Checkpoint Inhibitors for Non-Small Cell Lung Cancer Among Older Adults

Anthraquinones from the roots of Morinda scabrida Craib exhibit antiproliferative activity against A549 lung cancer cells and antitubulin polymerization

Six anthraquinones were isolated from Morinda scabrida Craib, an unexplored species of Morinda found in the tropical forest of Thailand. All six anthraquinones showed cytotoxicity against A549 lung cancer cells, with the most active compound, nordamnacanthal (MS01), exhibiting the IC50 value of 16.3 ± 2.5 μM. The cytotoxic effect was dose-dependent and led to cell morphological changes characteristic of apoptosis. In addition, flow cytometric analysis showed dose-dependent apoptosis induction and the G2/M phase cell cycle arrest, which was in agreement with the tubulin polymerization inhibitory activity of MS01. Molecular docking analysis illustrated the binding between MS01 and the α/β-tubulin heterodimer at the colchicine binding site, and UV-visible absorption spectroscopy revealed the DNA binding capacity of MS01.

P2X7 receptor promotes migration and invasion of non-small cell lung cancer A549 cells through the PI3K/Akt pathways

It has been demonstrated that the ATP-gated ion channel P2X7 receptor is involved in tumor progression and plays an important role in regulating tumor cell growth, invasion, migration and angiogenesis. However, P2X7 receptors have been relatively poorly studied in non-small cell lung cancer (NSCLC) cells. Therefore, the aim of this study was to investigate the effects of P2X7 receptor on A549 cells (NSCLC cell line) migration and invasion and to reveal the molecular mechanisms mediated by it. We detected the expression and function of P2X7 receptor in A549 cells. The effects and mechanisms of P2X7 receptor on A549 cells migration, invasion, and epithelial-mesenchymal transition were detected in vitro and in vivo. The results showed P2X7 receptor expressed by A549 cells had ion channel and macropore formation function. In addition, activation of P2X7 receptor by adenosine triphosphate (ATP) or 2'(3')-O-(4-Benzoylbenzoyl)-adenosine-5'-triphosphate (BzATP) promoted Epithelial-mesenchymal transition (EMT), migration and invasion of A549 cells, which was attenuated by treatment of cells with P2X7 receptor antagonist A438079 and Oxidized ATP. Furthermore, activation of P2X7 receptor increased phosphorylated protein kinase B (p-Akt) levels, and the phosphatidylinositol-tris-phosphate kinase 3 (PI3K)/protein kinase B (Akt) inhibitor LY294002 blocked migration and invasion of A549 cells induced by ATP or BzATP. At the same time, in vivo results showed that P2X7 receptor could also promote EMT and PI3K/Akt expression in transplanted tumors. Our study indicated that P2X7 receptor promotes A549 cells migration and invasion through the PI3K/Akt signaling pathway, suggesting that P2X7 receptor may be a potential therapeutic target for NSCLC.

Multi-Center Real-World Outcomes of Nivolumab Plus Ipilimumab and Chemotherapy in Patients with Metastatic Non-Small-Cell Lung Cancer

Immune checkpoint inhibitors have become the standard of care in the treatment of metastatic non-small-cell lung cancer (NSCLC). The combination of nivolumab plus ipilimumab and chemotherapy has been shown to improve outcomes in terms of overall survival (OS) and progression-free survival (PFS). The aim of this study was to evaluate the outcomes of metastatic NSCLC treated in routine practice on the treatment regimen of the CheckMate 9LA protocol. Medical records of 58 patients treated at Soroka and Bnai Zion Medical Centers between May 2020 and February 2022 were analyzed. All patients were treated with a regimen of platinum-based chemotherapy combined with immunotherapy of nivolumab every three weeks and ipilimumab every 6 weeks. The patients received 2-3 cycles of chemotherapy according to the physician's choice: platinum-based cisplatin or carboplatin with either pemetrexed or paclitaxel. The median PFS was 10.2 months, longer than that of the 9LA trial (6.7 months). Adenocarcinoma patients exhibited a higher median OS of 13.7 (range 5-33) months than squamous cell carcinoma (SCC) patients at 12.3 (5-20) months and PFS of 10.3 (4-33) months, while squamous cell carcinoma patients had a PFS of 9.2 (4-18) months. Patients whose programmed death ligand-1 (PD-L1) tumor expression level was ≥1% showed a higher median OS than those with PD-L1 expression of less than 1%. Treatment-related adverse events (TRAEs) were reported in 93.1% of patients, mostly grade 1 in severity. The first-line treatment of metastatic NSCLC patients in combination with nivolumab plus ipilimumab and chemotherapy can be given safely in routine clinical practice, with results comparable to those achieved in clinical trials of the regimen.

Long-Lasting Therapeutic Response following Treatment with Pembrolizumab in Patients with Non-Small Cell Lung Cancer: A Real-World Experience

Immune checkpoint inhibitors (ICIs), pembrolizumab in particular, have been shown to be vastly more efficacious than traditional cytotoxic or platinum-based chemotherapies in the treatment of non-small cell lung cancer (NSCLC). While there are plenty of data showing their efficacy and safety profiles, very little exists about the long-term effects of pembrolizumab. We compiled all patients with NSCLC who were treated with pembrolizumab at our institution and had progression-free survival (PFS) of at least 2 years during or after the treatment period. Within this group, we examined the long-term rates of PFS and overall survival (OS), side effect profiles, treatment, and overall disease course up to 60 months after starting treatment. This study included 36 patients with median (range) follow up times from treatment initiation in months as follows: 36 (28-65) overall; 39.5 (28-65) for adenocarcinoma; and 36 (30-58) for squamous cell carcinoma. The median (range) of OS and PFS (months) was comparable for adenocarcinoma, 36 (23-55); and squamous cell carcinoma, 35.5 (28-65). Overall, pembrolizumab shows remarkable long-term safety and efficacy in NSCLC patients. In patients who show an initially strong response and can make it to 24 months of PFS, disease progression after this period seems increasingly unlikely.

Recent Developments and Challenges in Molecular-Targeted Therapy of Non-Small-Cell Lung Cancer

Treatment of lung cancer with conventional therapies, which include radiation, surgery, and chemotherapy results in multiple undesirable adverse or side effects. The major clinical challenge in developing new drug therapies for lung cancer is resistance, which involves mutations and disturbance in various signaling pathways. Molecular abnormalities related to epidermal growth factor receptor (EGFR), v-Raf murine sarcoma viral oncogene homolog B1 (B-RAF) Kirsten rat sarcoma virus (KRAS) mutations, translocation of the anaplastic lymphoma kinase (ALK) gene, mesenchymal-epithelial transition factor (MET) amplification have been studied to overcome the resistance and to develop new therapies for non-small cell lung cancer (NSCLC). But, inevitable development of resistance presents limits the clinical benefits of various new drugs. Here, we review current progress in the development of molecularly targeted therapies, concerning six clinical biomarkers: EGFR, ALK, MET, ROS-1, KRAS, and B-RAF for NSCLC treatment.

Practical management of older adults with cancer: geriatric oncology in Japan

Japan has the highest proportion of older adults globally, and the average life expectancy of the Japanese population has increased in recent decades. Given that the incidence of cancer increases with age, it is a major health concern for older adults. However, geriatric oncology is a relatively new field and collaboration between oncologists and geriatricians in Japan is limited. Hence, oncologists and other healthcare professionals engaged in cancer care have not been able to adequately understand geriatric care, and information and experience are insufficient for this specific population. Thus, they may struggle with the assessment and management of older adults with cancer. Recently, several Japanese academic societies for cancer have developed practical guidelines and research policy with regard to geriatric research in older adults with cancer, in addition to organizing symposia and workshops focusing especially on geriatric oncology. Furthermore, because the Japan Geriatrics Society established a discipline committee on cancer, close collaboration between oncologists and geriatricians has grown steadily. Geriatric oncology is currently recognized as an important field of cancer care in Japan. The integration of oncology and geriatric care is anticipated in the near future. However, understanding the aspects of geriatric care and meanings of technical jargons used in geriatric oncology is difficult. Accordingly, this article provides an overview of the current knowledge and recent advancements in geriatric oncology. In addition, it outlines the current status and problems of geriatric oncology in Japan.

A Clinical Study on the Use of Yiqi Yangxue Decoction Combined with Chemotherapy to Promote Rapid Postoperative Recovery in Patients with Non-Small Cell Lung Cancer

Purpose. To observe the promotion effect of Yiqi Yangxue decoction combined with chemotherapy on the rapid recovery of non-small cell lung cancer (NSCLC) patients after surgery. Methods. Eighty postoperative NSCLC patients admitted to our hospital from April 2019 to September 2021 were divided into a chemotherapy group (n = 40) and a traditional Chinese medicine (TCM) group (n = 40) according to a random sampling method. Both groups were treated with surgery and postoperative routine chemotherapy. The TCM group was treated with Yiqi Yangxue decoction, one dose per day, starting from the first day of chemotherapy. Four weeks was a course of treatment, and three courses of treatment were taken continuously. The levels of serum tumour markers (carcinoembryonic antigen (CEA), cytokeratin 19 fragment (CYFRA21-1), carbohydrate antigen 125 (CA-125)), immune function indicators (CD3+, CD4+/CD8+, and NK cells), Pittsburgh Sleep Quality Index (PSQI) score, and Insomnia Severity Index (ISI) were compared between the two groups before and after treatment, and the clinical efficacy of the two groups was assessed with reference to the WHO efficacy criteria for solid tumours, and the toxic side effects of the two groups were assessed with reference to the WHO classification criteria for the toxic effects of chemotherapeutic drugs. Results. After treatment, the levels of CEA, CYFRA21-1, and CA-125 were lower than those before treatment in both groups, and they were lower in the TCM group than in the chemotherapy group ( $P<0.05$ ). After treatment, the levels of CD3+, CD4+/CD8+, and NK cells in both groups were higher than before treatment, and they were higher in the TCM group than in the chemotherapy group ( $P<0.05$ ). After treatment, the PSQI and ISI scores of both the groups were lower than those before treatment, and they were higher in the TCM group than in the chemotherapy group ( $P<0.05$ ). After treatment, the overall tumour control rate was higher in the TCM group than in the chemotherapy group ( $P<0.05$ ). During the treatment period, the TCM group showed lower levels of gastrointestinal reactions, leucopenia, anaemia, and neurotoxicity than the chemotherapy group ( $P<0.05$ ). Conclusion. The combination of Yiqi Yangxue decoction combined with chemotherapy for postoperative NSCLC patients can effectively reduce serum tumour marker levels, enhance the body’s immune function and sleep quality, and the patient’s efficacy and toxicity reduction are obvious, which is conducive to the rapid recovery of many indicators after surgery.

microRNA-1321 and microRNA-7515 contribute to the progression of non-small cell lung cancer by targeting CDC20

Cell division cycle 20 (CDC20) and microRNAs (miRNAs) are differentially expressed in non-small cell lung cancer (NSCLC). The current study aimed to investigate the role of miR-1321 and miR-7515 regulation in CDC20 during NSCLC development. CDC20 expression in paracancerous and tumor tissues was assessed using quantitative reverse transcription-polymerase chain reaction (qRT-PCR). The relationship between CDC20 expression and prognosis of patients was analyzed using the TCGA database. The expression profile of CDC20 in healthy lung cells and NSCLC cells was detected using qRT-PCR and western blotting. After the knockdown of CDC20 in NSCLC cells, the cell proliferation, apoptosis, migration, invasion, and cell cycle changes were investigated by CCK8, EdU, flow cytometry, wound healing, and Transwell assays. The miRNAs targeting CDC20 were predicted using two bioinformatics websites and validated using dual-luciferase assays. CDC20 was enhanced in NSCLC tissues and cells, thus predicting the poor prognosis in NSCLC patients. After CDC20 inhibition, the malignant phenotype of NSCLC cells was reverted. miR-1321 and miR-7515 targeted CDC20 and exhibited the same anti-tumor effects as CDC20 silencing. Functional rescue experiments showed that CDC20 overexpression averted the anti-tumor effects of miR-1321 and miR-7515 on NSCLC cells. miR-1321 and miR-7515 inhibited NSCLC development by targeting CDC20. Thus, the current study has implications in NSCLC treatment and provides novel insights into NSCLC management.

Surgical Treatment is Still Recommended for Patients Over 75 Years with IA NSCLC: A Predictive Model Based on Surveillance, Epidemiology and End Results Database

Background

To determine the populations who suitable for surgical treatment in elderly patients (age ≥ 75 y) with IA stage.

Methods

The clinical data of NSCLC patients diagnosed from 2010 to 2015 were collected from the SEER database and divided into surgery group (SG) and no-surgery groups (NSG). The confounders were balanced and differences in survival were compared between groups using PSM (Propensity score matching, PSM). Cox regression analysis was used to screen the independent factors that affect the Cancer-specific survival (CSS). The surgery group was defined as the patients who surgery-benefit and surgery-no benefit according to the median CSS of the no-surgery group, and then randomly divided into training and validation groups. A surgical benefit prediction model was constructed in the training and validation group. Finally, the model is evaluated using a variety of methods.

Results

A total of 7297 patients were included. Before PSM (SG: n = 3630; NSG: n = 3665) and after PSM (SG: n = 1725, NSG: n = 1725) confirmed that the CSS of the surgery group was longer than the no-surgery group (before PSM: 82 vs. 31 months, P < .0001; after PSM: 55 vs. 39 months, P < .0001). Independent prognostic factors included age, gender, race, marrital, tumor grade, histology, and surgery. In the surgery cohort after PSM, 1005 patients (58.27%) who survived for more than 39 months were defined as surgery beneficiaries, and the 720 patients (41.73%) were defined surgery-no beneficiaries. The surgery group was divided into training group 1207 (70%) and validation group 518 (30%). Independent prognostic factors were used to construct a prediction model. In training group (AUC = .678) and validation group (AUC = .622). Calibration curve and decision curve prove that the model has better performance.

Conclusions

This predictive model can well identify elderly patients with stage IA NSCLC who would benefit from surgery, thus providing a basis for clinical treatment decisions.

Distinctive Role of the Systemic Inflammatory Profile in Non-Small-Cell Lung Cancer Younger and Elderly Patients Treated with a PD-1 Immune Checkpoint Blockade: A Real-World Retrospective Multi-Institutional Analysis

An immune checkpoint blockade with mAbs to PD-1 and PD-L1 is an expanding therapeutic option for mNSCLC patients. This treatment strategy is based on the use of mAbs able to restore the anti-tumor activity of intratumoral T cells inhibited by PD-1 binding to PD-L1/2 on tumor and inflammatory cells. It has been speculated that a chronic status of systemic inflammation as well as the immunosenescence physiologically occurring in elderly patients may affect the efficacy of the treatment and the occurrence of irAEs. We performed a multi-institutional retrospective study aimed at evaluating the effects of these mAbs (nivolumab or atezolizumab) in 117 mNSCLC patients younger (90 cases) and older (27 cases) than 75 years in correlation with multiple inflammatory parameters (NLR, CRP, ESR, LDH and PCT). No differences were observed when the cohorts were compared in terms of the frequency of PFS, OS, inflammatory markers and immune-related adverse events (irAEs). Similarly, the occurrence of irAEs was strictly correlated with a prolonged OS survival in both groups. On the contrary, a negative correlation between the high baseline levels of inflammatory markers and OS could be demonstrated in the younger cohort only. Overall, PD-1/PD-L1-blocking mAbs were equally effective in young and elderly mNSCLC patients; however, the detrimental influence of a systemic inflammation at the baseline was only observed in young patients, suggesting different aging-related inflammation immunoregulative effects.

lncRNA cytoskeleton regulator reduces non‑small cell lung cancer radiosensitivity by downregulating miRNA‑206 and activating prothymosin α

The present study aimed to explore the role of the long noncoding RNA cytoskeleton regulator (CYTOR) in non-small cell lung cancer (NSCLC) radiosensitivity by manipulating the microRNA (miR)-206/prothymosin α (PTMA) axis. First, 58 pairs of NSCLC and paracancerous tissues, normal human lung epithelial cells and NSCLC cells were collected to analyze CYTOR expression and the relation- ship between CYTOR and NSCLC prognosis. Subsequently, CYTOR expression in radioresistant cells was assessed. Radioresistant cells with low CYTOR expression and parental cells with high CYTOR expression were established. Functional assays were then performed to assess changes in cell radiosensitivity after irradiation treatment. Subsequently, the downstream mechanism of CYTOR was explored. The binding interactions between CYTOR and miR-206 and between miR-206 and PTMA were predicted and certified. Xenograft transplantation was applied to confirm the role of CYTOR in the radiosensitivity of NSCLC. CYTOR was overexpressed in NSCLC and was associated with poor prognosis. CYTOR was further upregulated in NSCLC cells with radioresistance. CYTOR knockdown enhanced the radiosensitivity of NSCLC cells, while overexpression of CYTOR led to the opposite result. Mechanistically, CYTOR specifically bound to miR-206 and silencing CYTOR promoted miR-206 to enhance the radiosensitivity of NSCLC cells. PTMA is a target of miR-206 and silencing CYTOR inhibited PTMA expression via miR-206, thus promoting radiosensitivity of NSCLC cells. CYTOR knockdown also enhanced NSCLC cell radiosensitivity in vivo. CYTOR was highly expressed in NSCLC, while silencing CYTOR potentiated NSCLC cell radiosensitivity by upregulating miR-206 and suppressing PTMA. The present study preliminarily revealed the role of CYTOR in radiotherapy sensitivity of NSCLC and provided a novel potential target for the clinical treatment of NSCLC.

Pembrolizumab for Unresectable or Metastatic Melanoma in Patients Older than 85 Years of Age

Background: Programmed cell death protein-1 (PD-1) inhibitors (pembrolizumab and nivolumab) have been approved for the treatment of advanced melanoma. Over the past decades, patients older than 85 years represent an expanding group of patients in developed countries. In France, 25% of melanomas are diagnosed in patients older than 75 years. Objective: To perform a monocentric retrospective study of patients older than 85 years and treated with pembrolizu­mab for unresectable or metastatic melanoma in order to evaluate tolerance and potential benefits of this immunotherapy. Methods: Medical records of patients treated with the PD-1 inhibitor pembrolizumab between January 2015 and January 2018 were reviewed. Results: Nine patients (6 women and 3 men) older than 85 years were included in the study. The mean age was 89.6 (85–97) years at inclusion. All patients were PS 0 or 1. The mean number of infusions was 4 (1–12). However, most patients were not able to tolerate the 4-infusion schedule. One patient refused the second infusion for personal reasons. Seven patients had grade 3 or 4 treatment-related adverse events. Conclusion: These results indicate that pembrolizumab treatment in patients older than 85 years may induce responses but is associated with a high risk of toxicity and impaired autonomy.

Immunotherapy in Older Adults With Advanced Cancers: Implications for Clinical Decision-Making and Future Research

Immunotherapy has expanded the therapeutic landscape for advanced cancers, including solid tumors and lymphomas. For many patients with cancer, these agents have been shown to have substantial efficacy and favorable toxicity compared with cytotoxic agents, particularly in the second-line setting. With the advent of anti-PD-1 and anti-PD-L1 checkpoint inhibitors, combination immunotherapy- and chemoimmunotherapy-based strategies have emerged as promising novel regimens to improve cancer-related outcomes. Older adults age 65 or older represent the growing majority of patients diagnosed with cancer. However, older adults are under-represented in clinical trials in general, as well as in the landmark studies that led to approval of these immunotherapy agents. Because of increasing age and attendant multimorbidity and impaired functional status, many of these patients seen in the community-based oncology practices would not have been considered eligible for such studies. Thus, the results of these studies are difficult to generalize to a broader patient population with these competing risks. Furthermore, robust evaluation of toxicities, effect on quality of life and functional status, and aging-related (i.e., immunosenescence) and immunotherapy-related changes affecting the immune system remain underexplored research areas for older adults. This review examines the role of immunotherapy and its unique issues, specifically in older adults with lung cancer, bladder cancer, and lymphomas.

Speed of Adoption of Immune Checkpoint Inhibitors of Programmed Cell Death 1 Protein and Comparison of Patient Ages in Clinical Practice vs Pivotal Clinical Trials

Importance

The US Food and Drug Administration (FDA) is increasing its pace of approvals for novel cancer therapeutics, including for immune checkpoint inhibitors of programmed cell death 1 protein (anti-PD-1 agents). However, little is known about how quickly anti-PD-1 agents agents reach eligible patients in practice or whether such patients differ from those studied in clinical trials that lead to FDA approval (pivotal clinical trials).

Objectives

To assess the speed with which anti-PD-1 agents agents reached eligible patients in practice and to compare the ages of patients treated in clinical practice with the ages of those treated in pivotal clinical trials.

Design, Setting, and Participants

This retrospective cohort study, performed from January 1, 2011, through August 31, 2016, included patients from the Flatiron Health Network who were eligible for anti-PD-1 agents treatment of selected cancer types, which included melanoma, non-small cell lung cancer (NSCLC), and renal cell carcinoma (RCC).

Main Outcomes and Measures

Cumulative proportions of eligible patients receiving anti-PD-1 agents treatment and their age distributions.

Results

The study identified 3089 patients who were eligible for anti-PD-1 agents treatment (median age, 66 [interquartile range, 56-75] years for patients with melanoma, 66 [interquartile range, 58-72] years for patients with RCC, and 67 [interquartile range, 59-74] years for patients with NSCLC; 1742 male [56.4%] and 1347 [43.6%] female; 2066 [66.9%] white). Of these patients, 2123 (68.7%) received anti-PD-1 agents treatment, including 439 eligible patients with melanoma (79.1%), 1417 eligible patients with NSCLC (65.6%), and 267 eligible patients with RCC (71.2%). Within 4 months after FDA approval, greater than 60% of eligible patients in each cohort had received anti-PD-1 agents treatment. Overall, similar proportions of older and younger patients received anti-PD-1 agents treatment during the first 9 months after FDA approval. However, there were significant differences in age between clinical trial participants and patients receiving anti-PD-1 agents treatment in clinical practice, with more patients being older than 65 years in clinical practice (range, 327 of 1365 [60.6%] to 46 of 72 [63.9%]) than in pivotal clinical trials (range, 38 of 120 [31.7%] to 223 of 544 [41.0%]; all P < .001).

Conclusions and Relevance

Anti-PD-1 agents rapidly reached patients in clinical practice, and patients treated in clinical practice differed significantly from patients treated in pivotal clinical trials. Future actions are needed to ensure that rapid adoption occurs on the basis of representative trial evidence.

Checkpoint blockade in solid tumors and B-cell malignancies, with special consideration of the role of CD200

In the ontogeny of a normal immune response, a series of checkpoints must be overcome to ensure that unwanted and/or harmful self-directed activation responses are avoided. Many of the molecules now known to be active in this overseeing of the evolving immune activation cascade, contributing inhibitory signals to dampen an overexuberant response, belong to the immunoglobulin supergene family. These include members of the CD28/CTLA-4:B7.1/B7.2 receptor/ligand family, PD-1 and PDL-1, CD200 and CD200R, and the more recently described V-domain immunoglobulin suppressor of T-cell activation and its ligand (VSIG-3/IGSF11). Unfortunately, from the point of view of improving immunotargeting of cancer cells, triggering these checkpoint inhibitory signaling pathways, so necessary to maintain self-tolerance, simultaneously acts to prevent effective tumor immunity. The recent development of reagents, predominantly antibodies, to act as checkpoint blockade agents, has had a dramatic effect on human cancer treatment, with a marked reported success for anti-CTLA-4 and PD-1 in particular in clinical trials. This review provides a general overview of the data now available showing the promise of such treatments to our cancer armamentarium and elaborates in depth on the potential promise of what can be regarded as an underappreciated target molecule for checkpoint blockade in chronic lymphocytic leukemia and solid tumors, CD200.