Real-world effectiveness of third- or later-line treatment in Japanese patients with HER2-positive, unresectable, recurrent or metastatic gastric cancer: a retrospective observational study

Prognostic value of the pretreatment Glasgow prognostic score or modified Glasgow prognostic score in patients with advanced cancer receiving immune checkpoint inhibitors: A systematic review and meta‑analysis

The Glasgow prognostic score (GPS) and modified GPS (mGPS) have value in evaluating the prognosis of patients receiving immune checkpoint inhibitors (ICIs). However, with the continuous emergence of new research, the predictive value of GPS and mGPS for immunotherapy deserves further validation. The aim of the present study was to explore the predictive value of GPS or mGPS on the progression-free survival (PFS) and overall survival (OS) of patients with advanced cancer receiving ICIs. Eligible studies were systematically searched using the PubMed, Embase, Cochrane library and Web of Science databases until November 2022. Published data were extracted and the hazard ratios (HRs) with 95% confidence intervals (CIs) were pooled. A total of 18 studies with 1,355 patients were included in the present study. Patients were divided into the low GPS/mGPS (0) and high GPS/mGPS (1/2/1-2) groups. Overall, the high GPS group had a shorter OS (HR, 2.88; 95% CI, 2.06-4.03) with high heterogeneity, and a shorter PFS (HR, 2.08; 95% CI, 1.55-2.78) with low heterogeneity, compared with the low GPS group. Sensitivity analysis showed that the results were stable and the heterogeneity was significantly reduced from 56.4 to 30.3% after excluding one study. Subgroup analyses by score showed that GPS 1, GPS 2 and GPS 1-2 all had a poorer OS than GPS 0, with low heterogeneity. Overall, the high mGPS group had a poorer OS (HR, 2.56; 95% CI, 1.76-3.72) with low heterogeneity, and a poorer PFS (HR, 2.55; 95% CI, 1.81-3.60) with high heterogeneity, compared with the low mGPS group. The combined effect size was consistent but the heterogeneity was not eliminated after sensitivity analysis. Subgroup analyses by country and score also showed that the country had no effect on the results and that mGPS 1, mGPS 2 and mGPS 1-2 had a poorer PFS than mGPS 0. Therefore, high GPS and mGPS may be effective biomarkers for predicting the survival of patients with cancer receiving ICIs. Patients with high GPS and mGPS may be considered for supportive treatment; however, large prospective trials are needed to validate these findings.

Baseline (modified) Glasgow prognostic score as a predictor of therapeutic response to immune checkpoint inhibitors in solid tumors: A systematic review and meta‑analysis

A systemic analysis was performed to evaluate the prognostic utility of the Glasgow prognostic score (GPS) and the modified (m)GPS in cancer patients treated with immune checkpoint inhibitors (ICI). The PubMed, Cochrane Library, EMBASE and Google Scholar databases were searched for entries added until May 1st, 2023, to obtain relevant articles for this study. The analysis examined several clinical outcomes, including overall survival (OS), progression-free survival (PFS), objective response rate and disease control rate (DCR). In this analysis, a total of 38 articles with 3,772 patients were included. The pooled results indicated that patients with high GPS levels had shorter OS [GPS 2 vs. 0, hazard ratio (HR): 4.35, P<0.001; GPS 1 vs. 0, HR: 2.00, P<0.001; GPS 2 vs. 1/0, HR: 2.62, P<0.001; GPS 2/1 vs. 0, HR: 2.60, P<0.001) and PFS (GPS 2 vs. 0, HR: 2.11, P=0.001; GPS 1 vs. 0, HR: 1.33, P=0.001; GPS 2 vs. 1/0, HR: 2.11, P<0.001; GPS 2/1 vs. 0, HR: 1.62, P<0.001], as well as a lower DCR [GPS 2 vs. 1/0, odds ratio (OR): 0.53, P<0.001, GPS 2/1 vs. 0, OR: 0.51, P<0.001]. It was also found that patients with high mGPS levels had poorer OS (mGPS 2 vs. 0, HR: 3.15, P<0.001; mGPS 1 vs. 0, HR: 1.70, P<0.001; mGPS 2 vs. 1/0, HR: 1.95, P=0.049; mGPS 2/1 vs. 0, HR: 3.14, P=0.041; continuous variables, HR: 1.52, P<0.001) and PFS (mGPS 2 vs. 0, HR: 2.70, P<0.001; mGPS 1 vs. 0, HR: 1.74, P=0.016; mGPS 2 vs. 1/0, HR: 1.91, P=0.044; continuous variables, HR: 1.29, P<0.001), and lower DCR (mGPS 2 vs. 1/0, HR: 0.46, P<0.001). In conclusion, the GPS and mGPS were reliable predictors of outcomes in cancer patients treated with ICIs.

Baseline (derived) neutrophil-lymphocyte ratio associated with survival in gastroesophageal junction or gastric cancer treated with ICIs

Objective

We carried out the meta-analysis to determine the predictive value of baseline neutrophil to lymphocyte ratio (NLR) and derived neutrophil to lymphocyte ratio (dNLR) levels in patients with gastroesophageal junction or gastric cancer (GJGC) who underwent immune checkpoint inhibitor (ICI) treatment.

Methods

Eligible articles were obtained through PubMed, the Cochrane Library, EMBASE, and Google Scholar, until April 15, 2023. The clinical outcomes evaluated in this study encompassed overall survival (OS), progression-free survival (PFS), objective response rate (ORR), and disease control rate (DCR).

Results

A total of 24 articles with 2221 patients were included in this meta-analysis. The pooled results demonstrated that patients with high NLR levels had significantly poorer OS (HR: 1.860, 95% CI: 1.564-2.213, p < 0.001) and PFS (HR: 1.678, 95% CI: 1.354-2.079, p < 0.001), and lower ORR (OR: 0.754, 95% CI: 0.621-0.915, p = 0.004) and DCR (OR: 0.391, 95% CI: 0.262-0.582, p < 0.001). Besides, we also found that high dNLR levels were significantly associated with shorter OS (HR: 2.117, 95% CI: 1.590-2.820, p < 0.001) and PFS (HR: 1.803, 95% CI: 1.415-2.297, p < 0.001).

Conclusion

Low baseline (Derived) NLR has the potential to predict the good efficacy of ICIs and survival outcomes in patients with GJGC. (Derived) NLR could be useful in determining the optimal treatment strategies for these patients.

Pretreatment neutrophil-to-lymphocyte ratio is associated with immunotherapy efficacy in patients with advanced cancer: a systematic review and meta-analysis

This study aimed to systematically investigate the value of the pre-treatment neutrophil-to-lymphocyte ratio (NLR) in prognosticating the outcome of patients with advanced cancer receiving immunotherapy. We searched Embase, PubMed, Web of Science, and Cochrane Library to identify studies about cancer patients with immunotherapy until November 29, 2024. Retrospective or prospective cohort studies with pretreatment NLR data were included. The odds ratio (OR) and 95% confidence interval (CI) were calculated to evaluate the predictive value of NLR in prognosis and immunotherapy efficacy. The random effect model was applied for meta-analysis and the risk of bias was assessed by Egger test and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) method. A total of 129 articles involving 18780 cases were finally selected. Most cases were advanced cancers with the median follow-up period ranged 2-48.6 months. The high pretreatment NLR level was associated with the significantly reduced OS (HR (95%CI) = 2.26 (2.03, 2.53)), PFS (HR (95% CI) = 1.83 (1.69, 1.98)), ORR (OR (95%CI) = 0.53 (0.46, 0.61)) and DCR (OR (95% CI) = 0.36 (0.29, 0.43)) in patients with advanced cancer receiving immunotherapy. The quality of evidence was low, attributed to the serious risk of bias and incon¬sistency. An elevated NLR before immunotherapy was significantly associated with poor clinical outcomes in patients with advanced cancer.

Real-world effectiveness and safety of trastuzumab-deruxtecan in Japanese patients with HER2-positive advanced gastric cancer (EN-DEAVOR study)

BACKGROUND

Trastuzumab-deruxtecan (T-DXd) was approved for the treatment of HER2-positive patients with advanced gastric cancer in Japan based on the results of the DESTINY-Gastric01 trial. This study aimed to collect real-world data and evaluate the effectiveness and safety of T-DXd.

METHODS

Patients aged ≥ 20 years at the start of T-DXd administration with a histopathologically confirmed diagnosis of HER2-positive unresectable advanced or recurrent gastric or gastroesophageal junction (GEJ) adenocarcinoma that had worsened after chemotherapy were enrolled in this retrospective cohort study. Key outcomes included T-DXd treatment status, overall survival (OS), real-world progression-free survival (rwPFS), time to treatment failure (TTF), objective response rate and frequency of grade ≥ 3 adverse events (AEs).

RESULTS

Of the 312 patients included in the analysis, 75.3% were male, the median (range) age was 70.0 (27.0-89.0) years, 12.2% had an ECOG PS ≥ 2, 43.3% had ascites and the initial T-DXd dose was > 5.4- ≤ 6.4 mg/kg in 78.2% of patients. The median (95% confidence interval) OS, rwPFS and TTF (months) was 8.9 (8.0-11.0), 4.6 (4.0-5.1) and 3.9 (3.4-4.2), respectively. The response rate was 42.9% in patients with a target lesion. In total, 48.4% of patients experienced a grade ≥ 3 AE, 2.6% experienced grade 5 AEs and 60.9% experienced AEs leading to T-DXd dose adjustments (reduction: 36.9%, interruption: 34.0% or discontinuation: 23.7%). No new safety signals were detected.

CONCLUSIONS

T-DXd was effective and had a manageable safety profile as a third- or later-line treatment for patients with HER2-positive gastric or GEJ cancer in Japanese clinical practice.

CLINICAL TRIAL REGISTRATION

UMIN000049032.

Role of immunotherapy in gastroesophageal cancer with liver metastasis

The role of immune checkpoint inhibitors for patients with gastroesophageal cancer with liver metastasis remains unclear. Our objective was to investigate whether immune checkpoint inhibitors are beneficial in patients with gastroesophageal cancer with liver metastasis. We searched PubMed, Embase, European Society for Medical Oncology, and American Society of Clinical Oncology meeting abstracts for phase 3 randomized clinical trials testing immune checkpoint inhibitors in metastatic/advanced gastroesophageal cancer from 2017 to 2023. Seven studies were included. Overall survival was similar among all patients (hazard ratio [HR] = 0.72 [95% confidence interval (CI) = 0.67 to 0.77], P < .001), in patients without liver metastases (HR = 0.73 [95% CI = 0.67 to 0.81], P < .001, I2 = 0.0%), and in patients with liver metastases (HR = 0.74 [95% CI = 0.67 to 0.81], P < .001, I2 = 0.0%). Progression-free survival was also similar among all patients (HR = 0.63 [95% CI = 0.57 to 0.70], P < .001), in patients without liver metastases (HR = 0.62 [95% CI = 0.51 to 0.76], P < .001), and in patients with liver metastases (HR = 0.66 [95% CI = 0.57 to 0.76], P < .001). Immune checkpoint inhibitors showed no difference in benefit in patients with gastroesophageal cancer, regardless of liver metastasis. Future studies could focus on deciphering the tumor microenvironment of liver metastasis as an area of translational research.

Real-world outcomes of third-line immune checkpoint inhibitors versus irinotecan-based chemotherapy in patients with advanced gastric cancer: a Korean, multicenter study (KCSG ST22-06)

BACKGROUND

Immune checkpoint inhibitor (ICI) or irinotecan-based chemotherapy is frequently used after failure of second-line paclitaxel plus ramucirumab treatment for patients with locally advanced unresectable or metastatic advanced gastric cancer (AGC). This study aimed to compare the efficacy between ICI and irinotecan-based chemotherapy as third-line treatment in patients with AGC.

METHODS

We retrospectively reviewed patients with AGC, whose third-line treatment started between July 2019 and June 2021 at 17 institutions in Korea. The ICI group included patients who received nivolumab or pembrolizumab, and the irinotecan-based chemotherapy group included patients who received irinotecan or FOLFIRI (5-fluorouracil, leucovorin and irinotecan).

RESULTS

A total of 363 patients [n = 129 (ICI) and n = 234 (irinotecan-based chemotherapy)] were analyzed. The median progression-free survival was 2.3 and 2.9 months in ICI and irinotecan-based chemotherapy groups, respectively (p = 0.802). The median overall survival (OS) was 5.5 and 6.0 months in ICI and irinotecan-based chemotherapy groups, respectively (p = 0.786). For all patients included in this study, multivariable analysis showed that weight loss, peritoneal metastasis, low serum sodium or albumin, and short duration of second-line treatment were associated with inferior OS (p < 0.05). ICI showed significantly longer OS than irinotecan-based chemotherapy in patients without peritoneal metastasis. Whereas ICI showed significantly shorter OS in patients without PD-L1 expression than irinotecan-based chemotherapy.

CONCLUSIONS

No significant difference in survival outcome was observed between ICI and irinotecan-based chemotherapy as third-line treatment for AGC patients. ICI might be preferred for patients without peritoneal metastasis and irinotecan-based chemotherapy for patients with tumors without PD-L1 expression.

TRIAL REGISTRATION

This study was registered in the Clinical Trial Registry of Korea ( https://cris.nih.go.kr : KCT 0007732).

Impact of Patient Characteristics on the Outcomes of Patients with Gastrointestinal Cancers Treated with Immune Checkpoint Inhibitors

Gastrointestinal (GI) cancers are a group of malignancies that globally account for a significant portion of cancer incidence and cancer-related death. Survival outcomes for esophageal, gastric, pancreatic, and hepatobiliary cancers remain poor, but new treatment paradigms are emerging with the advent of immune checkpoint inhibitor (ICI) therapy. This review characterizes patient-related prognostic factors that influence the response to ICI therapy. We performed an analysis of the landmark randomized clinical trials in esophageal, gastric, colorectal, hepatocellular, pancreatic, and biliary tract cancers in terms of patient demographic factors. A literature review of smaller retrospective studies investigating patient-related factors was completed. The immunological bases for these associations were further explored. The key predictive factors identified include age, sex, performance status, geography, body mass index, sarcopenia, gut microbiome, various biochemical factors, and disease distribution.

Prognostic value of neutrophil to lymphocyte ratio in gastric cancer patients receiving immune checkpoint inhibitors: a systematic review and meta-analysis

Background

The neutrophil to lymphocyte ratio (NLR) is a cost-effective and easily identifiable inflammatory biomarker that has been shown to be closely associated with tumor prognosis and predict survival in patients with multiple malignancies. However, the predictive value of NLR in patients with gastric cancer (GC) treated with immune checkpoint inhibitors (ICIs) has not been fully explored. Therefore, we conducted a meta-analysis to explore the potential of NLR as a predictor of survival in this population.

Methods

We systematically searched the PubMed, Cochrane Library, and EMBASE databases from inception to the present for observational researches on NLR and its relationship with progression or survival in GC patients receiving ICIs. To assess the prognostic significance of NLR on overall survival (OS) or progression-free survival (PFS), we used fixed or random-effect models to derive and combine hazard ratios (HRs) with 95% confidence intervals (CIs). We also examined the relationship between NLR and treatment efficacy by calculating relative risks (RRs) with 95% CIs for objective response rate (ORR) and disease control rate (DCR) in patients with GC receiving ICIs.

Results

Nine studies of 806 patients were eligible. OS and PFS data were obtained from 9 and 5 studies, respectively. In nine studies, NLR was associated with poor survival, the pooled HR was 1.98 (95% CI 1.67- 2.35, p < 0.001), indicating a significant association between high NLR and worse OS. We conducted subgroup analyses based on study characteristics to confirm the robustness of our findings. A relationship between NLR and PFS were reported in five studies with a HR of 1.49 (95% CI 0.99- 2.23, p = 0.056), which was not significantly associated. Pooling four studies that examined the correlation between NLR and ORR/DCR in GC patients, we observed a significant correlation between NLR and ORR (RR = 0.51, p = 0.003), but no significant correlation between NLR and DCR (RR = 0.48, p = 0.111).

Conclusion

In summary, this meta-analysis indicates that increased NLR is significantly linked to worse OS in patients with GC receiving ICIs. In addition, lowering NLR can improve ORR. Thus, NLR can serve as a predictor for prognosis and treatment response in GC patients treated with ICIs. Nevertheless, further high-quality prospective studies are required to verify our findings in the future.

Apatinib as a Third-Line Treatment for HER2-Positive Metastatic Gastric Cancer: A Multi-Center Single-Arm Cohort Study

PURPOSE

Treatment options are limited after the failure of first-and second-line treatments in patients with HER2⁺ metastatic gastric cancer (mGC). The present study aimed to explore the efficacy, safety, and prognostic factors of apatinib efficacy as a third-line therapy for patients with human epithelial growth factor receptor 2-positive (HER2⁺) mGC.

MATERIALS AND METHODS

A total of 59 HER2⁺ mGC patients who received apatinib as third-line therapy were retrospectively enrolled in this two-center, single-arm, cohort study; the clinical response, survival data, and adverse events were retrieved.

RESULTS

The median progression-free survival (PFS) was 5.2 months (95% confidence interval [CI], 3.9-6.5), and the median overall survival (OS) was 8.2 months (95% CI, 6.6-9.8) Furthermore, forward stepwise multivariate Cox regression analysis showed that a higher Eastern Cooperative Oncology Group performance status score and multiple metastases were independently correlated with decreased PFS and OS (both P<0.05). The main adverse events were leukopenia (45.8%), hypertension (44.1%), thrombocytopenia (39.0%), hand-foot syndrome (37.3%), and elevated transaminase (33.9%). Grade 3 adverse events mainly included hypertension (5.1%) and neutropenia (5.1%); grade 4 adverse events did not occur.

CONCLUSIONS

Apatinib is efficient and well tolerated in patients with HER2⁺ mGC as a third-line treatment, suggesting that it may be a candidate of choice for these patients.