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Jordan J, Maki RG. The Weighted Toxicity Score: Confirmation of a Simple Metric to Communicate Toxicity in Randomized Trials of Systemic Cancer Therapy. Oncologist 2024; 29:67-74. [PMID: 37449664 PMCID: PMC10769778 DOI: 10.1093/oncolo/oyad192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 06/06/2023] [Indexed: 07/18/2023] Open
Abstract
INTRODUCTION FDA's Project Optimus was developed in part to better identify appropriate dose and schedule of cancer therapeutics. The tabular method to summarize patients' maximum toxicity in a clinical trial does not allow for ready comparison to the treatment's benefit. In this manuscript, we apply a simple tool, the weighted toxicity score (WTS), to trials involving lung cancer immunotherapy and chemotherapy, as well as those cited in a recent publication as examples of trials that represent successful reduction of the appropriate dose of anti-cancer agents. METHODS PubMed was queried for randomized controlled trials of therapy involving immune checkpoint inhibitors in lung cancer. Trial data from studies highlighting initial success with dose adjustments after FDA approval also were assembled and analyzed according to the WTS procedure described previously, compared to clinical outcomes data. RESULTS The WTS provided, with the clinical outcome(s), a data pair that leads to easy interpretation of the expected benefit versus relative toxicity of studies involving immunotherapy or chemoimmunotherapy in lung cancers. The WTS was consistent with the conclusions of the primary studies, helping to quantitate the toxicity difference between treatments in a previously unavailable way. CONCLUSION The WTS provides a tool to show the cost in toxicity of therapy in a randomized clinical trial, with applicability to studies involving chemotherapy, immunotherapy, or kinase-directed therapy. Inclusion of a running tally of WTS during conduct of a trial could serve as one means to adjust dosing or to provide feedback during data safety monitoring of a clinical trial.
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Affiliation(s)
- Jacob Jordan
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert G Maki
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Bardoscia L, Pasinetti N, Triggiani L, Cozzi S, Sardaro A. Biological Bases of Immune-Related Adverse Events and Potential Crosslinks With Immunogenic Effects of Radiation. Front Pharmacol 2021; 12:746853. [PMID: 34790123 PMCID: PMC8591245 DOI: 10.3389/fphar.2021.746853] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 10/19/2021] [Indexed: 01/03/2023] Open
Abstract
Immune checkpoint inhibitors have gained an established role in the treatment of different tumors. Indeed, their use has dramatically changed the landscape of cancer care, especially for tumor types traditionally known to have poor outcomes. However, stimulating anticancer immune responses may also elicit an unusual pattern of immune-related adverse events (irAEs), different from those of conventional chemotherapy, likely due to a self-tolerance impairment featuring the production of autoreactive lymphocytes and autoantibodies, or a non-specific autoinflammatory reaction. Ionizing radiation has proven to promote both positive pro-inflammatory and immunostimolatory activities, and negative anti-inflammatory and immunosuppressive mechanisms, as a result of cross-linked interactions among radiation dose, the tumor microenvironment and the host genetic predisposition. Several publications argue in favor of combining immunotherapy and a broad range of radiation schedules, based on the recent evidence of superior treatment responses and patient survival. The synergistic modulation of the immune response by radiation therapy and immunotherapeutics, particularly those manipulating T-cell activation, may also affect the type and severity of irAEs, suggesting a relationship between the positive antitumor and adverse autoimmune effects of these agents. As yet, information on factors that may help to predict immune toxicity is still lacking. The aim of our work is to provide an overview of the biological mechanisms underlying irAEs and possible crosslinks with radiation-induced anticancer immune responses. We believe such an overview may support the optimization of immunotherapy and radiotherapy as essential components of multimodal anticancer therapeutic approaches. Challenges in translating these to clinical practice are discussed.
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Affiliation(s)
- Lilia Bardoscia
- Radiation Oncology Unit, S. Luca Hospital, Healthcare Company Tuscany Nord Ovest, Lucca, Italy
| | - Nadia Pasinetti
- Radiation Oncology Department, ASST Valcamonica Esine and University of Brescia, Brescia, Italy
| | - Luca Triggiani
- Department of Radiation Oncology, University and Spedali Civili Hospital, Brescia, Italy
| | - Salvatore Cozzi
- Radiotherapy Unit, Clinical Cancer Centre, AUSL-IRCCS, Reggio Emilia, Italy
| | - Angela Sardaro
- Interdisciplinary Department of Medicine, Section of Radiology and Radiation Oncology, University of Bari "Aldo Moro", Bari, Italy
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Chen X, Nie J, Dai L, Hu W, Zhang J, Han J, Ma X, Tian G, Han S, Wu D, Wang Y, Long J, Zhang Z, Fang J. Immune-Related Adverse Events and Their Association With the Effectiveness of PD-1/PD-L1 Inhibitors in Non-Small Cell Lung Cancer: A Real-World Study From China. Front Oncol 2021; 11:607531. [PMID: 33747922 PMCID: PMC7973369 DOI: 10.3389/fonc.2021.607531] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 01/19/2021] [Indexed: 01/10/2023] Open
Abstract
Background Programmed cell death-1/programmed cell death ligand-1 (PD-1/PD-L1) inhibitors are increasingly used in China, but no real-world data are available about the immune-related adverse events (irAEs). This real-world retrospective study aimed to assess the safety and effectiveness of PD-1/PD-L1 inhibitors in patients with non-small cell lung cancer (NSCLC) and to analyze the association between irAEs and effectiveness. Methods This was a retrospective study of the clinical data of patients with NSCLC treated with PD-1/PD-L1 inhibitors from August 2016 to November 2019 at Beijing Cancer Hospital. The patients were divided into the irAE or non-irAE groups. Overall adverse events, the impact of irAE on tumor response, and the association of irAEs with effectiveness were evaluated. Results One hundred and ninety-one patients were included, including 70 (36.6%) patients in the irAE group and 121 (63.4%) patients in the non-irAE group. AE, grades 3–5 AEs, and irAE occurred in 107 (56.0%), 24 (12.6%), and 70 (36.6%) of the patients, respectively. The objective response rate (ORR) and disease control rate (DCR) were higher in the irAE group compared with the non-irAE group (42.0% vs. 25.8%, P=0.038; 91.9% vs. 70.8%, P=0.002). Multivariable analyses identified that irAE were associated with progression-free survival (HR=0.62, 95%CI: 0.43–0.91; P=0.015), but not with overall survival (HR=0.76, 95%CI: 0.44–1.28; P=0.299). Conclusion In NSCLC treated with PD-1/PD-L1 inhibitors, patients with irAEs showed improved effectiveness over patients without irAEs. Future studies of anti-PD-1/PD-L1 immunotherapy should explore this association and the underlying biological mechanisms of efficacy.
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Affiliation(s)
- Xiaoling Chen
- Department of Thoracic Oncology II, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital and Institute, Beijing, China
| | - Jun Nie
- Department of Thoracic Oncology II, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital and Institute, Beijing, China
| | - Ling Dai
- Department of Thoracic Oncology II, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital and Institute, Beijing, China
| | - Weiheng Hu
- Department of Thoracic Oncology II, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital and Institute, Beijing, China
| | - Jie Zhang
- Department of Thoracic Oncology II, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital and Institute, Beijing, China
| | - Jindi Han
- Department of Thoracic Oncology II, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital and Institute, Beijing, China
| | - Xiangjuan Ma
- Department of Thoracic Oncology II, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital and Institute, Beijing, China
| | - Guangming Tian
- Department of Thoracic Oncology II, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital and Institute, Beijing, China
| | - Sen Han
- Department of Thoracic Oncology II, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital and Institute, Beijing, China
| | - Di Wu
- Department of Thoracic Oncology II, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital and Institute, Beijing, China
| | - Yang Wang
- Department of Thoracic Oncology II, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital and Institute, Beijing, China
| | - Jieran Long
- Department of Thoracic Oncology II, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital and Institute, Beijing, China
| | - Ziran Zhang
- Department of Thoracic Oncology II, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital and Institute, Beijing, China
| | - Jian Fang
- Department of Thoracic Oncology II, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital and Institute, Beijing, China
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Naqash AR, Ricciuti B, Owen DH, Florou V, Toi Y, Cherry C, Hafiz M, De Giglio A, Muzaffar M, Patel SH, Sugawara S, Burkart J, Park W, Chiari R, Sugisaka J, Otterson GA, de Lima Lopes G, Walker PR. Outcomes associated with immune-related adverse events in metastatic non-small cell lung cancer treated with nivolumab: a pooled exploratory analysis from a global cohort. Cancer Immunol Immunother 2020; 69:1177-1187. [PMID: 32140762 DOI: 10.1007/s00262-020-02536-5] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 02/24/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Immune-related adverse events (irAEs) comprise a distinct spectrum of auto-inflammatory manifestations triggered due to immune checkpoint inhibitors (ICI). Current data on the association of irAEs with outcomes in NSCLC treated with nivolumab are limited. METHODS AND OBJECTIVES We pooled data from 531 metastatic NSCLC patients from five centers treated with nivolumab after failing platinum-based chemotherapy. The primary objective was to investigate the relationship between irAEs with clinical benefit to nivolumab as well as to elucidate patterns of irAE-related ICI discontinuations and their impact on survival. RESULTS 33.0% (173/531) of patients treated with nivolumab were noted to have an irAE. Patients with irAEs had a significantly longer median PFS [6.1 vs. 3.1 months, HR 0.68 95% CI (0.55-0.85); p = 0.001] and OS [14.9 vs. 7.4 months, HR 0.66 95% CI (0.52-0.82); p < 0.001)] compared to those without irAEs. In multivariate analysis, the presence of irAEs showed a significantly better PFS [HR 0.69, 95% CI (0.55-0.87); p = 0.002] and a trend for better OS [HR 0.62, 95% CI (0.55-1.03); p = 0.057]. Patients with permanent ICI discontinuation secondary to index irAE had a significantly shorter median PFS [2.3 vs. 6.6 months, HR 1.74 95% CI (1.06-2.80); p = 0.02] and median OS [3.6 vs. 17.6 months; HR 2.61 95% CI (1.61-4.21); p < 0.001] compared to those that did not have permanent ICI discontinuation. CONCLUSIONS Our pooled exploratory analysis demonstrates improved clinical benefit to nivolumab in NSCLC patients experiencing irAEs. We also observed negative impact of irAE-related treatment discontinuation on survival in this group of patients.
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Affiliation(s)
- Abdul Rafeh Naqash
- Division of Cancer Treatment and Diagnosis, Developmental Therapeutics Clinic, National Cancer Institute, Bldg 31/3A44, 31 Centre Drive, Bethesda, MD, 20892, USA. .,Division of Hematology/Oncology, Department of Internal Medicine, East Carolina University, Greenville, NC, USA.
| | - Biagio Ricciuti
- Thoracic Oncology Unit, Santa Maria Della Misericordia Hospital, University of Perugia, Perugia, Italy.,Lowe Center for Thoracic Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Dwight H Owen
- Division of Medical Oncology, Department of Internal Medicine, Ohio State University, Columbus, OH, USA
| | - Vaia Florou
- Division of Oncology, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA.,Division of Medical Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Yukihiro Toi
- Department of Pulmonary Medicine, Sendai Kousei Hospital, Hirosemachi, Aoba-Ku, Sendai, Japan
| | - Cynthia Cherry
- Division of Cancer Treatment and Diagnosis, Developmental Therapeutics Clinic, National Cancer Institute, Bldg 31/3A44, 31 Centre Drive, Bethesda, MD, 20892, USA.,Division of Hematology/Oncology, Department of Internal Medicine, East Carolina University, Greenville, NC, USA
| | - Maida Hafiz
- Department of Pulmonary Medicine, East Carolina University, Greenville, NC, USA
| | - Andrea De Giglio
- Thoracic Oncology Unit, Santa Maria Della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Mavish Muzaffar
- Division of Hematology/Oncology, Department of Internal Medicine, East Carolina University, Greenville, NC, USA
| | - Sandip H Patel
- Division of Medical Oncology, Department of Internal Medicine, Ohio State University, Columbus, OH, USA
| | - Shunichi Sugawara
- Department of Pulmonary Medicine, Sendai Kousei Hospital, Hirosemachi, Aoba-Ku, Sendai, Japan
| | - Jarred Burkart
- Division of Medical Oncology, Department of Internal Medicine, Ohio State University, Columbus, OH, USA
| | - Wungki Park
- Division of Oncology, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA.,Memorial Sloan Kettering Cancer Center, New York, USA
| | - Rita Chiari
- Thoracic Oncology Unit, Santa Maria Della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Jun Sugisaka
- Department of Pulmonary Medicine, Sendai Kousei Hospital, Hirosemachi, Aoba-Ku, Sendai, Japan
| | - Gregory A Otterson
- Division of Medical Oncology, Department of Internal Medicine, Ohio State University, Columbus, OH, USA
| | - Gilberto de Lima Lopes
- Division of Oncology, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Paul R Walker
- Division of Hematology/Oncology, Department of Internal Medicine, East Carolina University, Greenville, NC, USA
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