Real-World Impact of Comprehensive Genomic Profiling on Biomarker Detection, Receipt of Therapy, and Clinical Outcomes in Advanced Non-Small Cell Lung Cancer

PURPOSE

Therapeutic decision making for patients with advanced non-small cell lung cancer (aNSCLC) includes a growing number of options for genomic, biomarker-guided, targeted therapies. We compared actionable biomarker detection, targeted therapy receipt, and real-world overall survival (rwOS) in patients with aNSCLC tested with comprehensive genomic profiling (CGP) versus small panel testing (SP) in real-world community health systems.

METHODS

Patients older than 18 years diagnosed with aNSCLC between January 1, 2015, and December 31, 2020, who received biomarker testing were followed until death or study end (September 30, 2021), and categorized by most comprehensive testing during follow-up: SP (≤52 genes) or CGP (>52 genes).

RESULTS

Among 3,884 patients (median age, 68 years; 50% female; 73% non-Hispanic White), 20% received CGP and 80% SP. The proportion of patients with ≥one actionable biomarker (actionability) was significantly higher in CGP than in SP (32% v 14%; P < .001). Of patients with actionability, 43% (CGP) and 38% (SP) received matched therapies (P = .20). Among treated patients, CGP before first-line treatment was associated with higher likelihood of matched therapy in any line (odds ratio, 3.2 [95% CI, 1.84 to 5.53]). CGP testing (hazard ratio [HR], 0.80 [95% CI, 0.72 to 0.89]) and actionability (HR, 0.84 [95% CI, 0.77 to 0.91]) were associated with reduced risk of mortality. Among treated patients with actionability, matched therapy receipt showed improved median rwOS in months in CGP (34 [95% CI, 21 to 49] matched v 14 [95% CI, 10 to 18] unmatched) and SP (27 [95% CI, 21 to 43] matched v 10 [95% CI, 8 to 14] unmatched).

CONCLUSION

Patients who received CGP had improved detection of actionable biomarkers and greater use of matched therapies, both of which were associated with significant increases in survival.

Actionability of comprehensive genomic profiling (CGP) compared to single-gene and small panels in patients with advanced/metastatic non-small cell lung cancer (aNSCLC): A real-world study

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Background: Biomarker testing for patients with aNSCLC includes testing for specific alterations in single genes, hotspot multigene panels, or CGP. Historically, CGP has been used following progression on early lines of systemic therapy to identify genomic alterations not captured by single-gene/hotspot testing, or to determine clinical trial(CT) eligibility. We compared the proportion of patients with genomic alterations for which FDA has approved targeted therapies(TT) (actionable alterations) identified through CGP vs. single-gene/small panel(“small panel”) testing in the real-world setting. Methods: In a retrospective study, patients initially diagnosed-with/progressed-to aNSCLC between 1/1/2015-12/31/2020, treated in the US community health setting, were categorized based on small panel or CGP testing. Patients were followed until the earliest of last contact/death/study-end on 9/30/2021. Testing between 30 days prior to initial NSCLC diagnosis and end of follow-up was used to determine actionability based on OncoKB levels, and eligibility for two basket-CTs(ASCO-TAPUR, NCI-MATCH). Results: Of 7,242 aNSCLC patients in this study, 5,154 (72%) received molecular testing (50% only small panel; 14% CGP; and 7% with an unknown size panel), 22% of patients remained untested and 7% were tested for only PD-L1. Among CGP-tested patients evaluated for tumor mutational burden (TMB), 18% were classified as TMB-High. > 75% of patients presented with advanced cancer at initial diagnosis, 51% were female, 50% were White, and median age was 68 years. Molecular testing rate increased from 9% to 20%(CGP) and 42% to 51%(small panel) between 2015–2020. The proportion of patients with ≥1 actionable biomarker was significantly higher with CGP than small panels (34%vs.15%; p < 0.001). Of tested patients. the proportion of CT eligible patients was also significantly greater for CGP than small panels (56%vs.4%; p < 0.001). The proportion of tested patients that received an FDA-approved TT or immunotherapy(IO) within 30 days of testing was higher in CGP cohort compared to small panel (9%vs.3%; p < 0.001). Conclusions: Although rates of CGP and small panel testing are increasing over time, overall molecular testing remains underutilized, and the proportion of patients who received TT/IO post-testing is low. Use of CGP is associated with higher identification of actionable biomarkers and patients receiving TT/IO, and CT eligibility.

Biomarker testing patterns among patients with early and late-onset metastatic colon cancer

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Background: Molecular testing is essential in considering targeted therapies, particularly for the increasing number of metastatic colon cancer (mCC) patients (pts) diagnosed at younger ages who may present with more aggressive disease. This analysis compares demographic and clinical characteristics, and biomarker testing and positivity rates of mCC pts diagnosed at younger versus older ages. Methods: We analyzed 1029 pts with mCC (stage IV at diagnosis) between 01/01/2016 - 12/31/2020 who received care in community health systems in the United States. Pts 18-49 years at mCC diagnosis were considered early onset (EO), and those 50 or older were considered late onset (LO). We compared the distributions of year at diagnosis, gender, race/ethnicity, smoking status, histology, stage at diagnosis, tumor sidedness, KRAS, NRAS, and BRAF testing, and positivity rates between EO and LO mCC pts. Differences in distributions were assessed using chi-square tests. Results: EO pts (n = 148) were more likely to have left-sided tumors than LO pts (n = 881, 55% vs. 36%; p-value < 0.001), and were less likely to be ever smokers (24% vs. 40%; p-value < 0.001); the remaining demographic and clinical characteristics were similar between the two groups. Testing was significantly more common among EO than LO pts for KRAS (71% vs 48%), NRAS (39% vs 29%), and BRAF (41% vs 31%) (Table). Annual NRAS and BRAF testing rates increased between 2016 - 2020 for both groups: NRAS rates increased from 13% to 41%, and 5% to 37%, for EO and LO pts, respectively; BRAF rates increased from 13% to 41%, and 5% to 40%, for EO and LO pts, respectively. KRAS testing rates held at a consistent rate over time for EO pts, and increased over time among LO mCC pts (35% - 52%). The positivity rates for KRAS, NRAS and BRAF mutations were similar among tested pts in both groups. Conclusions: In this real world analysis, pts with EO mCC were more likely to have left sided primary cancers, and less likely to have a smoking history. Of note, BRAF testing showed a marked increase over time among all mCC pts. EO pts were more likely to receive KRAS, NRAS and BRAF testing. Further understanding of the correlates of EO mCC, biomarker testing practices, and subsequent treatment decisions is critical to improving pt outcomes.[Table: see text]

The Friends of Cancer Research Real-World Data Collaboration Pilot 2.0: Methodological Recommendations from Oncology Case Studies

The purpose of this study was to evaluate the potential collective opportunities and challenges of transforming real‐world data (RWD) to real‐world evidence for clinical effectiveness by focusing on aligning analytic definitions of oncology end points. Patients treated with a qualifying therapy for advanced non‐small cell lung cancer in the frontline setting meeting broad eligibility criteria were included to reflect the real‐world population. Although a trend toward improved outcomes in patients receiving PD‐(L)1 therapy over standard chemotherapy was observed in RWD analyses, the magnitude and consistency of treatment effect was more heterogeneous than previously observed in controlled clinical trials. The study design and analysis process highlighted the identification of pertinent methodological issues and potential innovative approaches that could inform the development of high‐quality RWD studies.

Real-world Overall Survival Using Oncology Electronic Health Record Data: Friends of Cancer Research Pilot

In prior work, Friends of Cancer Research convened multiple data partners to establish standardized definitions for oncology real-world end points derived from electronic health records (EHRs) and claims data. Here, we assessed the performance of real-world overall survival (rwOS) from data sets sourced from EHRs by evaluating the ability of the end point to reflect expected differences from a previous randomized controlled trial across five data sources, after applying inclusion/exclusion criteria. The KEYNOTE-189 clinical trial protocol of platinum doublet chemotherapy (chemotherapy) vs. programmed cell death protein 1 (PD-1) in combination with platinum doublet chemotherapy (PD-1 combination) in first-line nonsquamous metastatic non-small cell lung cancer guided retrospective cohort selection. The Kaplan-Meier product limit estimator was used to calculate 12-month rwOS with 95% confidence intervals (CIs) in each data source. Cox proportional hazards models estimated hazard ratios (HRs) and associated 95% CIs, controlled for prognostic factors. Once the inclusion/exclusion criteria were applied, the five resulting data sets included 155 to 1,501 patients in the chemotherapy cohort and 36 to 405 patients in the PD-1 combination cohort. Twelve-month rwOS ranged from 45% to 58% in the chemotherapy cohort and 44% to 68% in the PD-1 combination cohort. The adjusted HR for death ranged from 0.80 (95% CI: 0.69, 0.93) to 1.15 (95% CI: 0.71, 1.85), controlling for age, gender, performance status, and smoking status. This study yielded insights regarding data capture, including ability of real-world data to precisely identify patient populations and the impact of criteria on end points. Sensitivity analyses could elucidate data set-specific factors that drive results.

Evaluating real-world overall survival (rwOS) across oncology data sources: Friends of Cancer Research non-small cell lung cancer pilot study

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Background: Friends of Cancer Research and five data partners used electronic health record-sourced datasets to conduct parallel analyses in real-world data (RWD). The study assessed estimates of rwOS among patients taking platinum doublet chemotherapy (chemo) or pembrolizumab in combination with chemo (IO+chemo) in first-line treatment for metastatic non-small cell lung cancer (mNSCLC). Methods: The KEYNOTE-189 clinical trial was selected as a reference for cohort selection in the RWD. We applied select available KEYNOTE-189 eligibility criteria to compare rwOS in a homogenous real-world population. Analyses were conducted following a mutually developed statistical analysis plan that was harmonized across data partners. Twelve-month rwOS, and unadjusted and adjusted hazard ratios (HR) for death were calculated using time-to-event methods with patients censored at last structured activity prior to the data cutoff. Results: The five datasets included patients treated with chemo (range of n=155 to 1501) and IO+chemo patients (n=36 to 405, Table). Twelve-month rwOS estimates ranged from 45% to 58% in the chemo arm and 44% to 68% in the IO +chemo arm. The HR for death comparing IO+chemo to chemo varied across groups, ranging from 0.79 (95% CI: 0.68, 0.92) to 1.10 (95% CI: 0.70, 1.72). The HR for death adjusted for age, gender, performance status, and smoking status did not significantly alter results, ranging from 0.80 (95% CI: 0.69, 0.93) to 1.15 (96% CI: 0.71, 1.85). Conclusions: The systematic evaluation of reproducibility and performance of rwOS across five real-world cohorts and the impact of implementing consistent eligibility criteria and methods was useful to understand the consistency of results in real-world populations and relationship between treatments and outcomes in the absence of randomization. A well-articulated research question and a pre-specified analytic plan that includes covariate definitions are necessary preliminary steps to guide data harmonization, standardization, and analysis. A range of observed results highlights the complexity of real-world data, including differences in sample size, underlying patient variability across datasets, and missing covariate data. The harmonization process and observed results underscore the importance of a well-articulated research question and a pre-specified analytic plan to guide data harmonization, standardization, and analysis. [Table: see text]

Overall survival (OS) in advanced non-small cell lung cancer (aNSCLC) patients treated with frontline chemotherapy or immunotherapy by comorbidity: A real-world data (RWD) collaboration

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Background: Friends of Cancer Research convened 9 data partners to identify data elements and common definitions for real world (rw) endpoints to evaluate populations typically excluded from clinical trials. Here we report on rwOS by frontline treatment and comorbidities. Methods: A retrospective observational analysis of patients with aNSCLC initiating frontline platinum doublet chemotherapy (chemo) or PD-(L)1-based immuno-oncologic (IO) therapy (monotherapy or chemo combination) between 1 Jan 2011 to 31 Mar 2018 was conducted using administrative claims, EHR, and cancer registry RWD. We evaluated rwOS from frontline therapy initiation using Kaplan-Meier methods, stratified by ECOG status, brain metastases (ICD), history of chronic kidney or liver disease (CKD/ CLD, ICD), and evidence of kidney or liver dysfunction (KD/ LD, lab-based). Results: A total of 33,649 patients were included (N 972-17,454) with 10 to 26% of patients receiving IO as frontline therapy. There was a broad range of comorbidity prevalence across datasets and patients with evidence of comorbidity had comparatively shorter 12-month OS (Table). Conclusions: RWD analyses can generate expanded evidence on patient outcomes for populations routinely excluded from clinical trials and may help inform decision making where sparse data exist on appropriate treatment approaches. Additional understanding of data missingness, sensitivity of definitions, and covariate adjustment are needed to make direct comparisons across regimens and data sources. [Table: see text]

Trends in immunotherapy use in patients with advanced non-small cell lung cancer (aNSCLC) patients: Analysis of real-world data

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Background: Leveraging data from a collaboration with 9 data partners, Friends of Cancer Research convened the Real-world Evidence Pilot 2.0, to examine trends and real world (rw) data endpoints in immunotherapy (IO) use for the front line treatment of aNSCLC. Methods: This study leveraged parallel analyses of rw data elements across heterogenous data sources (EHR, administrative claims, and registry) to: a) describe trends in uptake and use of novel IO frontline therapy after advanced diagnosis in NSCLC patients treated in usual care settings and b) examine associations between treatment and rw outcomes at one-year follow-up. The proportion of patients treated on each regimen (IO single agent, chemo, or IO + chemo) from 2011 through 2017 were calculated. Analysis included proportion of patients across treatment regimens stratified by year to describe post approval uptake of IO. Kaplan-Meier survival estimates were reported to adjust for follow-up time and stratified by PD-L1 status and stage. Results: Seven datasets identified a range of 999 to 4617 patients per dataset for this analysis. Across datasets, 2508, 3446, and 4176 patients initiated treatment in 2015, 2016, and 2017, respectively. No patients received IO or IO + chemo regimens prior to 2015. Initial approvals for IO use in aNSCLC occurred in October 2015 and for first line in metastatic NSCLC in October 2016. When examining survival at 1 year, overall, OS in PD-(L)1 + patients appeared longer than those with a PD-(L)1 - status. Conclusions: RWE analyses may reveal important trends in clinical cancer patient care including patterns of off-label use. The heterogeneity in the timing of IO uptake across datasets ranged from immediately after approval to ~12 months post-approval. [Table: see text]

Overall survival in high and very high PD-L1 expressing patients with advanced non-small cell lung cancer treated with immune checkpoint inhibitors in a real-world data setting

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Background: Clinical trials show improved survival for advanced non-small cell lung cancer (aNSCLC) patients whose tumors are positive for PD-L1 expression when treated with immune checkpoint inhibitors (ICI), including pembrolizumab (Pb) and nivolumab (Nb). It is unclear whether relatively higher PD-L1 expression by tumor proportion score (TPS) is associated with better response to treatment, and whether this can be generalized to a real-world setting. Methods: We assessed overall survival (OS) across categories of PD-L1 expression levels among aNSCLC patients who received ICI monotherapy in the advanced/metastatic setting (stages IIIB or IV, or documented metastatic disease at diagnosis). Sub-analyses were performed based on first, second, or subsequent lines of treatment, as well as for patients receiving only Pb. The patient population is a sample from community health systems based in the United States, with data derived from electronic medical records and supplemented with molecular data integration from diagnostics labs. Results: 874 aNSCLC patients received ICI in the advanced/metastatic setting in the first line (n = 246, 28%), second line (n = 456, 52%), or third or later lines (n = 172, 20%). ICI-treated patients in any line with TPS of 1-49% (n = 148), 50-89% (n = 124), and 90-100% (n = 97) had OS of 6.9, 11.5, and 11.7 months, respectively. Pb-treated patients in any line with TPS of 1-49% (n = 38), 50-89% (n = 104), and 90-100% (n = 72) had OS of 5.5, 10.1, and 11.7 months, respectively. ICI-treated patients in the 1st line with TPS of 1-49% (n = 10), 50-89% (n = 80), and 90-100% (n = 59) had OS of 3.7, 8.0, and 7.4 months, respectively. Pb-treated patients in the first line with TPS of 1-49% (n = 7), 50-89% (n = 80), and 90-100% (n = 58) had OS of 3.7, 8.0, and 9.5 months, respectively. Conclusions: Results suggest OS benefit for real-world ICI-treated aNSCLC patients with PD-L1 TPS ≥50%, consistent with observations in clinical trials. The data further suggest additional benefits in the highest TPS category of 90-100% among Pb-treated patients, while the evidence is weaker for all ICI-treated patients, although comparisons did not reach statistical significance. A similar trend was seen in analyses of both patients treated in first-line only and in any line. Further analyses, to include comparison to clinical trial results, are warranted.

Prototyping a precision oncology 3.0 rapid learning platform

Background

We describe a prototype implementation of a platform that could underlie a Precision Oncology Rapid Learning system.

Results

We describe the prototype platform, and examine some important issues and details. In the Appendix we provide a complete walk-through of the prototype platform.

Conclusions

The design choices made in this implementation rest upon ten constitutive hypotheses, which, taken together, define a particular view of how a rapid learning medical platform might be defined, organized, and implemented.

Staff development to meet radical change

At times of radical change innovative methods of staff training and development are required to broaden horizons and increase personal confidence. Outdoor pursuits offer a range of personal and group experiences not available in a classroom. Real-life experiences in which actions have immediate consequences are vital components for staff development.