Plain language summary of the TOPAZ-1 study: durvalumab and chemotherapy for advanced biliary tract cancer

WHAT IS THIS SUMMARY ABOUT?

This is a summary describing the results of a Phase III study called TOPAZ-1. The study looked at treatment with durvalumab (a type of immunotherapy) and chemotherapy to treat participants with advanced biliary tract cancer (BTC). Advanced BTC is usually diagnosed at late stages of disease, when it cannot be cured by surgery. This study included participants with advanced BTC who had not received previous treatment, or had their cancer come back at least 6 months after receiving treatment or surgery that aimed to cure their disease. Participants received treatment with durvalumab and chemotherapy or placebo and chemotherapy. The aim of this study was to find out if treatment with durvalumab and chemotherapy could increase the length of time that participants with advanced BTC lived, compared with placebo and chemotherapy.

WHAT WERE THE RESULTS OF THE STUDY?

Participants who took durvalumab and chemotherapy had a 20% lower chance of experiencing death at any point in the study compared with participants who received placebo and chemotherapy. The side effects experienced by participants were similar across treatment groups, and less than 12% of participants in either treatment group had to stop treatment due to treatment-related side effects.

WHAT DO THE RESULTS OF THE STUDY MEAN?

Overall, these results support durvalumab and chemotherapy as a new treatment option for people with advanced BTCs. Based on the results of this study, durvalumab is now approved for the treatment of adults with advanced BTCs in combination with chemotherapy by government organizations in Europe, the United States and several other countries.

Outcomes by antibiotic use in participants with advanced biliary tract cancer treated with durvalumab or placebo plus gemcitabine and cisplatin in the phase 3 TOPAZ-1 study

550

Background: TOPAZ-1 (NCT03875235) is a double-blind, Phase 3 study of durvalumab (D), an immune checkpoint inhibitor (ICI), + gemcitabine and cisplatin (GC) in participants (pts) with advanced biliary tract cancer (BTC). D + GC improved overall survival (OS) in pts with advanced BTC versus placebo (PBO) + GC (Oh et al. NEJM Evid 2022). Use of antibiotics during ICI treatment has been correlated with poorer OS and progression-free survival (PFS; Jiang et al. Front Oncol 2022). Methods: Pts were randomized 1:1 to receive D (1500 mg) or PBO on Day 1 every 3 weeks (Q3W), + G (1000 mg/m2) and C (25 mg/m2) on Days 1 and 8 Q3W, for ≤8 cycles, followed by D or PBO monotherapy Q4W. This exploratory subgroup analysis of TOPAZ-1 assessed OS and PFS by systemic antibiotic use during the study (≥1 dose 14 days before first D/PBO dose to 14 days after last D/PBO dose). Hazard ratios (HRs) were estimated using an unstratified Cox proportional hazards model, adjusting for disease status (initially unresectable or recurrent) and primary tumor location (intrahepatic cholangiocarcinoma, extrahepatic cholangiocarcinoma, or gallbladder cancer). Data cut-off at primary analysis was Aug 11, 2021. Results: The number (%) of pts using antibiotics during the study (D + GC, 167/341 [49.0%]; PBO + GC, 167/344 [48.5%]) was similar between treatment arms. In the D + GC arm, median OS (95% CI) was similar regardless of antibiotics use: 12.6 (9.7–14.8) months in pts with antibiotics use vs 13.0 (10.8–14.7) months in pts without (Table). In the PBO + GC arm, median OS (95% CI) was 10.3 (8.7–12.5) in pts with antibiotics use vs 12.1 (11.0–13.8) in pts without. OS HRs (95% CI) in D + GC vs PBO + GC were 0.78 (0.59–1.02) in pts with antibiotics and 0.81 (0.62–1.07) in pts without. Median PFS (95% CI) was 7.3 (6.5–7.7) months in pts with antibiotics use vs 7.2 (5.9–7.4) months in pts without in the D + GC arm and 5.7 (5.4–6.6) months vs 6.1 (5.6–7.3) months, respectively, in the PBO + GC arm (Table). PFS HRs (95% CI) were 0.70 (0.55–0.89) in pts with antibiotics use and 0.82 (0.65–1.03) in pts without. Conclusions: In the TOPAZ-1 study of D in BTC, no meaningful difference was found in OS or PFS for participants who received antibiotics during the study period compared with those who did not, and results were consistent with the primary analysis. These results support that people receiving D may be treated with antibiotics when clinically indicated. Clinical trial information: NCT03875235 . [Table: see text]

Incidence and factors associated with cutaneous immune-related adverse events to immune check point inhibitors: An ambispective cohort study

Background

Although immune checkpoint inhibitors (ICIs) have become the frontline treatment option for patients with various advanced cancers due to improved survival, they can be associated with a spectrum of cutaneous immune-related adverse events (cirAEs). However, little is known regarding the occurrence and patterns of cirAE-related ICI therapy in patients of different races other than white populations. Therefore, we investigated the incidence and associated factors of cirAEs among cancer patients in northern Thailand.

Methods

A referral-center-based ambispective cohort study was conducted from January 1, 2017, to March 31, 2021. Based on a linked database and merged patient-level data, adult patients with pathologically confirmed cancer who were diagnosed and received ICI therapy regardless of cancer type and followed up through August 31, 2021, were included. All cirAE-related ICI therapy was based on clinical evaluation and ascertainment by a board-certified dermatologist. The incidence of cirAE-related ICI therapy with confidence intervals (CIs) across cancer- and ICI therapy-specific groups was estimated. Factors associated with cirAEs were evaluated using multivariable modified Poisson regression to estimate risk ratios (RRs) and 95% CIs.

Results

The study included 112 patients (67 men [59.8%]; mean age, 65.0 [range, 31.0-88.0] years), who were mainly diagnosed with lung cancer (56.3%), followed by liver cancer (19.6%). The overall incidence of cirAE-related ICI therapy was 32.1% (95% CI, 24.1-41.4); however, there was no substantial difference in sex, cancer type, or individual ICI therapy. The two identified prognostic risk factors of cirAE-related ICI therapy were age >75 years (adjusted RR, 2.13; 95% CI, 1.09-4.15; P=0.027) and pre-existing chronic kidney disease stages 3-4 (adjusted RR, 3.52; 95% CI, 2.33-5.31; P<0.001).

Conclusions

The incidence of cirAE-related ICI therapy among Thai cancer patients was comparable to that in white populations. Early identification, particularly in elderly patients and those with CKD, should be implemented in clinical practice to help optimize therapeutic decision-making and patient health outcomes.

Durvalumab plus Gemcitabine and Cisplatin in Advanced Biliary Tract Cancer

Durvalumab Combination for Biliary Tract CancerThis trial randomly assigned patients with previously untreated locally advanced or metastatic biliary tract cancer to receive durvalumab or placebo in combination with gemcitabine plus cisplatin. Median overall survival (95% Cl) was 12.8 (11.1-14.0) months in the durvalumab group. Rates of grade 3 or 4 adverse events were similar between groups.

Abstract CT572: Phase 1b dose-escalation and dose-expansion study evaluating trastuzumab deruxtecan (T-DXd) in combination with durvalumab and cisplatin, carboplatin, or pemetrexed in advanced or metastatic, HER2-overexpressing, nonsquamous non-small cell lung cancer (NSCLC): DESTINY-Lung03

Background: HER2 overexpression is an established molecular target in breast and gastric cancer therapy, but no HER2-targeted therapies are currently available for NSCLC. In studies of NSCLC and lung cancer overall, the prevalence of HER2 overexpression has been reported to be anywhere from &lt;5% to 35% (Cox et al. Int J Cancer. 2001;92:480-483; Hirsch et al. Lancet. 2017;389:299-311). T-DXd is an antibody-drug conjugate composed of a humanized anti-HER2 monoclonal antibody, a tetrapeptide-based cleavable linker, and a topoisomerase I inhibitor payload. Interim results from the DESTINY-Lung01 trial showed encouraging efficacy in extensively pretreated patients (pts) with unresectable/metastatic, HER2-overexpressing, nonsquamous NSCLC, with a confirmed objective response rate (ORR) of 24.5% and median overall survival (OS) of 11.3 months (Nakagawa et al. WCLC 2020. Abstract OA04.05). Preclinically, the combination of T-DXd and an anti-programmed cell death 1 antibody was more effective than either therapy alone. The DESTINY-Lung03 trial is evaluating the safety and tolerability of T-DXd in combination with durvalumab and chemotherapy in pts with unresectable/metastatic, HER2-overexpressing, nonsquamous NSCLC.

Methods: DESTINY-Lung03 (NCT04686305) is a phase 1b, open-label, multicenter, dose-escalation (part 1) and dose-expansion (part 2) study in pts with HER2-overexpressing (≥25% immunohistochemistry 2+/3+ tumor cells), unresectable, locally advanced or metastatic, nonsquamous NSCLC. In part 1, pts with progression after 1 or 2 lines of systemic therapy in the recurrent/metastatic setting are enrolled to receive T-DXd and durvalumab in combination with cisplatin (arm 1A), carboplatin (arm 1B), or pemetrexed (arm 1C), or T-DXd monotherapy (arm 1D). In part 2, pts who have not received prior curative treatment in the locally advanced setting or systemic treatment in the metastatic setting are enrolled to receive T-DXd and durvalumab in combination with cisplatin (arm 2A), carboplatin (arm 2B), or pemetrexed (arm 2C), or T-DXd plus durvalumab (arm 2D); pts in part 2 must not have activating EGFR mutations, an EML4-ALK fusion, or other targetable alterations. The primary endpoint is the frequency of adverse events (AEs) and serious AEs (SAEs) with T-DXd plus durvalumab plus chemotherapy combinations to assess safety and tolerability and determine the recommended phase 2 dose. Secondary endpoints include confirmed ORR, duration of response, disease control rate, progression-free survival, OS, frequency of AEs and SAEs with T-DXd monotherapy (part 1) and T-DXd plus durvalumab (part 2), pharmacokinetics, and immunogenicity.

Citation Format: David Planchard, Julie R. Brahmer, James C. Yang, Yuh-Min Chen, Kang-Yun Lee, Thatthan Suksombooncharoen, Natasha Viglianti, Mark Gustavson, Alejandra Ragone, Amaya Gasco Hernandez. Phase 1b dose-escalation and dose-expansion study evaluating trastuzumab deruxtecan (T-DXd) in combination with durvalumab and cisplatin, carboplatin, or pemetrexed in advanced or metastatic, HER2-overexpressing, nonsquamous non-small cell lung cancer (NSCLC): DESTINY-Lung03 [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr CT572.

A phase 3 randomized, double-blind, placebo-controlled study of durvalumab in combination with gemcitabine plus cisplatin (GemCis) in patients (pts) with advanced biliary tract cancer (BTC): TOPAZ-1

378

Background: BTC is a rare, heterogenous cancer with poor prognosis. Reports on immunogenic features of BTC suggest checkpoint inhibition may result in antitumor immune responses, and limited clinical activity has been seen with single agents in advanced settings. Durvalumab (PD-L1 inhibitor) + GemCis showed promising antitumor activity in advanced BTC in a phase 2 study. TOPAZ-1 (NCT03875235) is the first global phase 3 study to evaluate first-line immunotherapy + GemCis in advanced BTC. Methods: In this double-blind study, pts previously untreated for unresectable locally advanced, recurrent, or metastatic BTC were randomized 1:1 to receive durvalumab (1500 mg every 3 weeks [Q3W]) or placebo + GemCis (Gem 1000 mg/m2 and Cis 25 mg/m2 on Days 1 and 8 Q3W) for up to 8 cycles, followed by durvalumab (1500 mg Q4W) or placebo until disease progression or unacceptable toxicity. Randomization was stratified by disease status (initially unresectable, recurrent) and primary tumor location (intrahepatic cholangiocarcinoma, extrahepatic cholangiocarcinoma, gallbladder cancer). The primary objective was to assess overall survival (OS). Secondary endpoints included progression-free survival (PFS), objective response rate (ORR), and safety. Results: At data cutoff for this interim analysis (11 August 2021), 685 pts were randomized to durvalumab + GemCis (n=341) or placebo + GemCis (n=344; Table). The primary objective was met: durvalumab + GemCis significantly improved OS vs placebo + GemCis (hazard ratio [HR], 0.80; 95% confidence interval [CI], 0.66–0.97; p=0.021). PFS was also significantly improved with durvalumab vs placebo (HR, 0.75; 95% CI, 0.64–0.89; p=0.001). ORR was 26.7% with durvalumab and 18.7% with placebo. Grade 3/4 treatment-related adverse events (TRAEs) occurred in 62.7% of pts receiving durvalumab and 64.9% of pts receiving placebo. TRAEs led to discontinuation of any study medication in 8.9% of pts receiving durvalumab and 11.4% of pts receiving placebo. Conclusions: In pts with advanced BTC, durvalumab + GemCis significantly improved OS and PFS vs placebo + GemCis with manageable safety, indicating durvalumab + GemCis may be a new first-line standard of care regimen. Clinical trial information: NCT03875235. [Table: see text]

Effect of Insurance Type on Stage at Presentation, Surgical Approach, Tumor Recurrence and Cancer-Specific Survival in Resectable Non-Small Lung Cancer Patients

Purpose

The aim of this study was to identify the association between Thailand’s insurance types and stage at presentation, surgical approach, tumor recurrence and cancer-specific survival in resectable non-small cell lung cancer (NSCLC) patients in northern Thailand.

Patients and Methods

Medical records of patients with NSCLC who underwent pulmonary resection at Chiang Mai University Hospital from January 2007 through December 2015 were retrospectively reviewed. Patients were divided into two groups: patients with the Universal Coverage Scheme (UCS) or Social Security Scheme (SSS) and patients with the Civil Servant Medical Benefit Scheme (CSMBS) or private insurance (PI). Patient characteristics were assessed. The primary outcome was cancer-specific survival while the secondary outcome was tumor recurrence. Cox’s regression and matching propensity score analysis was used to analyze data.

Results

This study included 583 patients: 344 with UCS or SSS and 239 with CSMBS or PI. Patients with UCS or SSS were more likely to be active smokers, have a lower percent predicted FEV1, present with higher-stage tumors and worse differentiated tumors, present with tumor necrosis, and undergo an open surgical approach than those with CSMBS or PI. At multivariable analysis of all patients cohort, there were no significant differences in terms of early stage at presentation (adjusted odds ratio (OR_adj) = 0.94, 95% confidence interval (CI) = 0.65–1.37), undergoing lobectomy (OR_adj = 0.59, 95% CI = 0.24–1.46), and recurrent-free survival (adjusted hazard ratio (HR_adj) =1.20, 95% CI = 0.88–1.65) between groups (UCS/SSS versus CSMBS/PI). However, patients with UCS or SSS had shorter cancer-specific survival (HR_adj = 1.61, 95% CI = 1.22–2.15). The results from the propensity score matched patient cohort were not different from those analyses on the full patient cohort.

Conclusion

Thai insurance types have an effect on cancer-specific survival. The Thai government should recognize the importance of these differences, and further multi-center studies with a larger sample size are warranted to confirm this result.

Outcomes of pulmonary resection in non-small cell lung cancer patients older than 70 years old

BACKGROUND

An appropriate treatment of older lung cancer patients has become an important issue. The aim of this study is to evaluate the short and long-term surgical outcomes in lung cancer patients using 70 years as a cut-point, and to identify prognostic factors of cancer-specific mortality in patients older than 70 years.

METHODS

Medical records of non-small cell lung cancer (NSCLC) patients who underwent pulmonary resection at Chiang Mai University Hospital from January 2002 through December 2016 were retrospectively reviewed. Patients were divided into age less than 70 years (control group) and 70 years or more (study group). Primary outcomes were major post-operative complications and in-hospital death (POM); secondary outcome was long-term survival. Multivariable regression analysis was used.

RESULTS

This study included 583 patients, 167 for study group, and 416 for control group. There were no differences in POM, both at univariable and multivariable analyses, however, for long-term cancer-specific mortality, the study group was more likely to die (HR_adj = 1.40, 95%CI = 1.03-1.89). Adverse prognostic factors for long-term mortality in study group were having universal coverage scheme (HR_adj = 1.70, 95%CI = 1.03-2.79), the presence of intratumoral lymphatic invasion (HR_adj = 2.83, 95%CI = 1.28-6.29), perineural invasion (HR_adj = 2.80, 95%CI = 1.13-6.94), underwent lymph node sampling (HR_adj = 2.23, 95%CI = 1.16-4.30) and higher stage of disease (HR_adj = 2.02, 95%CI = 1.06-3.85 for stage III, HR_adj = 3.40, 95%CI = 1.29-8.94 for stage IV).

CONCLUSIONS

In-hospital mortality and composite post-operative complications are acceptable in pulmonary resection for NSCLC patients older than 70 years. However, these patients had shorter long-term survival, especially who have some adverse prognostic factors. Further studies with larger sample size are warranted.