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Hines JB, Cameron RB, Esposito A, Kim L, Porcu L, Nuccio A, Viscardi G, Ferrara R, Veronesi G, Forde PM, Taube J, Vokes E, Bestvina CM, Dolezal JM, Sacco M, Monteforte M, Cascone T, Garassino MC, Torri V. Evaluation of Major Pathologic Response and Pathologic Complete Response as Surrogate End Points for Survival in Randomized Controlled Trials of Neoadjuvant Immune Checkpoint Blockade in Resectable in NSCLC. J Thorac Oncol 2024:S1556-0864(24)00117-5. [PMID: 38461929 DOI: 10.1016/j.jtho.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 02/05/2024] [Accepted: 03/07/2024] [Indexed: 03/12/2024]
Abstract
INTRODUCTION Controversy remains as to whether pathologic complete response (pCR) and major pathologic response (MPR) represent surrogate end points for event-free survival (EFS) and overall survival (OS) in neoadjuvant trials for resectable NSCLC. METHODS A search of PubMed and archives of international conference abstracts was performed from June 2017 through October 31, 2023. Studies incorporating a neoadjuvant arm with immune checkpoint blockade alone or in combination with chemotherapy were included. Those not providing information regarding pCR, MPR, EFS, or OS were excluded. For trial-level surrogacy, log ORs for pCR and MPR and log hazard ratios for EFS and OS were analyzed using a linear regression model weighted by sample size. The regression coefficient and R2 with 95% confidence interval were calculated by the bootstrapping approach. RESULTS Seven randomized clinical trials were identified for a total of 2385 patients. At the patient level, the R2 of pCR and MPR with 2-year EFS were 0.82 (0.66-0.94) and 0.81 (0.63-0.93), respectively. The OR of 2-year EFS rates by response status was 0.12 (0.07-0.19) and 0.11 (0.05-0.22), respectively. For the 2-year OS, the R2 of pCR and MPR were 0.55 (0.09-0.98) and 0.52 (0.10-0.96), respectively. At the trial level, the R2 for the association of OR for response and HR for EFS was 0.58 (0.00-0.97) and 0.61 (0.00-0.97), respectively. CONCLUSIONS Our analyses reveal a robust correlation between pCR and MPR with 2-year EFS but not OS. Trial-level surrogacy was moderate but imprecise. More mature follow-up and data to assess the impact of study crossover are needed.
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Affiliation(s)
- Jacobi B Hines
- Department of Medicine, Section of Hematology/Oncology, University of Chicago, Chicago, Illinois
| | - Robert B Cameron
- Department of Medicine, Section of Hematology/Oncology, University of Chicago, Chicago, Illinois.
| | - Alessandra Esposito
- Department of Medicine, Section of Hematology/Oncology, University of Chicago, Chicago, Illinois
| | - Leeseul Kim
- Department of Medicine, Ascension Saint Francis Hospital, Chicago, Illinois
| | - Luca Porcu
- Cancer Research United Kingdom, Cambridge Institute, University of Cambridge, Cambridge, United Kingdom
| | - Antonio Nuccio
- Department of Medical Oncology, Scientific Institute for Research, Hospitalization and Healthcare (IRCCS), San Raffaele Scientific Institute, Milan, Italy
| | - Giuseppe Viscardi
- Department of Pneumology and Oncology, Azienda Ospedaliera di Rilievo Nazionale (AORN) Ospedali dei Colli, Naples, Italy
| | - Roberto Ferrara
- Department of Medical Oncology, Scientific Institute for Research, Hospitalization and Healthcare (IRCCS), San Raffaele Scientific Institute, Milan, Italy
| | - Giulia Veronesi
- School of Medicine and Surgery, Vita-Salute San Raffaele University, Milan, Italy; Department of Thoracic Surgery, Scientific Institute for Research, Hospitalization and Healthcare (IRCCS) San Raffaele Scientific Institute, Milan, Italy
| | - Patrick M Forde
- Department of Oncology, Division of Upper Aerodigestive Malignancies, Bloomberg-Kimmel Institute for Cancer Immunotherapy, John Hopkins Kimmel Cancer Center, Baltimore, Maryland
| | - Janis Taube
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Everett Vokes
- Department of Medicine, Section of Hematology/Oncology, University of Chicago, Chicago, Illinois
| | - Christine M Bestvina
- Department of Medicine, Section of Hematology/Oncology, University of Chicago, Chicago, Illinois
| | - James M Dolezal
- Department of Medicine, Section of Hematology/Oncology, University of Chicago, Chicago, Illinois
| | - Matteo Sacco
- Department of Medicine, Section of Hematology/Oncology, University of Chicago, Chicago, Illinois
| | - Marta Monteforte
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Tina Cascone
- Department of Thoracic/Head and Neck Medical Oncology, Division of Cancer Medicine, The University of Texas, Monroe Dunaway (MD) Anderson Cancer Center, Houston, Texas
| | - Marina C Garassino
- Department of Medicine, Section of Hematology/Oncology, University of Chicago, Chicago, Illinois
| | - Valter Torri
- Department of Clinical Oncology, "Mario Negri" Institute for Pharmacological Research- IRCCS, Milan, Italy
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Cameron RB, Hines JB, Torri V, Porcu L, Donington J, Bestvina CM, Vokes E, Dolezal JM, Esposito A, Garassino MC. What is the ideal endpoint in early-stage immunotherapy neoadjuvant trials in lung cancer? Ther Adv Med Oncol 2023; 15:17588359231198446. [PMID: 37720499 PMCID: PMC10504845 DOI: 10.1177/17588359231198446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 08/15/2023] [Indexed: 09/19/2023] Open
Abstract
Numerous clinical trials investigating neoadjuvant immune checkpoint inhibitors (ICI) have been performed over the last 5 years. As the number of neoadjuvant trials increases, attention must be paid to identifying informative trial endpoints. Complete pathologic response has been shown to be an appropriate surrogate endpoint for clinical outcomes, such as event-free survival or overall survival, in breast cancer and bladder cancer, but it is less established for non-small-cell lung cancer (NSCLC). The simultaneous advances reported with adjuvant ICI make the optimal strategy for early-stage disease debatable. Considering the long time required to conduct trials, it is important to identify optimal endpoints and discover surrogate endpoints for survival that can help guide ongoing clinical research. Endpoints can be grouped into two categories: medical and surgical. Medical endpoints are measures of survival and drug activity; surgical endpoints describe the feasibility of neoadjuvant approaches at a surgical level as well as perioperative attrition and complications. There are also several exploratory endpoints, including circulating tumor DNA clearance and radiomics. In this review, we outline the advantages and disadvantages of commonly reported endpoints for clinical trials of neoadjuvant regimens in NSCLC.
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Affiliation(s)
- Robert B. Cameron
- Department of Medicine, Section of Hematology/Oncology, University of Chicago, Chicago, IL, USA
| | - Jacobi B. Hines
- Department of Medicine, Section of Hematology/Oncology, University of Chicago, Chicago, IL, USA
| | - Valter Torri
- Department of Oncology, Institute of Pharmacological Research ‘Mario Negri’, IRCCS, Milan, Italy
| | - Luca Porcu
- Department of Oncology, Institute of Pharmacological Research ‘Mario Negri’, IRCCS, Milan, Italy
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, UK
| | - Jessica Donington
- Department of Surgery, Section Thoracic Surgery, University of Chicago, Chicago, IL, USA
| | - Christine M. Bestvina
- Department of Medicine, Section of Hematology/Oncology, University of Chicago, Chicago, IL, USA
| | - Everett Vokes
- Department of Medicine, Section of Hematology/Oncology, University of Chicago, Chicago, IL, USA
| | - James M. Dolezal
- Department of Medicine, Section of Hematology/Oncology, University of Chicago, Chicago, IL, USA
| | - Alessandra Esposito
- Department of Medicine, Section of Hematology/Oncology, University of Chicago, Chicago, IL, USA
| | - Marina C. Garassino
- Department of Medicine, Section of Hematology/Oncology, University of Chicago, 5841 S Maryland Avenue, Chicago, IL 60637, USA
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Hines JB, Bowar B, Levine E, Esposito A, Garassino MC, Bestvina CM. Targeted Toxicities: Protocols for Monitoring the Adverse Events of Targeted Therapies Used in the Treatment of Non-Small Cell Lung Cancer. Int J Mol Sci 2023; 24:9429. [PMID: 37298380 PMCID: PMC10253830 DOI: 10.3390/ijms24119429] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 05/24/2023] [Accepted: 05/27/2023] [Indexed: 06/12/2023] Open
Abstract
Targeted therapies have revolutionized the treatment for many patients with non-small cell lung cancer (NSCLC). Multiple new oral targeted therapies have been approved in the last decade; however, their overall efficacy may be reduced by poor adherence, treatment interruptions, or dose reductions due to adverse events. Most institutions lack standard monitoring protocols for toxicities from these targeted agents. This review describes important adverse events observed in clinical trials and reported by the U.S. Food and Drug Administration for both currently approved and upcoming promising therapies in the treatment of NSCLC. These agents cause a range of toxicities, including dermatologic, gastroenteric, pulmonary, and cardiac toxicities. This review proposes protocols for routine monitoring of these adverse events, both prior to initiation of therapy and while on treatment.
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Affiliation(s)
- Jacobi B. Hines
- Department of Medicine, Section of Hematology/Oncology, University of Chicago Medical Center, Chicago, IL 60637, USA; (J.B.H.); (B.B.); (A.E.); (C.M.B.)
| | - Benjamin Bowar
- Department of Medicine, Section of Hematology/Oncology, University of Chicago Medical Center, Chicago, IL 60637, USA; (J.B.H.); (B.B.); (A.E.); (C.M.B.)
| | - Emma Levine
- Booth School of Business, University of Chicago, Chicago, IL 60637, USA;
| | - Alessandra Esposito
- Department of Medicine, Section of Hematology/Oncology, University of Chicago Medical Center, Chicago, IL 60637, USA; (J.B.H.); (B.B.); (A.E.); (C.M.B.)
| | - Marina C. Garassino
- Department of Medicine, Section of Hematology/Oncology, University of Chicago Medical Center, Chicago, IL 60637, USA; (J.B.H.); (B.B.); (A.E.); (C.M.B.)
| | - Christine M. Bestvina
- Department of Medicine, Section of Hematology/Oncology, University of Chicago Medical Center, Chicago, IL 60637, USA; (J.B.H.); (B.B.); (A.E.); (C.M.B.)
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Abstract
PURPOSE OF REVIEW New therapies are needed to potentiate the effects of current immunotherapies and overcome resistance. The stimulator of interferon genes genes (STING) pathway is an innate immune activating cascade that may enhance current cancer immunotherapies. RECENT FINDINGS Preclinical data has shown that the addition of a STING agonist enhances the effect of current treatments such as immune checkpoint inhibitor antibodies and radiation therapy. Early phase trials have demonstrated modest efficacy of STING agonists and revealed new mechanistic and technical challenges. STING agonists are a new class of agents that activate the immune response to improve tumor control. A wide range of preclinical experiments, translational data, and ongoing clinical trials support the therapeutic use of STING agonists in patients. Trials to determine optimal drug combinations and novel delivery mechanisms are continuing in development.
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Affiliation(s)
- Jacobi B Hines
- Department of Medicine, Section of Hematology/Oncology, University of Chicago, 5841 S Maryland Ave, MC 2115, Chicago, IL, 60605, USA
| | - Alec J Kacew
- Pritzker School of Medicine, University of Chicago Medicine, Chicago, IL, USA
| | - Randy F Sweis
- Department of Medicine, Section of Hematology/Oncology, University of Chicago, 5841 S Maryland Ave, MC 2115, Chicago, IL, 60605, USA.
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Abstract
A novel schedule of 5-fluorouracil administration has been developed for biochemical modulation studies. In combination with the pyrimidine synthesis inhibitor PALA, 5-fluorouracil has been given as a 24-hour infusion, repeated weekly: a dose of 2600 mg/m2 is well tolerated. To identify a suitable dose of 5-fluorouracil as a single agent on this schedule, we treated 26 patients at doses ranging from 2800 to 3400 mg/m2 per week. Two-thirds of the patients had failed previous therapy, and most were symptomatic from their disease. Over half of the patients had metastatic colorectal cancer. The dose-limiting toxicity was diarrhea: Grade 3 or 4 toxicity occurred at every level tested. Twenty-two of the 26 patients required therapy interruption because of toxicity. The severity of this toxicity indicated that escalation of 5-fluorouracil on this schedule beyond the 2600 mg/m2 known to be tolerated in the PALA-containing regimen, would be impractical. Two patients, both with previously untreated colorectal cancer, had partial remissions lasting three and five months respectively. This dose-intense schedule of 5-fluorouracil administration will be explored further in large-scale randomized trials.
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Affiliation(s)
- N B Haas
- Fox Chase Cancer Center, Philadelphia, PA
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