Comparing the Therapeutic Efficacies of Lung Cancer: Network Meta-Analysis Approaches

BACKGROUND

In recent years, reduction of nuclear power generation and the use of coal-fired power for filling the power supply gap might have increased the risk of lung cancer. This study aims to explore the most effective treatment for different stages of lung cancer patients.

METHODS

We searched databases to investigate the treatment efficacy of lung cancer. The network meta-analysis was used to explore the top three effective therapeutic strategies among all collected treatment methodologies.

RESULTS

A total of 124 studies were collected from 115 articles with 171,757 participants in total. The results of network meta-analyses showed that the best top three treatments: (1) in response rate, for advanced lung cancer were Targeted + Targeted, Chemo + Immuno, and Targeted + Other Therapy with cumulative probabilities 82.9, 80.8, and 69.3%, respectively; for non-advanced lung cancer were Chemoradio + Targeted, Chemoradi + Immuno, and Chemoradio + Other Therapy with cumulative probabilities 69.0, 67.8, and 60.7%, respectively; (2) in disease-free control rate, for advanced lung cancer were Targeted + Others, Chemo + Immuno, and Targeted + Targeted Therapy with cumulative probabilities 93.4, 91.5, and 59.4%, respectively; for non-advanced lung cancer were Chemo + Surgery, Chemoradio + Targeted, and Surgery Therapy with cumulative probabilities 80.1, 71.5, and 43.1%, respectively.

CONCLUSION

The therapeutic strategies with the best effectiveness will be different depending on the stage of lung cancer patients.

Exploring the Evolving Scope of Neoadjuvant Immunotherapy in NSCLC

Simple Summary

Immunotherapy with immune checkpoint inhibitors has recently brought a paradigm shift in the treatment of non-small cell lung cancer (NSCLC), but until now, most clinical benefits of immunotherapy have been demonstrated in the setting of advanced or metastatic disease. However, there has been a recent explosion in trial development and research focus exploring whether the benefits of immunotherapy can extend to the neoadjuvant setting for patients with resectable NSCLC. The aim of this review is to thoroughly outline the preclinical rationale for neoadjuvant immunotherapy research. In addition, we summarize and analyze the published interim results as well as results presented at major conferences from the initial early phase trials. An overview of the current and upcoming randomized clinical trials in this field is also provided. Finally, we highlight future challenges and questions that need to be addressed in upcoming research to clarify the role of neoadjuvant immunotherapy in the treatment of NSCLC.

Abstract

While lung cancer remains the leading cause of cancer death worldwide, lung cancer mortality has notably decreased in the past decade. Immunotherapy with immune checkpoint inhibitors have played a noteworthy role in contributing to this improved survival, particularly for patients with non-small cell lung cancer (NSCLC). However, until now the benefits have primarily been seen in patients with advanced or metastatic disease. Several recent early phase and ongoing phase III trials have been assessing whether the treatment benefit of immunotherapy in NSCLC can extend to the neoadjuvant setting for resectable diseases. In this comprehensive narrative review, we evaluate the most recent efficacy and safety data from these studies. We also outline questions that will need to be further examined to legitimate neoadjuvant immunotherapy’s role in NSCLC treatment, including the best surrogate marker of response, the incorporation of liquid biopsy for disease monitoring, the ability to be combined with other treatment modalities, the need for further adjuvant therapy, and potential future treatment combinations.

Revisiting neoadjuvant therapy in non-small-cell lung cancer

Despite the rapidly evolving treatment landscape in advanced non-small-cell lung cancer (NSCLC), developments in neoadjuvant and adjuvant treatments have been nascent by comparison. Establishing overall survival benefit in the early-stage setting has been challenging because of the need for large trials and long-term survival data. Encouraged by improved treatment outcomes with a biomarker-driven approach in advanced NSCLC, and recognising the need to improve survival outcomes in early-stage NSCLC, there has been renewed interest in revisiting neoadjuvant strategies. Multiple neoadjuvant trials with targeted therapy and immunotherapy, either alone or in combination with chemotherapy, have yielded unique insights into traditional response parameters, such as the discordance between RECIST response and pathological response, and expanded opportunities for biomarker discovery. With further standardisation of trial endpoints across studies, coupled with the implementation of novel technologies including radiomics and digital pathology, individual risk-stratified neoadjuvant treatment approaches are poised to make a striking impact on the outcomes of early-stage NSCLC.

A Phase I/II Study of Neoadjuvant Cisplatin, Docetaxel, and Nintedanib for Resectable Non-Small Cell Lung Cancer

PURPOSE

Nintedanib enhances the activity of chemotherapy in metastatic non-small cell lung cancer (NSCLC). In this phase I/II study, we assessed safety and efficacy of nintedanib plus neoadjuvant chemotherapy, using major pathologic response (MPR) as primary endpoint.

PATIENTS AND METHODS

Eligible patients had stage IB (≥4 cm)-IIIA resectable NSCLC. A safety run-in phase was followed by an expansion phase with nintedanib 200 mg orally twice a day (28 days), followed by three cycles of cisplatin (75 mg/m²), docetaxel (75 mg/m²) every 21 days plus nintedanib, followed by surgery. With 33 planned patients, the study had 90% power to detect an MPR increase from 15% to 35%.

RESULTS

Twenty-one patients (stages I/II/III, N = 1/8/12) were treated. One of 15 patients treated with nintedanib 200 mg achieved MPR [7%, 95% confidence interval (CI), 0.2%-32%]. Best ORR in 20 evaluable patients was 30% (6/20, 95% CI, 12%-54%). Twelve-month recurrence-free survival and overall survival were 66% (95% CI, 47%-93%) and 91% (95% CI, 79%-100%), respectively. Most frequent treatment-related grade 3-4 toxicities were transaminitis and electrolyte abnormalities. On the basis of an interim analysis the study was discontinued for futility. Higher levels of CD3⁺ and cytotoxic CD3⁺CD8⁺ T cells were found in treated tumors of patients who were alive than in those who died (652.8 vs. 213.4 cells/mm², P = 0.048; 142.3 vs. 35.6 cells/mm², P = 0.018).

CONCLUSIONS

Although tolerated, neoadjuvant nintedanib plus chemotherapy did not increase MPR rate compared with chemotherapy historical controls. Additional studies of the combination in this setting are not recommended. Posttreatment levels of tumor-infiltrating T cells were associated with patient survival. Use of MPR facilitates the rapid evaluation of neoadjuvant therapies.See related commentary by Blakely and McCoach, p. 3499.