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van Not OJ, Verheijden RJ, van den Eertwegh AJM, Haanen JBAG, Aarts MJB, van den Berkmortel FWPJ, Blank CU, Boers-Sonderen MJ, de Groot JWB, Hospers GAP, Kamphuis AM, Kapiteijn E, May AM, de Meza MM, Piersma D, van Rijn R, Stevense-den Boer MA, van der Veldt AAM, Vreugdenhil G, Blokx WAM, Wouters MJM, Suijkerbuijk KPM. Association of Immune-Related Adverse Event Management With Survival in Patients With Advanced Melanoma. JAMA Oncol 2022; 8:1794-1801. [PMID: 36301521 PMCID: PMC9614679 DOI: 10.1001/jamaoncol.2022.5041] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 07/27/2022] [Indexed: 11/14/2022]
Abstract
Importance Management of checkpoint inhibitor-induced immune-related adverse events (irAEs) is primarily based on expert opinion. Recent studies have suggested detrimental effects of anti-tumor necrosis factor on checkpoint-inhibitor efficacy. Objective To determine the association of toxic effect management with progression-free survival (PFS), overall survival (OS), and melanoma-specific survival (MSS) in patients with advanced melanoma treated with first-line ipilimumab-nivolumab combination therapy. Design, Setting, and Participants This population-based, multicenter cohort study included patients with advanced melanoma experiencing grade 3 and higher irAEs after treatment with first-line ipilimumab and nivolumab between 2015 and 2021. Data were collected from the Dutch Melanoma Treatment Registry. Median follow-up was 23.6 months. Main Outcomes and Measures The PFS, OS, and MSS were analyzed according to toxic effect management regimen. Cox proportional hazard regression was used to assess factors associated with PFS and OS. Results Of 771 patients treated with ipilimumab and nivolumab, 350 patients (median [IQR] age, 60.0 [51.0-68.0] years; 206 [58.9%] male) were treated with immunosuppression for severe irAEs. Of these patients, 235 received steroids alone, and 115 received steroids with second-line immunosuppressants. Colitis and hepatitis were the most frequently reported types of toxic effects. Except for type of toxic effect, no statistically significant differences existed at baseline. Median PFS was statistically significantly longer for patients treated with steroids alone compared with patients treated with steroids plus second-line immunosuppressants (11.3 [95% CI, 9.6-19.6] months vs 5.4 [95% CI, 4.5-12.4] months; P = .01). Median OS was also statistically significantly longer for the group receiving steroids alone compared with those receiving steroids plus second-line immunosuppressants (46.1 months [95% CI, 39.0 months-not reached (NR)] vs 22.5 months [95% CI, 36.5 months-NR]; P = .04). Median MSS was also better in the group receiving steroids alone compared with the group receiving steroids plus second-line immunosuppressants (NR [95% CI, 46.1 months-NR] vs 28.8 months [95% CI, 20.5 months-NR]; P = .006). After adjustment for potential confounders, patients treated with steroids plus second-line immunosuppressants showed a trend toward a higher risk of progression (adjusted hazard ratio, 1.40 [95% CI, 1.00-1.97]; P = .05) and had a higher risk of death (adjusted hazard ratio, 1.54 [95% CI, 1.03-2.30]; P = .04) compared with those receiving steroids alone. Conclusions and Relevance In this cohort study, second-line immunosuppression for irAEs was associated with impaired PFS, OS, and MSS in patients with advanced melanoma treated with first-line ipilimumab and nivolumab. These findings stress the importance of assessing the effects of differential irAE management strategies, not only in patients with melanoma but also other tumor types.
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Affiliation(s)
- Olivier J. van Not
- Scientific Bureau, Dutch Institute for Clinical Auditing, Leiden, the Netherlands
- Department of Medical Oncology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Rik J. Verheijden
- Department of Medical Oncology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Alfonsus J. M. van den Eertwegh
- Department of Medical Oncology, Amsterdam UMC, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - John B. A. G. Haanen
- Department of Molecular Oncology and Immunology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Maureen J. B. Aarts
- Department of Medical Oncology, GROW School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | | | - Christian U. Blank
- Department of Molecular Oncology and Immunology, Netherlands Cancer Institute, Amsterdam, the Netherlands
- Department of Medical Oncology and Immunology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Marye J. Boers-Sonderen
- Department of Medical Oncology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | | | - Geke A. P. Hospers
- Department of Medical Oncology, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Anna M. Kamphuis
- Department of Medical Oncology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Ellen Kapiteijn
- Department of Medical Oncology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Anne M. May
- Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Melissa M. de Meza
- Scientific Bureau, Dutch Institute for Clinical Auditing, Leiden, the Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, the Netherlands
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Djura Piersma
- Department of Internal Medicine, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Rozemarijn van Rijn
- Department of Internal Medicine, Medical Centre Leeuwarden, Leeuwarden, the Netherlands
| | | | - Astrid A. M. van der Veldt
- Departments of Medical Oncology and Radiology and Nuclear Medicine, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Gerard Vreugdenhil
- Department of Internal Medicine, Maxima Medical Centre, Eindhoven, the Netherlands
| | - Willeke A. M. Blokx
- Department of Pathology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Michel J. M. Wouters
- Scientific Bureau, Dutch Institute for Clinical Auditing, Leiden, the Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, the Netherlands
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
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van Breeschoten J, Ismail RK, Wouters MW, Hilarius DL, de Wreede LC, Haanen JB, Blank CU, Aarts MJ, van den Berkmortel FW, de Groot JWB, Hospers GA, Kapiteijn E, Piersma D, van Rijn RS, Stevense-den Boer MA, van der Veldt AA, Vreugdenhil G, Boers-Sonderen MJ, Suijkerbuijk KP, van den Eertwegh AJ. End-of-Life Use of Systemic Therapy in Patients With Advanced Melanoma: A Nationwide Cohort Study. JCO Oncol Pract 2022; 18:e1611-e1620. [DOI: 10.1200/op.22.00061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE: The introduction of immune checkpoint inhibitors and targeted therapies improved the overall survival of patients with advanced melanoma. It is not known how often these costly treatments with potential serious side effects are ineffectively applied in the last phase of life. This study aimed to investigate the start of a new systemic therapy within 45 and 90 days of death in Dutch patients with advanced melanoma. METHODS: We selected patients who were diagnosed with unresectable IIIC or stage IV melanoma, registered in the Dutch Melanoma Treatment Registry, and died between 2013 and 2019. Primary outcome was the probability of starting a new systemic therapy 45 and 90 days before death. Secondary outcomes were type of systemic therapy started, grade 3/4 adverse events (AEs), and the total costs of systemic therapies. RESULTS: Between 2013 and 2019, 3,797 patients with unresectable IIIC or stage IV melanoma were entered in the registry and died. The percentage of patients receiving a new systemic therapy within 45 and 90 days before death was significantly different between Dutch melanoma centers (varying from 6% to 23% and 20% to 46%, respectively). Thirteen percent of patients (n = 146) developed grade 3/4 AEs in the last period before death. The majority of patients with an AE required hospital admission (n = 102, 69.6%). Mean total costs of systemic therapy per cohort year of the patients who received a new systemic therapy within 90 days before death were 2.3%-2.8% of the total costs spent on melanoma therapies. CONCLUSION: The minority of Dutch patients with metastatic melanoma started a new systemic therapy in the last phase of life. However, the percentages varied between Dutch melanoma centers. Financial impact of these therapies in the last phase of life is relatively small.
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Affiliation(s)
- Jesper van Breeschoten
- Dutch Institute for Clinical Auditing, Leiden, the Netherlands
- Department of Medical Oncology, Amsterdam UMC, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Rawa K. Ismail
- Dutch Institute for Clinical Auditing, Leiden, the Netherlands
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht, the Netherlands
| | - Michel W.J.M. Wouters
- Dutch Institute for Clinical Auditing, Leiden, the Netherlands
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Liesbeth C. de Wreede
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - John B. Haanen
- Department of Medical Oncology and Immunology, Netherlands Cancer Institute, Amsterdam, the Netherlands
- Division of Molecular Oncology and Immunology, Netherlands Cancer Institute, Amsterdam, the Netherlands
- Department of Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Christian U. Blank
- Department of Medical Oncology and Immunology, Netherlands Cancer Institute, Amsterdam, the Netherlands
- Division of Molecular Oncology and Immunology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Maureen J.B. Aarts
- Department of Medical Oncology, GROW School for Oncology and Developmental Biology. Maastricht University Medical Center, Maastricht, the Netherlands
| | | | | | - Geke A.P. Hospers
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Ellen Kapiteijn
- Department of Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Djura Piersma
- Department of Internal Medicine, Medisch Spectrum Twente, Enschede, the Netherlands
| | | | | | | | - Gerard Vreugdenhil
- Department of Internal Medicine, Maxima Medical Center, Eindhoven, the Netherlands
| | - Marye J. Boers-Sonderen
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Alfons J.M. van den Eertwegh
- Department of Medical Oncology, Amsterdam UMC, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, the Netherlands
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