Nivolumab versus docetaxel in previously treated advanced non-small-cell lung cancer (CheckMate 017 and CheckMate 057): 3-year update and outcomes in patients with liver metastases

Background

Long-term data with immune checkpoint inhibitors in non-small-cell lung cancer (NSCLC) are limited. Two phase III trials demonstrated improved overall survival (OS) and a favorable safety profile with the anti-programmed death-1 antibody nivolumab versus docetaxel in patients with previously treated advanced squamous (CheckMate 017) and nonsquamous (CheckMate 057) NSCLC. We report results from ≥3 years' follow-up, including subgroup analyses of patients with liver metastases, who historically have poorer prognosis among patients with NSCLC.

Patients and methods

Patients were randomized 1 : 1 to nivolumab (3 mg/kg every 2 weeks) or docetaxel (75 mg/m2 every 3 weeks) until progression or discontinuation. The primary end point of each study was OS. Patients with baseline liver metastases were pooled across studies by treatment for subgroup analyses.

Results

After 40.3 months' minimum follow-up in CheckMate 017 and 057, nivolumab continued to show an OS benefit versus docetaxel: estimated 3-year OS rates were 17% [95% confidence interval (CI), 14% to 21%] versus 8% (95% CI, 6% to 11%) in the pooled population with squamous or nonsquamous NSCLC. Nivolumab was generally well tolerated, with no new safety concerns identified. Of 854 randomized patients across both studies, 193 had baseline liver metastases. Nivolumab resulted in improved OS compared with docetaxel in patients with liver metastases (hazard ratio, 0.68; 95% CI, 0.50-0.91), consistent with findings from the overall pooled study population (hazard ratio, 0.70; 95% CI, 0.61-0.81). Rates of treatment-related hepatic adverse events (primarily grade 1-2 liver enzyme elevations) were slightly higher in nivolumab-treated patients with liver metastases (10%) than in the overall pooled population (6%).

Conclusions

After 3 years' minimum follow-up, nivolumab continued to demonstrate an OS benefit versus docetaxel in patients with advanced NSCLC. Similarly, nivolumab demonstrated an OS benefit versus docetaxel in patients with liver metastases, and remained well tolerated.

Clinical trial registration

CheckMate 017: NCT01642004; CheckMate 057: NCT01673867.

Second-line nivolumab in relapsed small-cell lung cancer: CheckMate 331☆

BACKGROUND

Patients with relapsed small-cell lung cancer (SCLC) have few treatment options and dismal survival. Phase I/II data show activity of nivolumab in previously treated SCLC.

PATIENTS AND METHODS

CheckMate 331 is a randomized, open-label, phase III trial of nivolumab versus standard chemotherapy in relapsed SCLC. Patients with relapse after first-line, platinum-based chemotherapy were randomized 1 : 1 to nivolumab 240 mg every 2 weeks or chemotherapy (topotecan or amrubicin) until progression or unacceptable toxicity. Primary endpoint was overall survival (OS).

RESULTS

Overall, 284 patients were randomized to nivolumab and 285 to chemotherapy. Minimum follow-up was 15.8 months. No significant improvement in OS was seen with nivolumab versus chemotherapy [median OS, 7.5 versus 8.4 months; hazard ratio (HR), 0.86; 95% confidence interval (CI), 0.72-1.04; P = 0.11]. A survival benefit with nivolumab was suggested in patients with baseline lactate dehydrogenase ≤ upper limit of normal and in those without baseline liver metastases. OS (nivolumab versus chemotherapy) was similar in patients with programmed death-ligand 1 combined positive score ≥1% versus <1%. Median progression-free survival was 1.4 versus 3.8 months (HR, 1.41; 95% CI, 1.18-1.69). Objective response rate was 13.7% versus 16.5% (odds ratio, 0.80; 95% CI, 0.50-1.27); median duration of response was 8.3 versus 4.5 months. Rates of grade 3 or 4 treatment-related adverse events were 13.8% versus 73.2%.

CONCLUSION

Nivolumab did not improve survival versus chemotherapy in relapsed SCLC. No new safety signals were seen. In exploratory analyses, select baseline characteristics were associated with improved OS for nivolumab.

Pembrolizumab as first-line therapy for patients with PD-L1-positive advanced non-small cell lung cancer: a phase 1 trial

Background

Pembrolizumab improved survival as first- and second-line therapy compared with chemotherapy in patients with highly programmed death ligand 1 (PD-L1) expressing advanced non-small cell lung cancer (NSCLC). We report the long-term safety and clinical activity of pembrolizumab as first-line therapy for patients with advanced NSCLC and the correlation between PD-L1 expression and efficacy.

Patients and methods

In the open-label phase 1b KEYNOTE-001 trial, treatment-naive patients with advanced NSCLC whose tumors expressed PD-L1 (≥1% staining, assessed using a prototype assay) were randomly assigned to intravenous pembrolizumab 2 or 10 mg/kg every 3 (Q3W) or 2 (Q2W) weeks. Response was assessed per central RECIST v1.1 every 9 weeks in all patients who received ≥1 pembrolizumab dose. Using pre-treatment tumor tissue, a clinical assay quantified the percentage of tumor cells expressing PD-L1 as tumor proportion score (TPS).

Results

Between 1 March 2013 and 18 September 2015, 101 patients received pembrolizumab 2 mg/kg Q3W (n = 6), 10 mg/kg Q3W (n = 49), or 10 mg/kg Q2W (n = 46). Of these, 27 (26.7%) had TPS ≥50%, 52 (51.5%) had TPS 1%-49%, and 12 (11.9%) had TPS <1%. The objective response rate (ORR) was 27% (27/101, 95% CI 18-37) and median overall survival was 22.1 months (95% CI 17.1-27.2). In patients with PD-L1 TPS ≥50%, ORR, 12-month PFS, and 12-month OS were higher [14/27 (51.9%; 95% CI 32%-71%), 54%, and 85%, respectively] than the overall population [27/101 (26.7%; 95% CI 18.4%-36.5%), 35%, 71%]. Pembrolizumab was well tolerated, with only 12 (11.9%) patients experiencing grade 3/4 treatment-related adverse events and no treatment-related deaths.

Conclusions

Pembrolizumab provides promising long-term OS benefit with a manageable safety profile for PD-L1-expressing treatment-naive advanced NSCLC, with greatest efficacy observed in patients with TPS ≥50%.

Clinical trial name and number

KEYNOTE-001 (ClinicalTrials.gov, NCT01295827).

Infrared observations of the saturnian system from voyager 1

During the passage of Voyager 1 through the Saturn system, the infrared instrument acquired spectral and radiometric data on Saturn, the rings, and Titan and other satellites. Infrared spectra of Saturn indicate the presence of H(2), CH(4), NH(3), PH(3), C(2)H(2), C(2)H(6), and possibly C(3)H(4) and C(3)H(8). A hydrogen mole fraction of 0.94 is inferred with an uncertainty of a few percent, implying a depletion of helium in the atmosphere of Saturn relative to that of Jupiter. The atmospheric thermal structure of Saturn shows hemisphere asymmetries that are consistent with a response to the seasonally varying insolation. Extensive small-scale latitudinal structure is also observed. On Titan, positive identifications of infrared spectral features are made for CH(4), C(2)H(2), C(2)H(4), C(2)H(6), and HCN; tentative identifications are made for C(3)H(4) and C(3)H(8). The infrared continuum opacity on Titan appears to be quite small between 500 and 600 cm(-1), implying that the solid surface is a major contributor to the observed emission over this spectral range; between 500 and 200 cm(-1) theopacity increases with decreasing wave number, attaining an optical thickness in excess of 2 at 200 cm(-1). Temperatures near the 1-millibar level are independent of longitude and local time but show a decrease of approximately 20 K between the equator and north pole, which suggests a seasonally dependent cyclostrophic zonal flow in the stratosphere of approximately 100 meters per second. Measurements of the C ring of Saturn yield a temperature of 85 +/- 1 K and an infrared optical depth of 0.09 +/- 0.01. Radiometer observations of sunlight transmitted through the ring system indicate an optical depth of 10(-1.3 +/-0.3) for the Cassini division. A phase integral of 1.02 +/- 0.06 is inferred for Rhea, which agrees with values for other icy bodies in the solar system. Rhea eclipse observations indicate the presence of surface materials with both high and low thermal inertias, the former most likely a blocky component and the latter a frost.

Infrared observations of the neptunian system

The infrared interferometer spectrometer on Voyager 2 obtained thermal emission spectra of Neptune with a spectral resolution of 4.3 cm(-1). Measurements of reflected solar radiation were also obtained with a broadband radiometer sensitive in the visible and near infrared. Analysis of the strong C(2)H(2) emission feature at 729 cm(-1) suggests an acetylene mole fraction in the range between 9 x 10(-8) and 9 x 10(-7). Vertical temperature profiles were derived between 30 and 1000 millibars at 70 degrees and 42 degrees S and 30 degrees N. Temperature maps of the planet between 80 degrees S and 30 degrees N were obtained for two atmospheric layers, one in the lower stratosphere between 30 and 120 millibars and the other in the troposphere between 300 and 1000 millibars. Zonal mean temperatures obtained from these maps and from latitude scans indicate a relatively warm pole and equator with cooler mid-latitudes. This is qualitatively similar to the behavior found on Uranus even though the obliquities and internal heat fluxes of the two planets are markedly different. Comparison of winds derived from images with the vertical wind shear calculated from the temperature field indicates a general decay of wind speed with height, a phenomenon also observed on the other three giant planets. Strong, wavelike longitudinal thermal structure is found, some of which appears to be associated with the Great Dark Spot. An intense, localizd cold region is seen in the lower stratosphere, which does not appear to be correlated with any visible feature. A preliminary estimate of the effective temperature of the planet yields a value of 59.3 +/- 1.0 kelvins. Measurements of Triton provide an estimate of the daytime surface temperature of 38(+3)(-4) kelvins.

Systematic evaluation of pembrolizumab dosing in patients with advanced non-small-cell lung cancer

BACKGROUND

In the phase I KEYNOTE-001 study, pembrolizumab demonstrated durable antitumor activity in patients with advanced non-small-cell lung cancer (NSCLC). We sought to characterize the relationship between pembrolizumab dose, exposure, and response to define an effective dose for these patients.

PATIENTS AND METHODS

Patients received pembrolizumab 2 mg/kg every 3 weeks (Q3W) (n = 55), 10 mg/kg Q3W (n = 238), or 10 mg/kg Q2W (n = 156). Response (RECIST v1.1) was assessed every 9 weeks. The relationship between the estimated pembrolizumab area under the concentration-time curve at steady state over 6 weeks (AUCss-6weeks) and the longitudinal change in tumor size (sum of longest diameters) was analyzed by regression and non-linear mixed effects modeling. This model was simultaneously fit to all tumor size data, then used to simulate response rates, normalizing the trial data across dose for prognostic covariates (tumor PD-L1 expression and EGFR mutation status). The exposure-safety relationship was assessed by logistic regression of pembrolizumab AUCss-6weeks versus occurrence of adverse events (AEs) of interest based on their immune etiology.

RESULTS

Overall response rates were 15% [95% confidence interval (CI) 7%-28%] at 2 mg/kg Q3W, 25% (18%-33%) at 10 mg/kg Q3W, and 21% (95% CI 14%-30%) at 10 mg/kg Q2W. Regression analyses of percentage change from baseline in tumor size versus AUCss-6weeks indicated a flat relationship (regression slope P > 0.05). Simulations showed the exposure-response relationship to be similarly flat, thus indicating that the lowest evaluated dose of 2 mg/kg Q3W to likely be at or near the efficacy plateau. Exposure-safety analysis showed the AE incidence to be similar among the clinically tested doses.

CONCLUSIONS

No significant exposure dependency on efficacy or safety was identified for pembrolizumab across doses of 2-10 mg/kg. These results support the use of a 2 mg/kg Q3W dosage in patients with previously treated, advanced NSCLC.

CLINICALTRIALSGOV REGISTRY

NCT01295827.

Safety and patient-reported outcomes of atezolizumab, carboplatin, and etoposide in extensive-stage small-cell lung cancer (IMpower133): a randomized phase I/III trial

BACKGROUND

The addition of atezolizumab to carboplatin and etoposide (CP/ET) significantly improved progression-free and overall survival for patients with extensive-stage small-cell lung cancer (ES-SCLC) in the IMpower133 study (NCT02763579). We have evaluated adverse events (AEs) and patient-reported outcomes in IMpower133 to assess the benefit-risk profile of this regimen.

PATIENTS AND METHODS

Patients received four 21-day cycles of CP/ET plus intravenous atezolizumab 1200 mg or placebo (induction phase), followed by atezolizumab or placebo (maintenance phase) until progression or loss of benefit. AEs were assessed and patient-reported outcomes were evaluated every 3 weeks during treatment using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire - Core 30 (QLQ-C30) and QLQ-LC13.

RESULTS

Overall, 394 patients were assessable for safety in the induction phase and 318 in the maintenance phase. The frequency of AEs, grade 3-4 AEs, and serious AEs was similar between arms in both phases. Immune-related AEs were more frequent in the atezolizumab arm during both induction (28% versus 17%; leading to atezolizumab/placebo interruption 9% versus 5%, leading to withdrawal 4% versus 0%) and maintenance (26% versus 15%; leading to atezolizumab/placebo interruption, 3% versus 2%, leading to withdrawal 1% versus 1%), most commonly rash (induction 11% versus 9%, maintenance 14% versus 4%), and hypothyroidism (induction 4.0% versus 0%, maintenance 10% versus 1%). Changes in patient-reported treatment-related symptoms commonly associated with quality of life impairment were generally similar during induction and most of the maintenance phase. Patient-reported function and health-related quality of life (HRQoL) improved in both arms after initiating treatment, with more pronounced and persistent HRQoL improvements in the atezolizumab arm.

CONCLUSIONS

In patients with ES-SCLC, atezolizumab plus CP/ET has a comparable safety profile to placebo plus CP/ET, and the addition of atezolizumab did not adversely impact patient-reported HRQoL. These data demonstrate the positive benefit-risk profile of first-line atezolizumab plus CP/ET in ES-SCLC and further support this regimen as a new standard of care in this setting.

CLINICAL TRIALS NUMBER

NCT02763579.

Infrared Observations of the Jovian System from Voyager 2

Infrared spectra obtainedfrom Voyager 2 have provided additional data on the Jovian system, complementing those obtained from Voyager 1. The abundance ratio of ethane to acetylene in Jupiter's atmosphere appears to be about three times larger in the polar regions than at lower latitudes. A decidedly hemispherical asymmetry exists, with somewhat higher ratios prevailing in northern latitudes. An overall increase in the abundance ratio by a factor of about 1.7 appears to have occurred between the Voyager 1 and 2 encounters. Global brightness temperature maps of Jupiter at 226 and 602 cm(-1) exhibit a large amount of local- and planetary-scale structure, as well as temporal variability. Although heterogeneous cloud structure and ammonia concentration in the lower troposphere may contribute to the appearance of the 226-cm(-1) map, the detail in the 602-cm(-1) maps probably represents the actual horizontal thermal structure near the tropopause and suggests that dynamical heating and cooling processes are important. Low-latitude surface temperatures on the Galilean satellites rangefrom approximately 80 K on the dark sides to 155 K at the subsolar point on Callisto. Below a thin insulating layer, the thermal inertia of Callisto is somewhat greater than that of Earth's moon. Upper limits on the infrared optical depth of the Jovian ring rangingfrom approximately 3 x 10(-4) at 250 cm(-1) to 3 x 10(-3) at 600 cm(-1) have been found.

Infrared Observations of the Saturnian System from Voyager 2

During the passage of Voyager 2 through the Saturn system, infrared spectral and radiometric data were obtained for Saturn, Titan, Enceladus, Tethys, Iapetus, and the rings. Combined Voyager 1 and Voyager 2 observations of temperatures in the upper troposphere of Saturn indicate a seasonal asymmetry between the northern and southern hemispheres, with superposed small-scale meridional gradients. Comparison of high spatial resolution data from the two hemispheres poleward of 60 degrees latitude suggests an approximate symmetry in the small-scale structure, consistent with the extension of a symmetric system of zonal jets into the polar regions. Longitudinal variations of 1 to 2 K are observed. Disk- averaged infrared spectra of Titan show little change over the 9-month interval between Voyager encounters. By combining Voyager 2 temperature measurements with ground-based geometric albedo determinations, phase integrals of 0.91 +/- 0.13 and 0.89 +/- 0.09 were derived for Tethys and Enceladus, respectively. The subsolar point temperature of dark material on Iapetus must exceed 110 K. Temperatures (and infrared optical depths) for the A and C rings and for the Cassini division are 69 +/- 1 K (0.40 +/- 0.05), 85 +/- 1 K (0.10 +/- 0.03), and 85 +/- 2 K (0.07 +/- 0.04), respectively.

Effects of a prolonged vitamin E deficiency in the rat

Rats fed a vitamin E-deficient diet containing 10% "stripped" corn oil had reduced growth rate and elevated platelet count by 12 weeks of age, and a normocytic anemia with elevated reticulocytes by 16 weeks of age. After 5 months, rats became emaciated and developed kyphoscoliosis. Some rats developed skin ulcers and tremors, and mortality was high. Neuromuscular lesions included a chronic necrotizing myopathy and localized axonal dystrophy. There was also a selective activation of lysosomes in the central nervous system microcirculation. Liver ascorbic acid of deficient rats was the same as in those receiving vitamin E. Urinary excretion of p-hydroxyphenylpyruvate after a tyrosine load was also the same in deficient and control rats. It was concluded that neither vitamin C synthesis or utilization was affected the E-deficient rats.

Statistical analysis of Salmonella test data and comparison to results of animal cancer tests

A quantitative framework for the analysis of results of the Salmonella (Ames) test is presented, and the relationship between mutagenesis and carcinogenesis is examined. Color graphics are used for the Salmonella data to describe variability, and trends across multiple chemicals and test conditions. Positivity in the Salmonella test, using statistical criteria to classify results, is compared to positivity in carcinogenesis bioassays for 48 chemicals tested in NCI/NTP-sponsored programs. Sensitivity of the Salmonella test across 5 tester strains was 91% (21/23), while specificity was only 36% (9/25). Results were most concordant for TA100 Aroclor-induced rat S9: sensitivity was 87%, specificity 64%. The correlation of mutagenic potency and carcinogenic potency was 0.41 (p less than 0.001) for 80 chemicals, using results from both the general published literature and the NCI/NTP-sponsored programs. After removal of 3 extreme values, the correlation was 0.24 (p = 0.04).

An evaluation of Salmonella (Ames) test data in the published literature: application of statistical procedures and analysis of mutagenic potency

We searched the published literature for Salmonella test data on some 450 chemicals. Only 137 of more than 400 articles containing original data satisfied minimum criteria for a quantitative analysis [1751 experiments, comprising data on 152 chemicals (Table 1)]. Many of these papers did not report basic information about the test protocol (Table 2). We used previously described statistical procedures (Bernstein et al., 1982) to estimate the initial slopes of the dose-response curves and corresponding standard errors. We also applied tests for significance and linear goodness-of-fit. We then used the results of these analyses to examine several issues: (1) Linearity of the low dose region of the dose-response curve. We found that the overwhelming majority of curves were linear, though ability to detect non-linearity of dose-response curves in the standard plate test is only limited. 7% of all experiments to which the goodness-of-fit test was applied were curves of increasing slope, and with a few possible exceptions, these were not obviously associated with any particular mutagens, even those generally considered to produce non-linear effects such as MNNG and EMS (Table 3). (2) Performance of the statistical test for significance. Results of the statistical test for significance of the dose-response were compared with author's opinions as to positivity. In almost all cases (94%) results of the statistical test and authors opinions were the same. In the examples of conflicting opinions, the reasons were: (a) the statistical test places more weight than do most authors on the presence of a linear dose-response; (b) most authors tend to require at least a 2-fold increase over the spontaneous background for 'significance', and (c) when the number of spontaneous revertants is small (e.g., TA1537), authors tend to require a larger increase in induced revertants than when the spontaneous background is large, whereas the statistical procedure makes no such distinction. These factors result in the statistical test tending to identify more experiments as positive than do authors, provided there is a linear dose-response, and authors tending to judge more experiments as positive when the dose-response is not linear. (3) Reproducibility. Among the 1751 experiments there were 122 data-sets (a total of 333 experiments) in which the same chemical was tested by two or more different laboratories under the same protocol. 21 of the 122 data-sets had some disagreement between experiments as to whether results were positive or negative (Table 4).(ABSTRACT TRUNCATED AT 400 WORDS)

Increased carcinogenic action of dimethylnitrosamine after prior administration of carbon tetrachloride

Rats were given a single dose of dimethylnitrosamine (DMN, 20 mg/kg body weight) alone or 42 or 60 hours after a non-lethal hepatotoxic dose of carbon tetrachloride (CC1(4)) and killed 12 months later. DMN alone produced no tumours in the kidney and a few in the liver, but when given 42 hours after CC1(4), tumours formed in the kidneys and the number in the liver was increased. When given after 60 hours, the incidence of kidney tumours was less but that of liver tumours was further increased. A larger dose of DMN (40 mg/kg) was tolerated 42 hours after CC1(4) and enhanced the number of kidney and liver tumours, the latter apparently due to an increased proportion of cholangiomata. Numerous small focal proliferations of atypical liver cells and of bile duct epithelium were observed after treatment with DMN. The incidence of these lesions in the different experimental treatments varied in a similar manner to the liver tumours.

Vasoactive intestinal polypeptide (VIP) innervation of rat spleen, thymus, and lymph nodes

In the thymus, VIP-positive (+) fibers were found in the capsular/septal system, cortex, and medulla. In the spleen, VIP+ nerves coursed along large arteries and central arterioles, and in the white pulp, venous/trabecular system, and red pulp. Splenic VIP innervation was more robust in Long-Evans hooded rats than in Fischer 344 rats. VIP+ nerves in mesenteric lymph nodes were found in the cortex, and along the cortical vasculature and medullary cords. No VIP innervation was observed in popliteal lymph nodes. Immunocytes also were VIP+, suggesting that both neural and cellular synthesis of VIP contributes to VIP concentration in lymphoid organs. Surgical sympathectomy did not alter splenic or thymic VIP content, respectively, and VIP innervation of these organs was not altered, suggesting an origin for VIP+ nerves other than the sympathetic nervous system.

Randomized phase III study of docetaxel plus bavituximab in previously treated advanced non-squamous non-small-cell lung cancer

Background

Bavituximab is a monoclonal antibody that targets phosphatidylserine in the presence of β2 glycoprotein 1 (β2GP1) to exert an antitumor immune response. This phase III trial determined the efficacy of bavituximab combined with docetaxel in patients with previously treated advanced non-small-cell lung cancer (NSCLC).

Patients and methods

Key eligibility criteria included advanced non-squamous NSCLC with disease progression after treatment with platinum-based doublet chemotherapy, evidence of disease control after at least two cycles of first-line therapy, presence of measurable disease, ECOG performance status 0 or 1, adequate bone marrow and organ function, and no recent history of clinically significant bleeding. Eligible patients were randomized 1 : 1 to receive up to six 21-day cycles of docetaxel plus either weekly bavituximab 3 mg/kg or placebo until progression or toxicity. The primary end point was overall survival (OS).

Results

A total of 597 patients were enrolled. Median OS was 10.5 months in the docetaxel + bavituximab arm and was 10.9 months in the docetaxel + placebo arm (HR 1.06; 95% CI 0.88-1.29; P = 0.533). There was no difference in progression-free survival (HR 1.00; 95% CI 0.82-1.22; P = 0.990). Toxicities were manageable and similar between arms. In subset analysis, among patients with high baseline serum β2GP1 levels ≥200 µg/ml, a nonsignificant OS trend favored the bavituximab arm (HR 0.82; 95% CI 0.63-1.06; P = 0.134). Among patients who received post-study immune checkpoint inhibitor therapy, OS favored the bavituximab arm (HR 0.46; 95% CI 0.26-0.81; P = 0.006).

Conclusions

The combination of bavituximab plus docetaxel is not superior to docetaxel in patients with previously treated advanced NSCLC. The addition of bavituximab to docetaxel does not meaningfully increase toxicity. The potential benefit of bavituximab observed in patients with high β2GP1 levels and in patients subsequently treated with immune checkpoint inhibitors requires further investigation.

Clinical trial number

NCT01999673.

A phase III, randomized, open-label study of ASP8273 versus erlotinib or gefitinib in patients with advanced stage IIIB/IV non-small-cell lung cancer

BACKGROUND

ASP8273, a novel, small molecule, irreversible tyrosine kinase inhibitor (TKI) specifically inhibits the epidermal growth factor receptor (EGFR) in patients with activating mutations or EGFR T790M resistance mutations. The current study examines the efficacy, safety, and tolerability of ASP8273 versus erlotinib or gefitinib in patients with non-small-cell lung cancer (NSCLC) with activating EGFR mutations not previously treated with an EGFR inhibitor.

PATIENTS AND METHODS

This global, phase III, open-label, randomized study evaluated ASP8273 versus erlotinib/gefitinib in patients with locally advanced, metastatic, or unresectable stage IIIB/IV NSCLC with activating EGFR mutations. They were ineligible if they received prior chemotherapy for metastatic disease. The primary end point was progression-free survival (PFS), and secondary end points included overall survival, investigator-assessed PFS, best overall response rate (ORR), disease control rate, duration of response (DoR), and the safety/tolerability profile.

RESULTS

Patients (n = 530) were randomized 1 : 1 to receive ASP8273 (n = 267) or erlotinib/gefitinib (n = 263). Patient demographics between both treatment groups were generally balanced. Median PFS was 9.3 months (95% CI 5.6-11.1 months) for patients receiving ASP8273 and 9.6 months (95% CI 8.8-NE) for the erlotinib/gefitinib group, with a hazard ratio of 1.611 (P = 0.992). The ORR in the ASP8273 group was 33% (95% CI 27.4-39.0) versus 47.9% (95% CI 41.7-54.1) in the erlotinib/gefitinib group. Median DoR was similar for both groups (9.2 months for ASP8273 versus 9.0 months for erlotinib/gefitinib). More grade ≥3 treatment-emergent adverse events (TEAEs) occurred in patients receiving ASP8273 than in those receiving erlotinib/gefitinib (54.7% versus 43.5%). An independent data monitoring committee carried out an interim safety analysis and recommended discontinuing the study due to toxicity and limited predicted efficacy of ASP8273 relative to erlotinib/gefitinib.

CONCLUSIONS

First-line ASP8273 did not show improved PFS or equivalent toxicities versus erlotinib/gefitinib.

CLINICALTRIAL.GOV NUMBER

NCT02588261.

Immunometabolic Status of COVID-19 Cancer Patients

Cancer patients appear to be more likely to be diagnosed with coronavirus disease 2019 (COVID-19). This is supported by the understanding of immunometabolic pathways that intersect patients with infection and cancer. However, data derived by case series and retrospective studies do not offer a coherent interpretation, since data from China suggest an increased risk of COVID-19, while data from the United States and Italy show a prevalence of COVID-19 in cancer patients comparable with the general population. Noteworthy, cancer and COVID-19 exploit distinct patterns of macrophage activation that promote disease progression in the most severe forms. In particular, the alternative activation of M2-polarized macrophages plays a crucial role in cancer progression. In contrast, the macrophage-activation syndrome appears as the source of M1-related cytokine storm in severe COVID-19 disease, thus indicating macrophages as a source of distinct inflammatory states in the two diseases, nonetheless as a common therapeutic target. New evidence indicates that NAMPT/NAD metabolism can direct both innate immune cell effector functions and the homeostatic robustness, in both cancer and infection. Moreover, a bidirectional relationship exists between the metabolism of NAD and the protective role that angiotensin converting enzyme 2, the COVID-19 receptor, can play against hyperinflammation. Within this immunometabolic framework, the review considers possible interference mechanisms that viral infections and tumors elicit on therapies and provides an overview for the management of patients with cancer affected by COVID-19, particularly for the balance of risk and benefit when planning normally routine cancer treatments and follow-up appointments.

Cost-effectiveness of tuberculosis screening and observed preventive therapy for active drug injectors at a syringe-exchange program

This study examined whether costs associated with tuberculosis (TB) screening and directly observed preventive therapy (DOPT) among drug injectors attending a syringe exchange are justified by cases and costs of active TB cases prevented and examined the impact of monetary incentives to promote adherence on cost-effectiveness. We examined program costs and projected savings using observed adherence and prevalence rates and literature estimates of isoniazid (INH) preventive therapy efficacy, expected INH hepatoxicity rates, and TB treatment costs; we conducted sensitivity analyses for a range of INH effectiveness, chest X-ray (CXR) referral adherence, and different strategies regarding anergy among persons affected with human immunodeficiency virus (HIV). For 1,000 patients offered screening, incorporating real observed program adherence rates, the program would avert $179,934 in TB treatment costs, for a net savings of $123,081. Assuming a modest risk of TB among HIV-infected anergic persons, all strategies with regard to anergy were cost saving, and the strategy of not screening for anergy and not providing DOPT to HIV-infected anergic persons resulted in the greatest cost savings. If an incentive of $25 per person increased CXR adherence from the observed 31% to 50% or 100%, over a 5-year follow-up the net cost savings would increase to $170,054 and $414,856, respectively. In this model, TB screening and DOPT at a syringe exchange is a cost-effective intervention and is cost-saving compared to costs of treating active TB cases that would have occurred in the absence of the intervention. This model is useful in evaluating the cost impact of planned program refinements, which can then be tested. Monetary incentives for those referred for screening CXRs would be justified on a cost basis if they had even a modest beneficial impact on adherence.

Infrared Observations of the Uranian System

The infrared interferometer spectrometer (IRIS) on Voyager 2 recorded thermal emission spectra of Uranus between 200 and 400 cm(-1) and of Miranda and Ariel between 200 and 500 cm(-1) with a spectral resolution of 4.3 cm(-1). Reflected solar radiation was also measured with a single-channel radiometer sensitive in the visible and near infrared. By combining IRIS spectra with radio science results, a mole fraction for atmospheric helium of 0.15 +/- 0.05 (mass fraction, 0.26 +/- 0.08) is found. Vertical temperature profiles between 60 and 900 millibars were derived from average polar and equatorial spectra. Temperatures averaged over a layer between 400 to 900 millibars show nearly identical values at the poles and near the equator but are 1 or 2 degrees lower at mid-latitudes in both hemispheres. The cooler zone in the southern hemisphere appears darker in reflected sunlight than the adjacent areas. An upper limit for the effective temperature of Uranus is 59.4 kelvins. Temperatures of Miranda and Ariel at the subsolar point are 86 +/- 1 and 84 +/- 1 kelvins, respectively, implying Bond albedos of 0.24 +/- 0.06 and 0.31 +/- 0.06, respectively. Estimates of phase integrals suggest that these satellites have unusual surface microstructure.

Plasma activity of pyruvate kinase and glutamic oxalacetic transaminase as indices of myopathy in the vitamin E deficient rat

Weanling rats were fed vitamin E deficient diets for 6 to 15 weeks and then given vitamin E orally for 4 days. Plasma obtained 1 day after the last dose was assayed for glutamic oxalacetic transaminase (GOT) and pyruvate kinase activity (PK). Administration of vitamin E resulted in reduction in activity of both enzymes. Plasma levels of alkaline phosphatase, lactic dehydrogenase, and bilirubin were unaffected by vitamin E and there was no histological evidence of liver degeneration. The number of phagocytized muscle fibers was greatly reduced by vitamin E treatment, but a substantial number of necrotic fibers were still present. With more prolonged (8 days) treatment, plasma PK and GOT levels were reduced to levels found in plasma of vitamin E replete animals and few degenerated muscle fibers could be observed. It was concluded that resolution of the necrotizing myopathy in vitamin E deficient rats is a rapid process and that the decreased activity of PK and GOT in plasma is a sensitive indicator of the resolution process. The decrease in plasma enzyme levels is an easily quantitated and reproducible biological response to vitamin E administration. Thus, this approach provides a basis for a sensitive and accurate bioassay for vitamin E activity.