The real-world efficacy and toxicity of first-line paclitaxel and cisplatin with bevacizumab in platinum-naïve primary stage IVB cervical cancer

OBJECTIVE

To investigate the real-world efficacy and toxicity of paclitaxel-cisplatin-bevacizumab and identify prognostic factors for paclitaxel-cisplatin-bevacizumab in platinum-naïve primary stage IVB cervical cancer.

MATERIALS AND METHODS

We retrospectively reviewed patients with stage IVB cervical cancer who received paclitaxel-cisplatin-bevacizumab as first-line treatment between July 2015 and December 2021 at Asan Medical Center, Korea. Patient data including clinicopathologic characteristics, imaging, paclitaxel-cisplatin-bevacizumab administration, recurrence, and survival were collected.

RESULTS

Overall, 61 patients were included in this study. The median age of the patients was 56 (range, 28-79) years. Patients received a median of 9 (range, 2-30) cycles of paclitaxel-cisplatin-bevacizumab. The most common adverse event (all grades) during treatment was azotemia (80.3 %). Dose reduction and drug interruption were conducted in 41.0 % and 26.2 % of patients, respectively. The median progression-free survival (PFS) and the median overall survival (OS) were 11.8 (95 % confidence interval [CI], 9.3-14.2) and 24.3 (95 % CI, 16.9-31.7) months, respectively. Multivariate analysis indicated that cervical mass size reduction rate ≥40 % at the longest diameter was an independent prognostic factor for PFS (adjusted hazard ratio, 0.24; 95 % CI, 0.11-0.53; p < 0.001). The median PFS of the patients with cervical mass size reduction rate ≥40 % and <40 % were 13.7 (95 % CI, 10.9-16.5) and 5.9 (95 % CI, 0-12.6) months, respectively (p < 0.001).

CONCLUSION

Paclitaxel-cisplatin-bevacizumab is effective and tolerable as a first-line treatment for platinum-naïve primary stage IVB cervical cancer. Cervical mass size reduction rate ≥40 % during paclitaxel-cisplatin-bevacizumab treatment might be a potential prognostic factor for PFS in patients with platinum-naïve primary stage IVB cervical cancer.

Delayed and immediate cutaneous adverse events during pembrolizumab combination chemotherapy against cervical cancer: Case series

Immune checkpoint inhibitors (ICIs), such as pembrolizumab (PEM), are widely recognized for their antitumor efficacy, but they can also lead to various cutaneous adverse events (CAEs). While most CAEs can be managed with topical corticosteroids, severe cases may necessitate halting immunotherapy. The incidence of severe CAEs is notably higher in combination therapies involving ICIs than in monotherapies, emphasizing the need for stringent, long-term management strategies. This includes potential modifications or discontinuations of the combination therapy. PEM, when added to the conventional paclitaxel + cisplatin (or carboplatin) ± bevacizumab regimen, has shown significant improvements in overall and progression-free survival for patients with Stage IVB metastatic or locally uncontrolled recurrent cervical cancer. This case series retrospectively examined the incidence and management of CAEs in 19 female patients treated with this combination therapy between October 2022 and May 2023. Four patients exhibiting CTCAE grade 3 were identified. The four cases of severe CAEs involved erythema multiforme after the initial course of PEM combination chemotherapy. Notably, three patients experienced immediate hypersensitivity reactions, including anaphylaxis, during subsequent treatments. This observation underscores the necessity for rigorous dermatological monitoring of patients undergoing PEM combination chemotherapy. Such vigilance is crucial for early detection of adverse reactions and timely adjustment of treatment regimens, thereby enhancing patient safety.

Cryoablation synergizes with anti-PD-1 immunotherapy induces an effective abscopal effect in murine model of cervical cancer

BACKGROUND

Immune checkpoint inhibitors (ICIs), especially anti-PD-1/PD-L1 antibodies, have emerged as promising therapeutic options for cervical cancer. However, the efficacy of anti-PD-1 antibody monotherapy is limited. Cryoablation could elicit an anti-tumor immune response, thereby presenting itself as a potential approach to augment the response of ICIs. The aim of our study was to investigate the systemic immunological effects of cryoablation and the potential synergistic anti-tumor effects of cryoablation and anti-PD-1 antibody in cervical cancer.

METHODS

We established U14 murine bilateral subcutaneous cervical cancer model, wherein the primary tumors were treated with cryoablation. Flow cytometry, immunohistochemistry and RNA-seq were used to analyze the immune cell infiltration and immune-associated pathways in the secondary tumor.

RESULTS

Our study revealed that cryoablation reprogrammed the immune landscape, leading to an enhanced infiltration of CD8+ T cell in distant tumors. Cryoablation created a conducive environment for increasing the efficacy of anti-PD-1 immunotherapy. Cryoablation in combination with anti-PD-1 antibody inhibited distant tumors growth and improved mouse survival. Mechanistically, this combination therapy could augment the infiltration of CD8+ T cells, CD4+ T cells, dendritic cells and M1-like tumor-associated macrophages, enhance multiple aspects of antitumor immune response, and reduce immunosuppressive cells such as M2-like tumor-associated macrophages and myeloid-derived suppressor cells in distant tumors.

CONCLUSIONS

Combination therapy with cryoablation and anti-PD-1 antibody induces an effective abscopal effect in murine model of cervical cancer and may be a novel therapeutic approach for patients with advanced/recurrent cervical cancer.

Clinicopathological characteristics of invasive stratified mucinous carcinoma of the cervix and the expression and clinical significance of SLC7A11, SLC3A2 and PD-L1

Introduction

Invasive Stratified Mucin-producing Carcinoma (ISMC) of the cervix is a newly named cervical adenocarcinoma associated with Human Papilloma virus (HPV). Due to its relative rarity, clinical data, pathological features, and molecular characteristics of ISMC are still under exploration. This study aims to retrospectively analyze the clinical data and pathological features of ISMC patients, summarizing the clinical and pathological morphological characteristics of ISMC. Immunohistochemistry for SLC7A11, SLC3A2, and PD-L1 will be performed on tumor tissues from ISMC patients to preliminarily explore potential therapeutic targets for ISMC.

Methods

We retrospectively reviewed the electronic medical records and pathological slides of 22 ISMC patients, and performed immunohistochemical staining for solute carrier family 7 member 11 (SLC7A11), solute carrier family 3 member 2 (SLC3A2), and programmed death-ligand 1 (PD-L1).

Results

The patients were aged between 31 and 70 years old. The most common symptoms were abnormal vaginal bleeding and unusual vaginal discharge. HPV testing indicated that the infection rate of HPV type 18 was the highest. All patients underwent extensive hysterectomy and pelvic lymph node dissection. The progression-free survival (PFS) ranged from 3 to 112 months, with a postoperative recurrence rate of 22.7% (5/22). ISMC exhibited diverse characteristic microstructures. Immunohistochemistry results showed that the positive rates of SLC7A11 and SLC3A2 were both 91.0% (20/22). The staining intensity of SLC7A11 in frequent ISMC recurrence cases was significantly stronger than in non-recurrent ISMC cases. PD-L1 positivity was observed in 86.4% (19/22) of cases, defined as having a Combined Positive Score(CPS)≥1.

Discussion

ISMC demonstrates a high rate of lymph node metastasis and a high recurrence rate, indicating strong invasiveness. Additionally, ISMC exhibits a wide morphological spectrum. SLC7A11, SLC3A2, and PD-L1 are all highly expressed in ISMC tissues. The high expression of SLC7A11 may indicate a high recurrence rate for ISMC. Immunotherapy with checkpoint inhibitors and iron death-related treatments show potential in the treatment of ISMC, with SLC7A11, SLC3A2, and PD-L1 serving as potential therapeutic targets for ISMC.

Silencing of STEAP3 suppresses cervical cancer cell proliferation and migration via JAK/STAT3 signaling pathway

BACKGROUND

Six-transmembrane epithelial antigen of prostate 3 (STEAP3), an essential constituent of the STEAP family protein, plays a notable role in promoting cancer proliferation and metastasis. Despite the importance of the STEAP gene family in tumor progression, the function of STEAP3 in cervical cancer (CC) remains unclear.

MATERIALS AND METHODS

The expression of STEAP3 protein in CC tissues and cell lines was identified using immunohistochemistry. The Reduced Representation Bisulfite Sequencing (RRBS) was used to detect global gene DNA methylation in CC tissues and paracancerous tissues. Cell viability, proliferation, migration, and invasion, were evaluated using the Cell Counting Kit-8 (CCK8), 5-ethynyl-2'-deoxyuridine (EdU), wound repair assay, and transwell assay, respectively. RNA sequencing was applied to explore STEAP3-related signaling pathways. Western blotting was performed to detect the expression of related proteins, including epithelial-mesenchymal transition (EMT) and Janus kinase/signal transducer and activator of transcription (JAK/STAT) signaling markers.

RESULTS

Herein, STEAP3 was strongly expressed in CC tissues and associated with poor prognosis. CC samples exhibited lower levels of STEAP3 methylation than normal samples, and the methylation levels of CpG islands in STEAP3 were association with prognosis. In contrast to control group, STEAP3 knockdown suppressed the proliferation and invasion of CC cells and enhanced sensitivity to oxaliplatin. Silencing of STEAP3 led to reduced N-cadherin and vimentin levels and increased E-cadherin expression. RNA sequencing analysis suggested that STEAP3 mediated the activation of the JAK STAT3 signaling pathway. Additionally, inhibition of STEAP3 decreased the phosphorylation of JAK2 and STAT3. Interestingly, colivelin (a STAT3 activator) modified STEAP3-induced cell proliferation, invasion, and expression of related proteins in the EMT and JAK/STAT3 signaling pathway.

CONCLUSION

STEAP3 was significantly associated with CC progression mediated via the JAK/STAT3 signaling pathway and may serve as an effective therapeutic target.

Atezolizumab Combined With Platinum and Maintenance Niraparib for Recurrent Ovarian Cancer With a Platinum-Free Interval >6 Months: ENGOT-OV41/GEICO 69-O/ANITA Phase III Trial

PURPOSE

To evaluate atezolizumab combined with platinum-based chemotherapy (CT) followed by maintenance niraparib for late-relapsing recurrent ovarian cancer.

METHODS

The multicenter placebo-controlled double-blind randomized phase III ENGOT-OV41/GEICO 69-O/ANITA trial (ClinicalTrials.gov identifier: NCT03598270) enrolled patients with measurable high-grade serous, endometrioid, or undifferentiated recurrent ovarian cancer who had received one or two previous CT lines (most recent including platinum) and had a treatment-free interval since last platinum (TFIp) of >6 months. Patients were stratified by investigator-selected carboplatin doublet, TFIp, BRCA status, and PD-L1 status in de novo biopsy and randomly assigned 1:1 to receive either atezolizumab or placebo throughout standard therapy comprising six cycles of a carboplatin doublet followed (in patients with response/stable disease) by maintenance niraparib until progression. The primary end point was investigator-assessed progression-free survival (PFS) per RECIST v1.1.

RESULTS

Between November 2018 and January 2022, 417 patients were randomly assigned (15% BRCA-mutated, 36% PD-L1-positive, 66% TFIp >12 months, 11% previous poly [ADP-ribose] polymerase inhibitor after frontline CT, and 53% previous bevacizumab). Median follow-up was 28.6 months (95% CI, 26.6 to 30.5 months). Atezolizumab did not significantly improve PFS (hazard ratio, 0.89 [95% CI, 0.71 to 1.10]; P = .28). Median PFS was 11.2 months (95% CI, 10.1 to 12.1 months) with atezolizumab versus 10.1 months (95% CI, 9.2 to 11.2 months) with standard therapy. Subgroup analyses generally showed consistent results, including analyses by PD-L1 status. The objective response rate (ORR) was 45% (95% CI, 39 to 52) with atezolizumab and 43% (95% CI, 36 to 49) with standard therapy. The safety profile was as expected from previous experience of these drugs.

CONCLUSION

Combining atezolizumab with CT and maintenance niraparib for late-relapsing recurrent ovarian cancer did not significantly improve PFS or the ORR.

Drugs and drug targets for the treatment of HPV-positive cervical cancer

Cervical cancer is primarily driven by persistent infection with high-risk human papillomavirus (HPV) strains and remains a significant global health challenge, particularly in low- and middle-income countries where late-stage diagnoses is common. While vaccination and screening programs have reduced incidence rates, the need for novel and more effacacious and cost-effective therapeutic options is therefore critical especially for advanced cervical cancer. This review highlights several key advances in the understanding of HPV-induced carcinogenesis and the development of therapeutic strategies over the past five years. Important areas of focus include the role of HPV oncoproteins E5, E6 and E7 in modulating signalling pathways, treatment strategies for precancerous lesions, the potential of natural compounds to target cervical cancer cells, and the emergence of immunotherapies, checkpoint inhibitors, antibody-drug conjugates, and novel drug combinations to treat cervical cancer. Additionally, lifestyle recommendations and the integration of natural supplements are discussed for their potential to enhance treatment efficacy and improve patient outcomes. The developments reported in this review underscore the evolving landscape of cervical cancer treatment and the need for continued research to validate and integrate these emerging therapies into clinical practice.

The potential role of HPV oncoproteins in the PD-L1/PD-1 pathway in cervical cancer: new perspectives on cervical cancer immunotherapy

Cervical cancer (CC) is a common malignant tumour of the female reproductive system that is highly harmful to women's health. The efficacy of traditional surgery, radiotherapy and chemotherapy is limited, especially for recurrent and metastatic CC. With continuous progress in diagnostic and treatment technology, immunotherapy has become a new approach for treating CC and has become a new therapy for recurrent and metastatic CC. However, immunotherapy is not effective for all patients with CC. Therefore, factors related to immunotherapy efficacy in CC patients have become the focus of researchers. High-risk human papillomavirus (HPV) infection is an important factor that drives CC development and affects its progression and prognosis. Increasing attention has been given to the mechanism of the E5, E6 and E7 proteins, which are encoded by the HPV gene, in the occurrence and development of CC and their interaction with programmed cell death ligand-1/programmed cell death-1 (PD-L1/PD-1). Although some preliminary studies have been conducted on these topics, a comprehensive and systematic review of these topics is not available. This review comprehensively summarizes related articles from journals with impact factors greater than 3 and published in the past 5 years; it also reviews studies on the mechanism of HPV and CC, the mechanism of PD-L1/PD-1 axis regulation in CC, and the mechanism by which the interaction between HPV-related oncoproteins and the PD-L1/PD-1 pathway affects the development and prognosis of CC. This study provides theoretical support for the use of immunotherapies for CC, provides a basis for the selection of specific medications that target different HPV-related proteins, and provides a new perspective for the discovery of new immunotherapy targets for CC.

Interferon response and epigenetic modulation by SMARCA4 mutations drive ovarian tumor immunogenicity

Cell-intrinsic mechanisms of immunogenicity in ovarian cancer (OC) are not well understood. Damaging mutations in the SWI/SNF chromatin remodeling complex, such as SMARCA4 (BRG1), are associated with improved response to immune checkpoint blockade; however, the mechanism by which this occurs is unclear. We found that SMARCA4 loss in OC models resulted in increased cancer cell-intrinsic immunogenicity, characterized by up-regulation of long-terminal RNA repeats, increased expression of interferon-stimulated genes, and up-regulation of antigen presentation machinery. Notably, this response was dependent on STING, MAVS, and IRF3 signaling but was independent of the type I interferon receptor. Mouse ovarian and melanoma tumors with SMARCA4 loss demonstrated increased infiltration and activation of cytotoxic T cells, NK cells, and myeloid cells in the tumor microenvironment. These results were recapitulated in BRG1 inhibitor-treated SMARCA4-proficient tumor models, suggesting that modulation of chromatin remodeling through targeting SMARCA4 may serve as a strategy to overcome cancer immune evasion.

Efficacy and safety of adding immune checkpoint inhibitors to first-line standard therapy for recurrent or advanced cervical cancer: a meta-analysis of phase 3 clinical trials

Background

Immune checkpoint inhibitors (ICIs) combined with standard therapy (ST) have emerged as a novel treatment strategy for recurrent or advanced cervical cancer (r/a CC). However, the available data from phase 3 clinical trials have yielded mixed results. This study aims to evaluate the therapeutic efficacy and safety of adding ICIs to ST in the treatment of r/a CC.

Methods

Data from four phase 3 clinical trials (KEYNOTE-826, CALLA, BEATcc, and ENGOT-cx11/GOG-3047/KEYNOTE-A18), involving 2,857 patients, were analyzed. Meta-analyses were conducted to combine hazard ratios (HRs) for overall survival (OS) and progression-free survival (PFS), odds ratios (ORs) for the objective response rate (ORR), and relative risks (RRs) for adverse events (AEs).

Results

The addition of ICIs to ST significantly improved PFS (HR, 0.67; 95% CI, 0.60-0.75), OS (HR, 0.66; 95% CI, 0.58-0.75), and ORR (OR, 1.48; 95% CI, 1.13-1.94) compared to ST alone. However, there was a modest increase in grade 3-5 AEs (RR, 1.08; 95% CI, 1.03-1.13) with the combined therapy.

Conclusion

This meta-analysis indicates that the combination of ICIs with ST in the treatment of r/a CC not only demonstrates superior efficacy over ST alone but also maintains a comparable toxicity profile, offering strong evidence for an effective and relatively safe treatment approach for managing this disease.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42024593895.

Efficacy and Safety of Immune Checkpoint Inhibitors on Advanced Cervical Cancer: A Systematic Review and Meta-analysis

This study aims to evaluate the efficacy and safety of immune checkpoint inhibitors (ICIs) in patients with histologically proven advanced cervical cancer. MEDLINE (through PubMed), Web of Science, Embase, and the Cochrane Library were comprehensively searched. Eligible studies were clinical trials investigating the efficacy and safety on ICIs in patients with confirmed advanced cervical cancer. Response rates and adverse events rates were pooled using either a random-effects model or a fixed-effects model based on the I2 value. A total of 12 clinical trials with 523 women diagnosed with advanced cervical cancer were included. Programmed cell death-1 (PD-1)/programmed cell death ligand-1 (PD-L1), and cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) inhibitors were identified. The pooled objective response (OR) rate, complete response (CR) rate, partial response (PR) rate, and stable disease (SD) rate of PD1 antibodies were 0.24 (95% CIs: 0.11-0.39; I2=90%, P<0.01), 0.03 (95% CIs: 0.02-0.05; I2=0%, P =0.92), 0.20 (95% CIs: 0.08-0.36; I2=91%, P<0.01), 0.31 (95% CIs: 0.23-0.40; I2=79%, P<0.01), respectively. Adverse events (AEs) rate of any grade was 0.81 (95% CIs: 0.72-0.88; I2=83%, P<0.01). This study indicates that PD-1/PD-L1 inhibitors reveal acceptable clinical responses and tolerable adverse events in the treatment of advanced cervical cancer. Well-designed clinical trials investigating the efficacy and safety of immune checkpoint inhibitors (ICIs) are needed.

Are we making progress in curing advanced cervical cancer-again?

Major improvements in radiotherapy over the past two decades in the definitive treatment of locally advanced cervical cancer have significantly improved loco-regional control and survival, whereas little progress has been made with chemotherapy since the implementation of concomitant cisplatin 25 years ago. However, the randomized study INTERLACE (A phase III multicenter trial of weekly induction chemotherapy followed by standard chemoradiation versus standard chemoradiation alone in patients with locally advanced cervical cancer) of neoadjuvant chemotherapy presented recently, has shown significant improvement in survival with the use of six cycles of weekly carboplatin and paclitaxel. Although INTERLACE is yet to be published, neoadjuvant chemotherapy is already being advocated as the new standard, and studies are being designed with neoadjuvant chemotherapy followed by chemoradiation and brachytherapy as the standard arm. It is noteworthy that INTERLACE was initiated before the improvements in radiotherapy mentioned above were broadly implemented. The survival rate in the standard arm of INTERLACE was therefore inferior to the results obtained with the latest state-of-the-art external beam radiotherapy and image guided adaptive brachytherapy (EMBRACE, Magnetic Resonance Imaging (MRI)-Guided Brachytherapy in Locally Advanced Cervical Cancer). Moreover, patient selection impedes the comparison of INTERLACE with other studies as the patients included in INTERLACE were younger, had better performance status, and had less advanced disease than in other studies. Notably patients with involved para-aortic nodes were excluded. In this review, we discuss neoadjuvant chemotherapy in the frame of the EMBRACE studies and show how the impact of modern radiotherapy and patient selection affects the interpretation of the results of INTERLACE. This has led us to conclude that neoadjuvant chemotherapy is not needed for the majority of patients with cervical cancer treated with definitive modern radiotherapy, and may cause harm. However, it is possible that short course neoadjuvant chemotherapy may benefit a minor subgroup of patients who need to be identified. Comprehensive understanding, including cost utility analyses, are needed to draw conclusions regarding the potential benefit of neoadjuvant chemotherapy in low and middle income countries with limited access to modern radiotherapy.

Surgery, chemoradiotherapy, or chemoradiation plus immunotherapy: Treatment strategies for nonmetastatic anal squamous cell carcinoma

The current standard of care for anal squamous cell carcinoma (ASCC) is definitive concurrent chemoradiotherapy (CRT). However, about a third of patients may experience treatment failure. Recently, immunotherapy has emerged as a novel strategy for metastatic ASCC patients. We evaluated the efficacy and safety of surgery, CRT alone, and CRT with immunotherapy (CRT-I) in 100 nonmetastatic ASCC patients, treated from April 2012 through May 2023, by determining survival outcomes and acute adverse events. The median (range) follow-up was 30.7 (7.6 to 134.9) months. The study cohort 3-year overall survival (OS), progression-free survival (PFS), distant metastasis-free survival (DMFS), and locoregional recurrence-free survival (LRFS) rates were 80.7 %, 62.2 %, 71.1 %, and 67.6 %, respectively. The Surgery group had significantly lower rates than the CRT and CRT-I groups for 3-year PFS (33.1% vs. 65.2% vs. 92.9 %, P < 0.001), DMFS (46.7% vs. 74.6% vs. 92.9 %, P = 0.002) and LRFS (37.0% vs. 73.3% vs. 92.9 %, P < 0.001), respectively. All patients receiving CRT-I were alive at last follow-up. Of 100 patients, 26 (26.0 %) experienced severe (≥ grade 3) acute toxicity. Of 24 patients receiving CRT-I, 8 (33.3 %) had severe acute toxicity. Using immunohistochemistry, peritumoural stromal infiltration by CD8+ T cells was significantly higher after CRT-I compared to before CRT-I and to after CRT alone. The addition of immunotherapy to CRT may be an effective first-line treatment option with favourable survival outcomes and acceptable toxicity for patients with ASCC. A prospective, randomized trial assessing the efficacy of CRT combined with a PD-1 inhibitor in patients with locally advanced ASCC is in progress.

Contemporary Review of Adenocarcinoma of the Cervix

OPINION STATEMENT

Among cervical cancers, adenocarcinoma is less common than squamous cell carcinoma of the cervix; however, the incidence of these cancers is rising. The incidence has changed largely due to a shift in risk factors as well as the evolution of the diagnosis and classification of adenocarcinoma. Adenocarcinoma of the cervix is composed of a diverse group of neoplasms that can be classified by various factors. In this review article, preinvasive disease, updated classifications of adenocarcinoma, and treatment options for cervical adenocarcinoma are discussed with a focus on current and future therapies. Advances in antibody-drug conjugates (ADC) and immunotherapy have increased the treatment options available for usual-type adenocarcinoma but there is still a lack of variety of treatment options for the remaining 25% of non-usual-type adenocarcinomas.

Standard of care treatment for stage IVB cervical cancer: A systematic review and meta-analysis

OBJECTIVE

Our aim was to perform a systematic review and meta-analysis evaluating the efficacy of standard treatment for stage IVB cervical cancer.

METHOD

Databases were searched for Phase III trials evaluating stage IVB CC patients according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. Systematic review included Phase III trials evaluating first-line treatment of stage IVB cervical cancer (CC). A meta-analysis was pursued for Phase III trials establishing standard of care treatment that included independent analyses of stage IVB, persistent, and recurrent CC.

RESULTS

For the systematic review, 8 studies met inclusion criteria, with a total of 3,161 CC patients analyzed. Of these studies, three met criteria and included suitable data for meta-analysis - GOG 240, KEYNOTE-826, and BEATcc. Of the 1,479 women included in the meta-analysis, 289 (19.5 %) had stage IVB and 1,190 (80.5 %) had persistent or recurrent CC. HR of OS was 0.64 (95 % confidence interval (CI): 0.55-0.75) and 0.85 (95 % CI: 0.64-1.14) for persistent/recurrent and stage IVB CC, respectively. In the test of group differences, p-value was insignificant at 0.098.

CONCLUSION

While trials have assessed outcomes in stage IVB, persistent, and recurrent CC, new treatments demonstrate poorer PFS and OS for stage IVB compared to persistent and recurrent CC. The exact benefit for current standard of care for stage IVB CC could be better defined. Given that stage IVB CC has a different clinical course and treatment history compared to persistent and recurrent disease, stage IVB CC should be analyzed independently in future clinical trials.

Phase II study of enlonstobart (SG001), a novel PD-1 inhibitor in patients with PD-L1 positive recurrent/metastatic cervical cancer

BACKGROUND

Platinum-based chemotherapy with or without bevacizumab is the first-line treatment for patients with recurrent or metastatic cervical cancer (r/mCC), and the treatment options are limited for r/mCC after first-line treatment. Enlonstobart (SG001) is a fully humanized and high-affinity anti-PD-1 immunoglobulin G4 monoclonal antibody. Previous phase Ib study demonstrated that SG001 had a promising efficacy in patients with PD-L1 positive r/mCC.

METHODS

In this multicenter, single-arm, open-label, phase II study, eligible patients were ≥ 18 years with PD-L1-positive cervical cancer who had progression on or intolerance to the first-line platinum-based chemotherapy. Patients received SG001 240 mg every two weeks for 24 months or until disease progression, intolerable toxicities, or other study discontinuation criteria were met. The primary endpoint was confirmed objective response rate (ORR) assessed by RECIST version 1.1 by independent review committee.

RESULTS

107 patients were enrolled with median age of 53 years (range 26-72). 64.5 % of patients had a ECOG of 1. After a median follow-up of 14.0 months (range 0.4-21.9), confirmed ORR was 29.0 %, with two complete responses and twenty-nine partial responses. The disease control rate was 54.2 %. Median duration of response was 16.6 months (95 % CI 10.8-NA), median progression free survival was 3.1 months (95 % CI 2.2-6.9). Median overall survival was not reached. 104 patients (97.2 %) experienced at least one treatment emergent adverse events TEAEs, of which 38 patients (35.5 %) had grade 3 or higher TEAEs. The most common treatment-related adverse events were leukopenia (19.6 %), increased aspartate aminotransferase (18.7 %), anemia (17.8 %), increased alanine aminotransferase (15.9 %), hypothyroidism (15.0 %), neutropenia (15.0 %), and hyperthyroidism (11.2 %).

CONCLUSION

SG001 monotherapy demonstrated durable anti-tumor activity with acceptable safety in patients with PD-L1 positive r/mCC with progression on or intolerance to the first-line platinum-based chemotherapy.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT04886700).

A Narrative Review of the Clinical, Humanistic, and Economic Value of Pembrolizumab-Based Immunotherapy for the Treatment of Breast and Gynecologic Cancers

Breast and gynecologic cancers are common across the world and are associated with substantial societal and economic burden. Pembrolizumab was among the first immune checkpoint inhibitors targeting programmed cell death protein 1 to be approved for the treatment of patients with triple-negative breast cancer, cervical cancer, and endometrial cancer. Recent clinical trials have established pembrolizumab regimens as a standard of care treatment for these tumor types. Clinical data are further supported by patient-reported outcome, cost-effectiveness, and real-world evidence. Pembrolizumab monotherapy and combination regimens do not negatively influence health-related quality of life and are cost-effective relative to comparators. Ongoing phase 3 studies with pembrolizumab will expand the current understanding of its use in breast and gynecologic cancers. Several of these studies are in patients with early-stage disease with the hope of curing patients. The main objective of this review is to summarize the clinical, humanistic, and economic value of pembrolizumab in these settings and to describe the future challenges for patients, caregivers, clinicians, and payers.

Targeting Hypoxia and Autophagy Inhibition via Delivering Sonodynamic Nanoparticles With HIF-2α Inhibitor for Enhancing Immunotherapy in Renal Cell Carcinoma

Immune checkpoint blockers (ICBs) therapy stands as the first-line treatment option for advanced renal cell carcinoma (RCC). However, its effectiveness is hindered by the immunosuppressive tumor microenvironment (TME). Sonodynamic therapy (SDT) generates tumor cell fragments that can prime the host's antitumor immunity. Nevertheless, the hypoxic microenvironment and upregulated autophagy following SDT often lead to cancer cell resistance. In response to these challenges, a hypoxia-responsive polymer (Poly(4,4'-azobisbenzenemethanol-PMDA)-mPEG5k, P-APm) encapsulating both a HIF-2α inhibitor (belzutifan) and the ultrasonic sensitize (Chlorin e6, Ce6) is designed, to create the nanoparticle APm/Ce6/HIF. APm/Ce6/HIF combined with ultrasound (US) significantly suppresses tumor growth and activates antitumor immunity in vivo. Moreover, this treatment effectively transforms the immunosuppressive microenvironment from "immune-cold" to "immune-hot", thereby enhancing the response to ICBs therapy. The findings indicate that APm/Ce6/HIF offers a synergistic approach combining targeted therapy with immunotherapy, providing new possibilities for treating RCC.

Meta-analysis of efficacy and safety of pembrolizumab for the treatment of advanced or recurrent cervical cancer

BACKGROUND

This meta-analysis seeks to assess the efficacy and safety of pembrolizumab in individuals with advanced or recurrent cervical cancer.

METHODS

Databases from PubMed, Embase, and the Cochrane Library were all thoroughly searched for pertinent research. Outcomes include complete response (CR), partial response (PR), stable disease (SD), disease progression (PD), overall response rate (ORR), disease control rate (DCR), median progression-free survival (mPFS), median overall survival (mOS), and adverse events (AEs) were retrieved for further analysis.

RESULTS

Ten trials with 721 patients were included in this meta-analysis. The pooled results for patients with cervical cancer receiving pembrolizumab were as follows: CR (0.06, 95%CI: 0.02-0.10), PR (0.15, 95%CI: 0.08-0.22), SD (0.16, 95%CI: 0.13-0.20), PD (0.50, 95%CI: 0.25-0.75), ORR (0.26, 95%CI: 0.11-0.41) and DCR (0.42, 95%CI: 0.13-0.71), respectively. Regarding survival analysis, the pooled mPFS and mOS were 3.81 and 10.15 months. Subgroup analysis showed that pembrolizumab in combination was more beneficial in CR (0.16 vs. 0.03, p = 0.012), PR (0.24 vs. 0.08, p = 0.032), SD (0.11 vs. 0.19, p = 0.043), ORR (0.42 vs. 0.11, p = 0.014), and mPFS (5.54 months vs. 2.27 months, p < 0.001) than as single agent. The three most common AEs were diarrhoea (0.25), anaemia (0.25), and nausea (0.21), and the incidence of grade 3-5 AEs was significantly lower, rarely surpassing 0.10.

CONCLUSIONS

For patients with advanced or recurrent cervical cancer, this systematic review and meta-analysis demonstrated that pembrolizumab had a favourable efficacy and tolerability. Future research will primarily focus on optimising customised regiments that optimally integrate pembrolizumab into new therapies and combination strategies. Designed to maximise patient benefit and efficiently control adverse effects while maintaining a high standard of living.

Cervical adenocarcinoma presenting as an ovarian torsion

Background

Cervical adenocarcinoma is increasing in incidence and can rarely present as ovarian metastasis.Case: A 41-year-old female who presented with left lower quadrant pain and vomiting. Intra-operative findings revealed bilateral ovarian cysts with initial pathology results of mucinous ovarian adenocarcinoma. Final histopathology revealed an invasive poorly differentiated mucinous adenocarcinoma of the cervix.

Conclusions

Mucinous adenocarcinoma in the ovary is usually a metastasis and an extensive and comprehensive work-up is required to try to locate the primary tumor.Précis: Mucinous adenocarcinoma in the ovary is usually a metastasis and an extensive and comprehensive work-up is required to try to locate the primary tumor.

Current management of cervical cancer in women living with HIV

Cervical cancer is a significant global health issue, particularly in low- and middle-income countries. Women living with HIV (WLWH) are not only at higher risk of cervical cancer due to their increased susceptibility to high-risk human papillomavirus (HPV) infection and compromised immune status, but also higher mortality rates have been reported. Therefore, prevention, optimal screening, use of highly active antiretroviral therapy (HAART), and early access to treatment are of utmost importance in this population. While international guidelines for cervical cancer state no treatment differences should be made for WLWH, there is evidence that this population of patients represents a challenge in decision-making for medical oncologists, radiation oncologists, and surgical oncologists. This review summarizes the available evidence on the different treatment strategies for WLWH and invasive cervical cancer and highlights the need for special considerations in screening andprevention of cervical cancer in WLWH.

Safety and efficacy of antibody-drug conjugates plus immunotherapy in solid tumours: A systematic review and meta-analysis

BACKGROUND

Combining antibody-drug conjugate (ADCs) with immune checkpoint inhibitors (ICIs) is emerging as a promising treatment option to increase efficacy outcomes. However, concerns arise regarding the safety of these combinations, as some toxicities may overlap. Currently, there is still limited information about the safety profiles of this strategy.

METHODS

A systematic review and meta-analysis was conducted to identify clinical trials investigating FDA-approved ADCs in combination with ICI drugs in the metastatic setting across all solid tumors. The primary endpoint of this study was the percentage of adverse events (AEs) of any grade and grade ≥ 3. Secondary endpoints include the percentage of patients with AEs leading to death, treatment discontinuation, proportion of complete responses (CR) and overall response rate (ORR). A parallel search was conducted to quantify the safety profile of ADCs and ICIs in monotherapy. Random effects models were used to estimate pooled outcomes.

RESULTS

Sixteen trials involving 1,133 patients treated with ADC plus ICI met the inclusion criteria with six different ADCs evaluated. Overall, 55.3 % of patients developed grade ≥ 3 AEs, 30.0 % of patients had treatment discontinuation, and 3.0 % experienced AEs leading to death. When compared to trials evaluating ADC or ICI as monotherapy, the combination results in similar rates of the most common AEs. However, it increases the risk of specific toxicities, such as ILD/pneumonitis (15.0 % with T-DXd plus ICI vs. 11.5 % with T-DXd alone). The pooled ORR was 48.8 % (95 %CI 39.4 % - 58.4 %) and the CR rate was 9.0 % (95 %CI 5.5 - 14.5). PD-L1-positive tumors showed numerically better efficacy outcomes.

CONCLUSIONS

This meta-analysis shows that the safety profile of the ADC plus ICI is comparable to that of ADC monotherapy. However, it increases the risk of certain toxicities of special interest, such as ILD/pneumonitis, highlighting the need for careful monitoring.

Opportunities to advance cervical cancer prevention and care

Cervical cancer (CaCx) is a major public health issue, with over 600,000 women diagnosed annually. CaCx kills someone every 90 s, mostly in low- and middle-income countries. There are effective yet imperfect mechanisms to prevent CaCx. Since human papillomavirus (HPV) infections cause most CaCx, they can be prevented by vaccination. Screening methodologies can identify premalignant lesions and allow interventions before a CaCx develops. However, these tools are less feasible in resource-poor environments. Additionally, current screening modalities cannot triage lesions based on their relative risk of progression, which results in overtreatment. CaCx care relies heavily on genotoxic agents that cause severe side effects. This review discusses ways that recent technological advancements could be leveraged to improve CaCx care and prevention.

Crosstalk of T cells within the ovarian cancer microenvironment

Ovarian cancer (OC) represents ecosystems of highly diverse tumor microenvironments (TMEs). The presence of tumor-infiltrating lymphocytes (TILs) is linked to enhanced immune responses and long-term survival. In this review we present emerging evidence suggesting that cellular crosstalk tightly regulates the distribution of TILs within the TME, underscoring the need to better understand key cellular networks that promote or impede T cell infiltration in OC. We also capture the emergent methodologies and computational techniques that enable the dissection of cell-cell crosstalk. Finally, we present innovative ex vivo TME models that can be leveraged to map and perturb cellular communications to enhance T cell infiltration and immune reactivity.

The Utilization of the Accelerated Approval Pathway in Oncology: A Case Study of Pembrolizumab

The accelerated approval (AA) pathway was established by the United States Food and Drug Administration (FDA) to provide earlier access to therapies for patients with serious medical conditions and unmet medical needs. Since its inception, the AA pathway has been used for novel treatments across different therapeutic areas, but most prominently in oncology, including the immune checkpoint inhibitor class. This review article describes the history of regulatory approvals for pembrolizumab, an immunotherapy agent targeting programmed death receptor-1 (PD-1), and use of the AA pathway and the corresponding regulatory decisions made by the FDA. From its first AA in September 2014 to February 2024, pembrolizumab has used the accelerated pathway for roughly 40% of the approved indications listed in the US Prescribing Information and was the first oncology therapy to receive an AA for an alternate dosing regimen and a tissue-agnostic indication. As of February 2024, 14 of the 18 indication-specific AAs and 1 post-marketing requirement (PMR) for the alternate dosing regimen AA were converted to traditional approvals. Accelerated approvals for two indications were withdrawn, and the remaining ongoing PMRs are not due until later in 2024 or 2025. The median conversion time from AA to traditional approval was 2.6 years, which is roughly 6 months earlier than the median time reported for oncology AAs. While FDA was the first agency to establish an expedited approval pathway, regulators from other countries have established similar pathways. For pembrolizumab, approximately half of the datasets that supported US AAs also supported expedited approval, or sometimes full approval, in Canada, EU, Australia or Japan. Ultimately, the AA pathway balances the provision of earlier access to therapies with overcoming uncertainty about potential effectiveness, and therefore it is important to confirm treatment benefit and withdraw indications that do not confirm benefit in a timely manner. The regulatory strategy and use of this expedited program for pembrolizumab highlights the importance of the AA pathway in providing oncology patients with earlier access to life-saving medications.

Cost-effectiveness analysis of immune checkpoint inhibitors combined with targeted therapy and chemotherapy for HPV/HIV-related cervical cancer

BACKGROUND

To systematically assess the cost-effectiveness of immune checkpoint inhibitors compared to the current standard therapy for human papillomavirus (HPV) and human immunodeficiency virus (HIV)-related cervical cancer.

METHODS

A partitioned survival model spanning a 20-year period was created to evaluate the cost and effectiveness of atezolizumab combined with bevacizumab and chemotherapy (ABC), and pembrolizumab combined with bevacizumab and chemotherapy (PBC) vs bevacizumab combined with chemotherapy (BC), based on clinical data from the BEATcc and KEYNOTE-826 trials. Royston-Parmar models were used for survival estimation. Costs and health state utilities were sourced from existing literature and publicly accessible databases. Cumulative costs (in US dollars), life years, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs) were measured and compared. The evaluation was from the US healthcare payer perspective, with the willingness-to-pay threshold set at $100,000 to $150,000. Deterministic sensitivity analysis (DSA), probabilistic sensitivity analysis (PSA), and scenario analyses were conducted.

RESULTS

The base-case analysis showed QALYs of 2.05 for BC, 3.18 for PBC, and 2.85 for ABC. PBC increased life-years by 1.76 and ABC by 1.18, with PBC showing the highest effectiveness. Total costs were $272,377 for BC, $715,472 for ABC, and $694,239 for PBC; severe adverse event (SAE) costs were $6189 for BC, $7603.31 for ABC, and $13,640 for PBC, indicating BC had the lowest SAE costs. The ICERs compared to BC were $372,151/QALY for PBC and $553,995/QALY for ABC. Given that the willingness-to-pay threshold was $100,000 to $150,000/QALY, both PBC and ABC exceed this threshold and were not considered cost-effective. BC had the lowest QALYs and the lowest costs, making it the least expensive option and the most cost-effective choice. DSA results indicated that drug prices and utility values were the main factors affecting cost-effectiveness. PSA confirmed BC as the most cost-effective option within a willingness-to-pay threshold of $0 to $300,000, primarily because it was the least costly.

CONCLUSIONS

Immune checkpoint inhibitors significantly improve survival benefits for patients. However, their addition is costly and unlikely to be cost-effective for HPV/HIV-related metastatic cervical cancer.

Sintilimab plus HPV vaccine for recurrent or metastatic cervical cancer

PURPOSE

Recurrent or metastatic cervical cancer (r/m CC) presents limited treatment options for patients failed or progressed quickly following first-line therapy. This study investigated the potential of sintilimab with a prophylactic human papillomavirus (HPV) quadrivalent vaccine as a second-line treatment for r/m CC.

METHODS

In this phase 2 clinical trial, patients with r/m CC previously unresponsive or intolerant to standard treatments for metastatic or recurrent lesions were enrolled. Participants received sintilimab (3 mg/kg for body weight <60 kg; 200 mg for ≥60 kg) every 3 weeks until 24 months or 35 cycles and 3 doses of the HPV quadrivalent vaccine (initial dose prior to sintilimab initiation, with subsequent doses at 2 and 6 months). The primary endpoint was the objective response rate (ORR). A Simon two-stage optimal design was used.

RESULTS

From October 2019 to October 2022, 13 patients with r/m CC were enrolled. ORR achieved 53.8% (95% CI 25.1% to 80.8%), and the disease control rate was 76.9% (95% CI 46.2% to 95.0%). Median follow-up duration was 16.07 months (range: 3.64-48.2 months), and median progressive free survival was 7.16 months (95% CI 1.91 -not applicable (NA)). The median overall survival (OS) was not reached (95% CI 9.89 -NA). Hypothyroidism (15.6%) was the most common treatment-related adverse event (AE). No grade 3 or above AEs were observed.

CONCLUSIONS

This study suggests the combination of sintilimab plus prophylactic HPV vaccine offers a potentially promising therapeutic strategy for patients with r/m CC unresponsive or intolerant to standard therapies.Trial registration numberNCT04096911.

Atezolizumab plus bevacizumab and chemotherapy as first-line therapy for cervical cancer: a cost-effectiveness analysis in the US

Objective

Medication is the predominant therapy for advanced cancers. However, the use of novel anticancer medications is a major contributor to disease-related financial hardships. Recently, numerous countries have mandated the pharmacoeconomic assessments of novel oncological agents to mitigate patient financial risks and optimize resource allocation. The present study evaluated the cost-effectiveness of adding atezolizumab to standard therapy (atezolizumab plus bevacizumab [BC]) for metastatic, persistent, and recurrent cervical cancer from the perspective of US healthcare payers, with the aim of supporting policymaking and promoting the rational use of healthcare resources.

Methods

Using clinical efficacy and safety data from the BEATcc clinical trial, in addition to cost and utility values from publicly available databases and published literature, a partitioned survival model over a 20-year lifetime horizon was developed to assess the cost-effectiveness of atezolizumab plus bevacizumab and chemotherapy (ABC) versus BC. The primary output of the model was the incremental cost-effectiveness ratio (ICER) and sensitivity analyses were performed to assess its robustness.

Results

At both 20 and 4.5 y of time horizon, ABC therapy showed poor cost-effectiveness, with ICER of $193926.48/QALY and $168482.26/QALY, respectively, which were higher than the $150,000/QALY willingness-to-pay threshold. One-way sensitivity analysis showed that the price of atezolizumab had the most significant impact on the model results. When the price of atezolizumab was reduced by 10%, ABC changed from being not cost-effective to cost-effective (ICER = $121531.24/QALY). Probabilistic sensitivity analysis showed a 32.6% probability that ABC would be cost-effective, which increased to 58.6% when the price of atezolizumab was reduced by 10%.

Conclusions

For patients with metastatic, persistent, and recurrent cervical cancer in the US, ABC was not as cost-effective as BC. Appropriate price reduction (10%) is recommended for atezolizumab to improve cost-effectiveness of ABC therapy.

A surprising complete response to cadonilimab in a primary metastatic cervical cancer: a case report

The outcome of patients with recurrent/metastatic cervical cancer (R/M CC) is poor, with a 5-year survival rate of only 10%-20%. Recent advances in immunotherapy renewed its interest in R/M CC treatment. It has been suggested that cadonilimab, a novel bispecific antibody targeting programmed death 1 (PD-1) and cytotoxic T-lymphocyte antigen-4 (CTLA-4), significantly improved the survival outcomes of the R/M CC. In the present study, we reported a programmed death ligand 1 (PD-L1) and human epidermal growth factor receptor 2 (HER-2) positive CC case at stage IV who was treated with cadonilimab and achieved a surprising radiographic complete response (CR) for 10 months, even in the PD-L1 negative metastatic site. Demographic, clinical, histopathological, laboratory, treatment regime and imaging data were recorded. Unfortunately, the patient progressed rapidly during maintenance therapy when cadonilimab was replaced by sintilimab, the monoclonal antibody against PD-1, indicating the more powerful anti-tumor activity of dual blockade immunotherapy. To conclude, cadonilimab offers a promising and effective therapeutic approach for R/M CC. Notably, HER-2 is also expected to be a new reference target for cadonilimab therapy.

An early combination of concurrent chemoradiotherapy with immune checkpoint inhibitors for cervical cancer is superior to a late combination: a propensity-score matching analysis

Purpose

This study compared the timing effects of immune checkpoint inhibitor (ICIs) administration on the efficacy and safety of concurrent chemoradiotherapy for cervical cancer.

Methods

This study included patients with advanced cervical cancer who received concurrent chemoradiotherapy with ICIs. The patients were divided into early-application (n=51) and late-application groups (n=56) according to the ICI application timing. The primary objective was assessing progression-free survival (PFS) and its associated factors; secondary objectives included assessing objective remission rates (ORR) and treatment-related adverse events (TRAEs).

Results

Before propensity score matching (PSM), the median PFS (mPFS) times were significantly different: 11.5 months (95% CI: 11.0-13.2) and 7.5 months (95% CI: 6.5-9.0) for the early and late groups, respectively (P<0.001). After PSM, the mPFS times remained significantly different: 11.5 months (95% CI: 11.0-13.8) and 6.5 months (95% CI: 6.1-9.0), respectively (P<0.001). The PSM tumor-response ORR in the early combination group (74.3%) was significantly greater than the 31.4% in the late combination group (P<0.001). After PSM, multivariate Cox analysis showed tumor diameter (P=0.004), distant organ metastasis (P=0.047), and timing of combination therapy (P<0.001) were independently associated factors affecting PFS. The most common TRAEs in the two groups of patients were neutropenia, nausea and vomiting, and fatigue, with no significant difference in incidence (P>0.050).All adverse reactions were resolved, and no adverse reaction-related deaths occurred.

Conclusion

In patients with cervical cancer treated with concurrent chemoradiotherapy, earlier immunotherapy improves survival and is equivalent in safety to ICIs late application.

Systemic immune-related spleen radiomics predict progression-free survival in patients with locally advanced cervical cancer underwent definitive chemoradiotherapy

PURPOSE

Systemic immunity is essential for driving therapeutically induced antitumor immune responses, and the spleen may reflect alterations in systemic immunity. This study aimed to evaluate the predictive value of contrast-enhanced CT-based spleen radiomics for progression-free survival (PFS) in patients with locally advanced cervical cancer (LACC) who underwent definitive chemoradiotherapy (dCRT). Additionally, we investigated the role of spleen radiomics features and changes in spleen volume in assessing systemic immunity.

METHODS

This retrospective study included 257 patients with LACC who underwent dCRT. The patients were randomly divided into training and validation groups in a 7:3 ratio. Radiomic features were extracted from CT images obtained before and after dCRT. Radiomic scores (Radscore) were calculated using features selected through least absolute shrinkage and selection operator (LASSO) Cox regression. The percentage change in spleen volume was determined from measurements taken before and after treatment. Independent prognostic factors for PFS were identified through multivariate Cox regression analyses. Model performance was evaluated with the receiver operating characteristic (ROC) curve and the C-index. The Radscore cut-off value, determined from the ROC curve, was used to stratify patients into high- and low-risk survival groups. The Wilcoxon test was used to analyze differences in hematological parameters between different survival risk groups and between different spleen volume change groups. Spearman correlation analysis was used to explore the relationship between spleen volume change and hematological parameters.

RESULTS

Independent prognostic factors included FIGO stage, pre-treatment neutrophil-to-lymphocyte ratio (pre-NLR), spleen volume change, and Radscore. The radiomics-combined model demonstrated the best predictive performance for PFS in both the training group (AUC: 0.923, C-index: 0.884) and the validation group (AUC: 0.895, C-index: 0.834). Compared to the low-risk group, the high-risk group had higher pre-NLR (p = 0.0054) and post-NLR (p = 0.038). Additionally, compared to the decreased spleen volume group, the increased spleen volume group had lower post-NLR (p = 0.0059) and post-treatment platelet-to-lymphocyte ratio (p < 0.001).

CONCLUSION

Spleen radiomics combined with clinical features can effectively predict PFS in patients with LACC after dCRT. Furthermore, spleen radiomics features and changes in spleen volume can reflect alterations in systemic immunity.

Cost-Effectiveness of Pembrolizumab as First-Line Treatment in Patients with Persistent, Recurrent, or Metastatic Cervical Cancer in the United States

INTRODUCTION

First-line treatment of persistent, recurrent, or metastatic (advanced) cervical cancer in patients who have a combined positive score (CPS) ≥ 1 with pembrolizumab + chemotherapy versus standard-of-care chemotherapy provides meaningful improvements in overall survival. We conducted a cost-effectiveness analysis from a US payer perspective. A societal perspective scenario was also considered, including productivity gains.

METHODS

The cost-effectiveness of pembrolizumab + chemotherapy versus chemotherapy was assessed using a state-transition model comprising the health states "pre-progression," "post-progression," and "death," with a 1-week cycle length and 50-year time horizon. Patient-level KEYNOTE-826 data informed the efficacy, safety, and health-related quality of life of pembrolizumab + chemotherapy versus chemotherapy at first-line and subsequent treatments. Real-world data were sought to cost subsequent treatments according to US clinical practice. Transition probabilities were derived from parametric survival models fit to time-to-progression, progression-free survival, and post-progression survival patient-level KEYNOTE-826 data. Sensitivity analyses explored the impact on outcomes from variables such as bevacizumab use.

RESULTS

According to the state-transition model, pembrolizumab + chemotherapy extended mean life expectancy versus chemotherapy from 1.8 to 6.7 life-years. The mean gain of 4.9 life-years/patient was mostly caused by pembrolizumab delaying progression. Total discounted quality-adjusted life-years (QALY) were 5.0 and 1.3 per patient for pembrolizumab + chemotherapy and chemotherapy, respectively (mean gain: 3.7 QALY/patient). Pembrolizumab + chemotherapy had comparable safety outcomes to chemotherapy alone. Total costs incurred were US $320,247 (pembrolizumab + chemotherapy) versus US $105,446 (chemotherapy; mean incremental costs: US $214,801/patient). The incremental cost-effectiveness ratio of pembrolizumab + chemotherapy versus chemotherapy was US $58,446/QALY. Sensitivity analyses showed results were insensitive to bevacizumab use. Including productivity gains led to an incremental cost-effectiveness ratio of US $58,385 per QALY.

CONCLUSIONS

Our model-based analysis suggests that first-line treatment of pembrolizumab + chemotherapy in advanced cervical cancer with a CPS ≥ 1 offers a substantial clinical benefit over standard-of-care chemotherapy alone and is cost-effective at a willingness-to-pay threshold of US $150,000. The approximate doubling of life-years and QALYs associated with pembrolizumab + chemotherapy represents a step improvement in the treatment of advanced cervical cancer.

TRIAL REGISTRATION

ClinicalTrials.gov Identification Number: NCT03635567.

Cost-effectiveness analysis of atezolizumab plus bevacizumab and chemotherapy for the treatment of metastatic, persistent, or recurrent cervical cancer (BEATcc)

BACKGROUND

The addition of atezolizumab to bevacizumab plus platinum regimen has demonstrated notable improvements in treating metastatic, persistent, or recurrent cervical cancer, but its cost-effectiveness requires further investigation. From a US payer perspective, we aimed to evaluate the cost-effectiveness of atezolizumab plus bevacizumab and chemotherapy vs. standard chemotherapy as a first-line treatment for metastatic, persistent, or recurrent cervical cancer.

METHODS

A partitioned survival model based on the data from the BEATcc trial was used to calculate the incremental cost-effectiveness ratio (ICER), using cost and health utility information obtained from literature and publicly accessible databases. One-way and probabilistic sensitivity analyses were performed to evaluate the model's responsiveness to variations in parameters.

RESULTS

The addition of atezolizumab resulted in an additional 0.839 quality-adjusted life years (QALY) at an additional cost of $458,237, leading to an ICER of $545,943/QALY. One-way sensitivity analysis indicated that the cost of atezolizumab had the greatest impact on the ICER, followed by the utility value of progression-free survival (PFS) and follow-up costs. Probabilistic sensitivity analysis showed a 0% cost-effectiveness probability at the current willingness-to-pay (WTP) threshold of $150,000 per QALY.

CONCLUSION

Adding atezolizumab to chemotherapy is cost-prohibitive in the US and may not be cost-effective for patients.

Prevalence and prognostic value of PD-L1 expression and tumor mutational burden in persistent, recurrent, or metastatic cervical cancer

OBJECTIVE

To evaluate the prevalence and prognostic role of programmed death ligand 1 (PD-L1) expression and tumor mutational burden (TMB) in patients with non-immunotherapy-treated advanced cervical cancer.

METHODS

Clinical data were retrospectively collected from medical records between January 1, 2008, and December 31, 2016, at Asan Medical Center (Korea); archived tumor samples were assessed for PD-L1 expression (combined positive score [CPS] ≥1) and TMB (≥175 mutations/exome). Overall survival (OS) was defined as time from advanced diagnosis or initiation of first-line or second-line systemic therapy until death/last follow-up. The association of OS with PD-L1 expression and TMB were analyzed using the log-rank test and Cox proportional hazards model adjusted for covariates.

RESULTS

Of 267 patients, 76.0% had squamous cell carcinoma (SCC), 24.0% had adenocarcinoma (AC)/adenosquamous carcinoma (ASC), 64.4% had PD-L1 CPS ≥1, and 32.6% had TMB ≥175 mutations/exome. PD-L1 CPS ≥1 and TMB ≥175 mutations/exome were more prevalent in SCC than in AC/ASC (73.9% and 37.2% vs. 34.4% and 17.7%). There was no association between OS and PD-L1 expression (CPS ≥1 vs. <1: adjusted hazard ratio [HR]=1.14; 95% confidence interval [CI]=0.84-1.53 from advanced diagnosis); OS trended shorter for the subgroup with TMB ≥175 versus <175 mutations/exome (adjusted HR=1.29; 95% CI=0.95-1.75).

CONCLUSION

Retrospective analysis of non-immunotherapy-treated patients with advanced cervical cancer demonstrated a higher prevalence of PD-L1 CPS ≥1 and TMB ≥175 mutations/exome in SCC versus AC/ASC. PD-L1 CPS ≥1 was not associated with OS; TMB ≥175 mutations/exome showed a trend toward shorter OS. Additional studies are needed to confirm these findings.

First-Line Treatment With Atezolizumab Plus Bevacizumab and Chemotherapy for US Patients With Metastatic, Persistent, or Recurrent Cervical Cancer: A Cost-Effectiveness Analysis

OBJECTIVES

The BETAcc clinical trial demonstrated that chemotherapy combined with bevacizumab plus atezolizumab (CBA) significantly prolonged progression-free survival and overall survival in patients with metastatic, persistent, or recurrent cervical cancer. However, to the best of our knowledge, the economic value of using this new therapy for this indication is currently unknown. Therefore, our study aimed to evaluate the cost-effectiveness of CBA for the first-line treatment of metastatic, persistent, or recurrent cervical cancer from the United States healthcare payers perspective.

METHODS

A state-transition Markov model over a 10-year lifetime horizon was developed to compare the cost and effectiveness of CBA with that of chemotherapy plus bevacizumab (CB). The primary outcomes of our study included costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios. One-way sensitivity analysis and probabilistic sensitivity analysis were performed to assess the robustness of the results.

RESULTS

CBA was associated with an additional 0.58 QALY at an extra cost of $172 495.90 compared with CB. The incremental cost-effectiveness ratio was $295 972.43/QALY, significantly higher than the willingness-to-pay threshold value of $150 000/QALY. One-way sensitivity analyses revealed that results were most sensitive to the progression-free disease utility, the unit cost of atezolizumab, and progressed disease utility. Probabilistic sensitivity analysis indicated that CBA achieved a 4.3% probability of cost-effectiveness at a $150 000/QALY threshold. To achieve cost-effectiveness, the unit price of atezolizumab must be reduced by approximately 56.6%.

CONCLUSIONS

CBA treatment is unlikely to be a cost-effective option compared with CB for patients with persistent, recurrent, or metastatic cervical cancer in the United States.

QL1604 plus paclitaxel-cisplatin/carboplatin in patients with recurrent or metastatic cervical cancer: an open-label, single-arm, phase II trial

OBJECTIVE

QL1604 is a highly selective, humanized monoclonal antibody against programmed death protein 1. We assessed the efficacy and safety of QL1604 plus chemotherapy as first-line treatment in patients with advanced cervical cancer.

METHODS

This was a multicenter, open-label, single-arm, phase II study. Patients with advanced cervical cancer and not previously treated with systemic chemotherapy were enrolled to receive QL1604 plus paclitaxel and cisplatin/carboplatin on day 1 of each 21-day cycle for up to 6 cycles, followed by QL1604 maintenance treatment.

RESULTS

Forty-six patients were enrolled and the median follow-up duration was 16.5 months. An 84.8% of patients had recurrent disease and 13.0% had stage IVB disease. The objective response rate (ORR) per Response Evaluation Criteria in Advanced Solid Tumors (RECIST) v1.1 was 58.7% (27/46). The immune ORR per immune RECIST was 60.9% (28/46). The median duration of response was 9.6 months (95% confidence interval [CI]=5.5-not estimable). The median progression-free survival was 8.1 months (95% CI=5.7-14.0). Forty-five (97.8%) patients experienced treatment-related adverse events (TRAEs). The most common grade≥3 TRAEs (>30%) were neutrophil count decrease (50.0%), anemia (32.6%), and white blood cell count decrease (30.4%).

CONCLUSION

QL1604 plus paclitaxel-cisplatin/carboplatin showed promising antitumor activity and manageable safety profile as first-line treatment in patients with advanced cervical cancer. Programmed cell death protein 1 inhibitor plus chemotherapy may be a potential treatment option for the patient population who have contraindications or can't tolerate bevacizumab, which needs to be further verified in phase III confirmatory study.