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Kelly RJ, Bever K, Chao J, Ciombor KK, Eng C, Fakih M, Goyal L, Hubbard J, Iyer R, Kemberling HT, Krishnamurthi S, Ku G, Mordecai MM, Morris VK, Paulson AS, Peterson V, Shah MA, Le DT. Society for Immunotherapy of Cancer (SITC) clinical practice guideline on immunotherapy for the treatment of gastrointestinal cancer. J Immunother Cancer 2023; 11:jitc-2022-006658. [PMID: 37286304 DOI: 10.1136/jitc-2022-006658] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2023] [Indexed: 06/09/2023] Open
Abstract
Gastrointestinal (GI) cancers, including esophageal, gastroesophageal junction, gastric, duodenal and distal small bowel, biliary tract, pancreatic, colon, rectal, and anal cancer, comprise a heterogeneous group of malignancies that impose a significant global burden. Immunotherapy has transformed the treatment landscape for several GI cancers, offering some patients durable responses and prolonged survival. Specifically, immune checkpoint inhibitors (ICIs) directed against programmed cell death protein 1 (PD-1), either as monotherapies or in combination regimens, have gained tissue site-specific regulatory approvals for the treatment of metastatic disease and in the resectable setting. Indications for ICIs in GI cancer, however, have differing biomarker and histology requirements depending on the anatomic site of origin. Furthermore, ICIs are associated with unique toxicity profiles compared with other systemic treatments that have long been the mainstay for GI cancer, such as chemotherapy. With the goal of improving patient care by providing guidance to the oncology community, the Society for Immunotherapy of Cancer (SITC) convened a panel of experts to develop this clinical practice guideline on immunotherapy for the treatment of GI cancer. Drawing from published data and clinical experience, the expert panel developed evidence- and consensus-based recommendations for healthcare professionals using ICIs to treat GI cancers, with topics including biomarker testing, therapy selection, and patient education and quality of life considerations, among others.
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Affiliation(s)
- Ronan J Kelly
- Charles A. Sammons Cancer Center, Baylor University Medical Center at Dallas, Dallas, Texas, USA
| | - Katherine Bever
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joseph Chao
- City of Hope Comprehensive Cancer Center, Duarte, California, USA
| | - Kristen K Ciombor
- Department of Medicine, Division of Hematology/Oncology, Vanderbilt-Ingram Cancer Center, Nashville, Tennessee, USA
| | - Cathy Eng
- Department of Hematology and Oncology, Vanderbilt-Ingram Cancer Center, Nashville, Tennessee, USA
| | - Marwan Fakih
- Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center Duarte, Duarte, California, USA
| | - Lipika Goyal
- Department of Medicine, Stanford University, Palo Alto, California, USA
| | - Joleen Hubbard
- Department of Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Renuka Iyer
- Department of GI Medical Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Holly T Kemberling
- Department of GI Immunology Oncology, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland, USA
| | | | - Geoffrey Ku
- Gastrointestinal Oncology Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | | | - Van K Morris
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center Division of Cancer Medicine, Houston, Texas, USA
| | - Andrew Scott Paulson
- Department of Medical Oncology, Texas Oncology-Baylor Charles A Sammons Cancer Center, Dallas, Texas, USA
| | - Valerie Peterson
- Department of Thoracic Medical Oncology, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore, Maryland, USA
| | - Manish A Shah
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Dung T Le
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Messori A, Rivano M, Cancanelli L, Damuzzo V, Ossato A, Chiumente M, Mengato D. The “One-to-Many” Survival Analysis to Evaluate a New Treatment in Comparison With Therapeutic Alternatives Based on Reconstructed Patient Data: Enfortumab Vedotin Versus Standard of Care in Advanced or Metastatic Urothelial Carcinoma. Cureus 2022; 14:e28369. [PMID: 36171827 PMCID: PMC9508613 DOI: 10.7759/cureus.28369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2022] [Indexed: 11/05/2022] Open
Abstract
Objective This paper presents a preliminary experience based on the "one-to-many" approach of the Shiny method. Numerous (or "many") treatments for advanced or metastatic urothelial carcinoma have recently been reviewed. More recently, "one" potentially innovative treatment has been made available. Our analysis was aimed at assessing the benefits of the new treatment in comparison with the alternatives developed previously. Materials and methods The Shiny method was employed to reconstruct patient-level survival data. This information allowed us to compare the Kaplan-Meier (KM) curves of five treatments previously available (i.e., pembrolizumab, nivolumab, atezolizumab, vinflunine, and standard chemotherapy) with the potentially innovative agent represented by enfortumab vedotin. Overall survival was evaluated for each agent. Statistical tests to assess head-to-head indirect comparisons were performed through standard survival analysis. The hazard ratio (HR) was the main parameter. Results In ranking the efficacy across these agents, enfortumab vedotin was first, followed by immune checkpoint inhibitors (ICIs). Standard chemotherapy and vinflunine were the least effective. The remarkable survival results of enfortumab were, to some extent, influenced by the slightly better prognosis of the population enrolled in the enfortumab trial in comparison with patients enrolled in the three ICI trials. Conclusions The experience described herein shows that, when a potential innovative treatment (enfortumab vedotin) is developed in an already investigated area (metastatic urothelial cancer), the Shiny method can be applied according to the "one-to-many" approach. This allows us to quickly assess the place in therapy of the new treatment (the "one") and to evaluate whether the new treatment determines a relevant incremental benefit in comparison with previous treatments (the "many").
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Ossato A, Damuzzo V, Baldo P, Mengato D, Chiumente M, Messori A. Immune checkpoint inhibitors as first line in advanced melanoma: Evaluating progression-free survival based on reconstructed individual patient data. Cancer Med 2022; 12:2155-2165. [PMID: 35920297 PMCID: PMC9939083 DOI: 10.1002/cam4.5067] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 06/13/2022] [Accepted: 07/13/2022] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND In patients with advanced melanoma, immune-checkpoint inhibitors (ICIs) represent the mainstay for first line treatment. Recently, relatlimab+nivolumab was proposed as a new combination therapy. This review was aimed at summarizing the current data of effectiveness for ICIs. Progression-free survival (PFS) was the endpoint of our analysis. METHODS After a standard literature search, Phase II/III studies comparing different ICI regimens in previously untreated advanced melanoma patients were analyzed. Patient-level data were reconstructed from Kaplan-Meier curves by application of the IPDfromKM method. These reconstructed datasets were used to perform indirect comparisons between treatments. Standard statistical testing was used, including hazard ratio and medians. A secondary analysis employed the restricted mean survival time. RESULTS Six trials were included in our analysis. Information on PFS from these trials was pooled according to the following treatments: nivolumab or pembrolizumab as monotherapy, or in combination with ipilimumab, and relatlimab + nivolumab. Pembrolizumab+ipilimumab showed significantly better PFS compared with the other treatments; nivolumab+ipilimumab ranked second; the other treatments showed a similar survival pattern. CONCLUSIONS The picture of comparative effectiveness resulting from our analysis is complex. The IPDfromKM method is advantageous because it accounts for the length of follow-up but loses the balance between treatment group and controls determined by randomization. Based on indirect comparisons, the combination of pembrolizumab+ipilimumab showed a particularly high efficacy, and so deserves further investigation. While the effect of between-trial differences in inclusion criteria plays an important role, our results do not support the proposal of relatlimab+nivolumab as a new standard of care.
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Affiliation(s)
- Andrea Ossato
- Department of Pharmaceutical and Pharmacological SciencesUniversity of PadovaPadovaItaly
| | - Vera Damuzzo
- Department of Pharmaceutical and Pharmacological SciencesUniversity of PadovaPadovaItaly
| | - Paolo Baldo
- Centro di Riferimento Oncologico di Aviano IRCCSAvianoItaly
| | - Daniele Mengato
- Italian Society of Clinical Pharmacy and Therapeutics‐SIFaCTMilanItaly
| | - Marco Chiumente
- Italian Society of Clinical Pharmacy and Therapeutics‐SIFaCTMilanItaly
| | - Andrea Messori
- HTA Unit, Regione Toscana, Regional Health ServiceFlorenceItaly
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Trippoli S, Di Spazio L, Chiumente M, Messori A. Medical Therapy, Radiofrequency Ablation, or Cryoballoon Ablation as First-Line Treatment for Paroxysmal Atrial Fibrillation: Interpreting Efficacy Through the Shiny Method. Cureus 2022; 14:e22645. [PMID: 35237496 PMCID: PMC8882246 DOI: 10.7759/cureus.22645] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2022] [Indexed: 01/22/2023] Open
Abstract
In patients with paroxysmal atrial fibrillation, cryoballoon ablation (CBA) and radiofrequency ablation (RFA) represent two therapeutic approaches supported by increasing literature. While both these ablation techniques play a role during different stages of the patient’s therapeutic pathway, their use as first-line is being increasingly recognized. This scoping review comparatively examined the evidence of effectiveness for these two ablation techniques. Our analysis was limited to the evaluation of the end-point of time to recurrence of atrial fibrillation (or other forms of atrial arrhythmias), which was the primary end-point in most clinical trials. The method used for pooling the information from clinical trials (Shiny method) is original and based on an artificial intelligence (AI) method that reconstructs individual patient data from published Kaplan-Meier time-to-event curves. Because a network meta-analysis has been published on this same clinical material, one objective of the present work was to compare the meta-analytic results with those generated by the Shiny method. A standard literature search was conducted on PubMed/Medline. Only randomized studies comparing CBA versus medical therapy, RFA versus medical therapy, or CBA versus RFA in previously untreated patients were eligible. Trials presenting a Kaplan-Meier curve to present the above-mentioned end-point were included. Patient-level data were reconstructed by application of the Shiny method. These individual patient data were then analyzed by standard statistical testing based on hazard ratio (HR) for risk of recurrence and medians of time to recurrence. Our analysis compared the two ablation treatments and medical therapy. A total of five trials were identified through our literature search. Information from these trials was pooled according to the three treatments (CBA: three trials, n = 365; RFA: two trials, n = 99; medical therapy: five trials, n = 457). CBA showed higher effectiveness than medical therapy (HR, 0.51; 95% confidence interval (CI): 0.38 to 0.67). In comparison with medical therapy, RFA showed a numerical trend that remained far from statistical significance (HR, 0.89; 95% CI: 0.62 to 1.27). Medians for time to recurrence were 14.1 months (95% CI: 10.0 to not reached) for RFA and 11.5 months (95% CI: 9.3 to 25.3) for medical therapy. This parameter was not reached for CBA. The current evidence from five randomized trials suggests that CBA ranks first in effectiveness, followed by RFA and medical therapy. In our comparison between the results generated by the Shiny method with those published in the previous meta-analysis, the Shiny method confirmed its ability to account for the length of follow-up in individual trials, whereas the meta-analytic approach confirmed its ability to account for the effects of randomizations performed in the trials.
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Affiliation(s)
- Sabrina Trippoli
- Health Technology Assessment Unit, Regione Toscana, Firenze, ITA
| | - Lorenzo Di Spazio
- Hospital Pharmacy Department, Santa Chiara Trento Hospital, Trento, ITA
| | - Marco Chiumente
- Scientific Direction, Società Italiana di Farmacia Clinica e Terapia (SIFaCT), Milano, ITA
| | - Andrea Messori
- Health Technology Assessment Unit, Regione Toscana, Firenze, ITA
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Di Spazio L, Rivano M, Cancanelli L, Chiumente M, Mengato D, Messori A. The Degree of Programmed Death-Ligand 1 (PD-L1) Positivity as a Determinant of Outcomes in Metastatic Triple-Negative Breast Cancer Treated With First-Line Immune Checkpoint Inhibitors. Cureus 2022; 14:e21065. [PMID: 35028245 PMCID: PMC8743568 DOI: 10.7759/cureus.21065] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2022] [Indexed: 12/31/2022] Open
Abstract
In metastatic triple-negative breast cancer (TNBC), the efficacy of immune checkpoint inhibitors (ICIs) in combination with chemotherapy has been demonstrated in randomized clinical trials (RCTs). Despite this, an indirect comparison is not yet available. Reconstruction of individual patient data from Kaplan-Meier curves allows the indirect comparison of different treatments. We analyzed six overall survival (OS) curves from three RCTs. In patients with ≥1% positivity, atezolizumab was found to determine a significantly better OS than pembrolizumab. As regards pembrolizumab, adopting a threshold of PD-L1 positivity ≥10% (as opposed to ≥1%) improved median survival to a remarkable extent (23.0 vs 15.5 months).
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Affiliation(s)
| | - Melania Rivano
- Clinical Oncology Pharmacy, A. Businco Hospital, Cagliari, ITA
| | - Luca Cancanelli
- Hospital Pharmacy, Azienda Ulss 2 Marca Trevigiana, Treviso, ITA
| | - Marco Chiumente
- Scientific Direction, Italian Society for Clinical Pharmacy and Therapeutics, Milano, ITA
| | - Daniele Mengato
- Hospital Pharmacy, Azienda Ospedale Università di Padova, Padova, ITA
| | - Andrea Messori
- Health Technology Assessment (HTA) Unit, Regione Toscana, Firenze, ITA
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