Efficacy and safety of immune checkpoint inhibitors in patients with non-small cell lung cancer aged 80 years or older

Incidence Rates of Cutaneous Immune-Related Adverse Events in Patients with Lung Cancer: A Systematic Review and Meta-Analysis

OBJECTIVE

Cutaneous immune-related adverse events (cirAEs) represent a prevalent manifestation of adverse reactions linked to immune checkpoint inhibitors (ICIs) therapy, substantially affecting patients' quality of life. This systematic review and meta-analysis aimed to quantify the pooled incidence of cirAEs in this population and strengthen clinical awareness for early recognition and management.

METHODS

A comprehensive search of PubMed, Embase, CINAHL, Cochrane Library, CBM, CNKI, and Wanfang databases was conducted from inception to December 2022. Literature that reported the incidence of cirAEs in patients with lung cancer receiving ICIs therapy was included. A meta-analysis was conducted using R software, version 4.4.1 to estimate the pooled incidence of cirAEs, and a random-effects model was used for data synthesis. Begg's rank correlation and funnel plots were used to assess publication bias.

RESULTS

A total of 99 articles involving 23,814 patients with lung cancer receiving ICIs therapy were included, with publication dates ranging from 2012 to 2022. The meta-analysis results reveal that the incidence of cirAEs in patients with lung cancer was 20.26% (95% confidence interval [CI (17.12-23.81)]. Significant differences were observed between all subgroups, including continent, study type, combination therapy, dual ICIs therapy, and diagnostic criteria for cirAEs for Grade 1-2 and Grade 3-4 incidences.

CONCLUSIONS

The incidence of cirAEs in patients with lung cancer is relatively high, particularly undergoing combined or dual ICIs therapy. To comprehensively characterize cirAEs in patients with lung cancer, large-scale multicenter studies integrating real-world pharmacovigilance data are warranted to establish precise incidence estimates and identify clinically significant risk factors.

IMPLICATIONS FOR CLINICAL PRACTICE

This review's insights aroused clinical staff's attention and concern about cirAEs, potentially enhancing the quality of life of patients with cancer.

The Impact of Immune-Related Adverse Event Severity on Prognosis in Elderly Patients With Nonsmall-Cell Lung Cancer in First-Line Immune Checkpoint Inhibitor Treatment

BACKGROUND

Recently, the treatment needs of elderly lung cancer patients have become comparable with those of younger patients. This study evaluated the efficacy and safety of first-line immune checkpoint inhibitors (ICI) in elderly patients with nonsmall-cell lung cancer (NSCLC), stratified by immune-related adverse events (irAEs) severity, and identified key prognostic factors.

METHODS

This retrospective study targeted patients with advanced or recurrent NSCLC who received ICI therapy as first-line treatment between April 2017 and March 2023.

RESULT

Of the 138 patients enrolled in this study, 81 and 57 patients were classified into the elderly (aged 70 and above) and nonelderly (under 70 years old) groups, respectively. Severe irAEs were significantly associated with shorter overall survival (OS) in the elderly group (severe irAEs vs. others, 9.9 vs. 24.7 months; p = 0.043) and favorable OS in nonelderly group (severe irAEs vs. others, NR [not reached] vs. 21.0 months, p = 0.026). The OS of patients with severe irAEs was significantly worse in the elderly group than in the nonelderly group (elderly group vs. nonelderly group, 9.9 vs. NR months, p = 0.001). In the multivariate analysis, mild irAEs were associated with a favorable prognosis in elderly patients (hazard ratio, 0.446; p = 0.032).

CONCLUSION

Severe irAEs demonstrated different outcomes in elderly and nonelderly patients. Contrastingly, mild irAEs were associated with a favorable prognosis in elderly patients, emphasizing the need for appropriate patient selection, early intervention for irAEs and new tools to accurately predict irAE severity in elderly patients.

Real-World Efficacy and Safety of Atezolizumab for Advanced Non-Small Cell Lung Cancer in Japan: A Retrospective Multicenter Analysis

Background/Objectives: Atezolizumab, an immune checkpoint inhibitor (ICI), was used in a phase III clinical trial, i.e., the OAK trial, of previously treated patients with non-small cell lung cancer. We aimed to evaluate the real-world efficacy and safety of atezolizumab in a non-selected population and identify the clinical characteristics that influence its efficacy. Methods: This was a multicenter, retrospective, single-arm observational study. Seventy-four patients with advanced non-small cell lung cancer, who received atezolizumab monotherapy at Keio University and affiliated hospitals in Japan between April 2018 and March 2019, were enrolled. The follow-up period was until 28 February 2024. The efficacy of treatment and adverse events were reviewed retrospectively. Statistical analyses using Pearson's χ2 test, Fisher's exact test, log-rank test, and Student's t-test were performed. Results: The median age of patients was 70 (range, 45-85) years. The overall survival duration was 7.54 (95% confidence interval [CI], 5.14-11.3) months, and the median time to treatment failure (TTF) was 2.00 (95% CI, 1.75-2.54) months. Patients treated with atezolizumab as their first ICI had a longer TTF than those treated with atezolizumab as their second or subsequent ICI (p = 0.04). Conclusions: Atezolizumab may be more effective when used as the first ICI for previously treated patients and may be safely used in elderly patients with non-small cell lung cancer in real-world settings.

Bone marrow biopsy in geriatric patients above the age of 85 years: invaluable or unnecessary? A retrospective analysis

Bone marrow biopsy (BMB) is a well-established diagnostic tool for various hematological, oncological, and other medical conditions. However, treatment options for geriatric patients (pts) facing these diseases are often constrained. In this single-center, retrospective analysis we assessed the diagnostic value of BMB in geriatric pts aged ≥ 85 years and examined its impact on therapeutic decisions. We examined 156 BMB procedures in 129 pts, extracting data from the electronic patient records and applying descriptive statistical methods. Nearly half of the primary diagnostic procedures (26; 44.1%) resulted in a modification of the initially suspected diagnosis. Notably, 15 (25.4%) of these procedures, led to changes in both the diagnosis and planned interventional treatment. Among the 15 follow-up procedures (36.6%), disease progression was initially suspected based on symptoms, but BMB results excluded such progression. In lymphoma staging biopsies, only 2 (3.6%) prompted a change in therapeutic intervention. Importantly, no BMB-related complications, such as bleeding, infection or nerve damage, were reported. Median survival after BMB was 16.1 months across all pts, yet it varied based on the diagnosis and comorbidity score. The survival of pts with a change in therapy based on BMB results did not significantly differ from those who did not undergo a therapy change. In conclusion, BMB proved to be generally safe and beneficial in this geriatric cancer patient cohort beyond the age of 85 years. However, the advantages of lymphoma staging in this patient population warrant further consideration.

Safety of flexible bronchoscopy and clinical course for elderly patients with suspected primary lung cancer

BACKGROUND

There have been several reports demonstrating the safety of flexible bronchoscopy (FB) in the elderly, but none have focused specifically on lung cancer, which is a frequent biopsy procedure.

METHODS

In this study, we retrospectively evaluated the safety of FB and subsequent treatment in elderly patients with suspected primary lung cancer. Elderly patients were defined as 75 years of age or older.

RESULTS

A total of 141 patients, 77 in the elderly group and 64 in the nonelderly group, were reviewed. The median age of the elderly group was 80 years. Transbronchial lung biopsy was performed in more than 80% of all patients. Primary lung cancer was diagnosed in 42 (54.4%) of the elderly group and 35 (54.7%) of the nonelderly group (p = 0.38). Approximately 70% of the elderly patients with a confirmed diagnosis were treated, while more than half of the undiagnosed elderly patients had best supportive care. Complications such as bleeding, pneumothorax, fever, and pneumonia were similar in the elderly and nonelderly groups.

CONCLUSIONS

This study suggests that flexible bronchoscopy can be performed as safely in the elderly as in the nonelderly. Furthermore, even elderly patients may have a greater chance of receiving treatment when a definitive diagnosis is achieved.

Safety and Efficacy of Flexible Bronchoscopy in Elderly Patients: A Retrospective Comparative Study

Background

Flexible bronchoscopy (FB) is a common method used for diagnostic sampling of the thorax. Although the safety and efficacy of FB in the general population are well-established, data on the elderly population are limited. This study aimed to determine the safety and efficacy of FB in elderly people aged ≥80 years.

Materials and Methods

We retrospectively studied elderly patients aged ≥80 years who underwent FB at our hospital between April 2021 and March 2022. Outcomes, such as indications, sampling methods, diagnostic results, and complications, were compared with those of a control group of patients aged 18-79 years.

Results

In total, 247 patients (154 men) were included in the study, with 65 and 182 patients in the elderly and non-elderly groups, respectively. The most frequent indication for FB was the presence of a mass or nodule, with transbronchial lung biopsy, transbronchial biopsy, and endobronchial ultrasound-guided transbronchial needle aspiration performed in 162 (65.6%), 29 (11.7%), and 36 (15.6%) patients, respectively. FB led to a diagnosis in 36 (57.1%) and 103 (56%) patients in the elderly and non-elderly groups, respectively, with no significant difference observed. There were no patient deaths or significant differences in the incidence of hemorrhage, hypoxia, pneumothorax, fever, or pneumonia between the two groups.

Conclusions

The findings of this study indicate that FB can be performed effectively and safely in elderly patients aged ≥80 years, similar to non-elderly patients.

Impact of Patient Age on Clinical Efficacy and Toxicity of Checkpoint Inhibitor Therapy

The addition of immune checkpoint inhibitors (ICIs) to the therapeutic armamentarium for solid malignancies has resulted in unprecedented improvements in patient outcomes in many cancers. The landscape of ICIs continues to evolve with novel approaches such as dual immune checkpoint blockade and combination therapies with other anticancer agents including cytotoxic chemotherapies and/or antiangiogenics. However, there is significant heterogeneity seen in antitumor responses, with certain patients deriving durable benefit, others experiencing initial benefit followed by acquired resistance necessitating change in therapy, and still others who are primarily refractory to ICIs. While generally better tolerated than traditional cytotoxic chemotherapy, ICIs are associated with unique toxicities, termed immune-related adverse events (irAEs), which can be severe or even lethal. As a disease of aging, older individuals make up a large proportion of patients diagnosed with cancer, yet this population is often underrepresented in clinical trials. Because ICIs indirectly target malignant cells through T cell activation, it has been hypothesized that age-related changes to the immune system may impact the efficacy and toxicity of these drugs. In this review, we discuss differences in the clinical efficacy and toxicity of ICIs in patients at the extremes of age.