Comparative Effectiveness of Pemetrexed-platinum Doublet Chemotherapy With or Without Bevacizumab as First-line Therapy for Treatment-naive Patients With Advanced Nonsquamous Non-small-cell Lung Cancer in China

The Use of Real-World Evidence for Regulatory Decisions in China

There is a growing demand for the use of high-quality real-world evidence (RWE) to support regulatory decision-making worldwide and in China, which highlights the need for conducting literature reviews to evaluate the available data and evidence. This study aims to review the use of RWE in Chinese regulatory decisions and to summarize relevant regulatory and methodological considerations to inform the future use of RWE in China. We identified policy documents, technical guidance documents, and cases on official Chinese government websites and extracted their contents separately. We consulted experts from the National Medical Products Administration (NMPA) and academic institutes and searched case-related articles for enrichment. We also searched and included articles related to the use of RWE/Real-world data in Chinese regulatory decisions. Six trial versions of technical guidance documents, 7 case studies, and 40 articles related to the Chinese regulatory decisions were included in this study. Based on the technical guidance, data quality, and appropriate study design and statistical analysis are the main concerns for RWE generation. The cases and articles related to regulatory decisions revealed 9 main concerns, including data sources and applicability, data quality, strength of existing evidence, appropriate study design and statistical analysis, regulated and transparent process for analysis and evidence generation, product safety and efficacy, product characteristics and clinical needs, ethical considerations and data security, and communicate adequately with regulatory authorities. Among these concerns, data issues are central. Preliminary attempts have been made by the NMPA to promote the use of RWE, but substantial challenges still remain.

PD-1 inhibitor versus bevacizumab in combination with platinum-based chemotherapy for first-line treatment of advanced lung adenocarcinoma: A retrospective-real world study

BACKGROUND

Chemotherapy combined with immunotherapy or anti-vascular therapy is both recommended by guidelines for first-line treatment of lung adenocarcinoma. However, no head-to-head clinical trial has ever compared which strategy is the optimal choice. This real-world retrospective study was done to compare the efficacy and treatment-related adverse events of immunotherapy and bevacizumab in combination with chemotherapy.

PATIENTS AND METHODS

From January 2018 to March 2021, we retrospectively collected 276 patients with advanced lung adenocarcinoma managed with chemotherapy combined with bevacizumab or PD-1 inhibitors at our center. Among them, 139 patients were treated with chemotherapy combined with bevacizumab, while 137 patients were treated with chemotherapy combined with PD-1 inhibitors. After receiving four cycles of combination therapy, all patients received maintenance therapy until disease progression. Progression-free survival (PFS), overall response rate (ORR), overall survival (OS), disease control rate (DCR), and adverse events (AE) were analyzed between the two groups.

RESULTS

Compared to patients who received anti-vascular therapy, patients who underwent immunotherapy achieved better PFS (7.3 months vs. 10 months, p = 0.002) while ORR (40.9% vs. 51.1%, p = 0.093), as well as OS (18 months vs. 24 months, p = 0.060), had no statistical difference between the two groups. In the PD-L1-negative population, there was no statistical difference in PFS and OS between the two groups. (8.0 months VS. 6.0 months, p = 0.738; and 19 months vs. 13 months, p = 0.274). In the PD-L1-positive population, there was a significant benefit in PFS in the population receiving immunotherapy (7.0 months vs. 10.0 months, p = 0.009). Proteinuria and hypertension occurred more frequently in the bevacizumab-treated group (p = 0.001 and p = 0.002), whereas immune-related pneumonia and hypothyroidism occurred more frequently in the immunotherapy-treated group (p = 0.007 and p = 0.030).

CONCLUSIONS

The addition of a PD-1 inhibitor was superior to bevacizumab in terms of PFS among patients with advanced lung adenocarcinoma. PD-L1-positive patients appeared to exhibit better PFS, OS, and ORR. Toxic reactions were manageable in both groups.

Recent advances in immune checkpoint inhibitors for non-small lung cancer treatment

Lung cancer is one of the deadliest types of cancer responsible for thousands of cancer-related deaths. Its treatment has remained a challenge for researchers, but an increase in the knowledge of molecular pathways and biology of lung cancer has dramatically changed its management in recent decades. Immunotherapies and immunomodulation of lung cancer have previously failed for a long time but thanks to continuous research work and enthusiasm, now, this field is emerging as a novel effective therapy. Now, it is hope with potential benefits and promising results in the treatment of lung cancer. This review article focuses on immune checkpoints inhibitors: CTLA-4 inhibitors (ipilimumab and tremelimumab) and PDL-1 inhibitors (durvalumab and atezolizumab) that can be blocked to treat lung carcinoma. It is also focused on critically analyzing different studies and clinical trials to determine the potential benefits, risks, and adverse events associated with immunotherapeutic treatment.

Research Progress and Challenges in the Treatment of Central Nervous System Metastasis of Non-Small Cell Lung Cancer

Non-small cell lung cancer (NSCLC) is one of the most common malignant tumors and has high morbidity and mortality rates. Central nervous system (CNS) metastasis is one of the most frequent complications in patients with NSCLC and seriously affects the quality of life (QOL) and overall survival (OS) of patients, with a median OS of untreated patients of only 1-3 months. There are various treatment methods for NSCLC CNS metastasis, including surgery, chemotherapy, radiotherapy, targeted therapy, and immunotherapy, which do not meet the requirements of patients in terms of improving OS and QOL. There are still many problems in the treatment of NSCLC CNS metastasis that need to be solved urgently. This review summarizes the research progress in the treatment of NSCLC CNS metastasis to provide a reference for clinical practice.

Pemetrexed-Platinum With or Without Bevacizumab for Chinese Chemo-Naive Advanced Lung Adenocarcinoma Patients: A Real-World Study

Despite recent advances in the treatment of advanced non-small-cell lung cancer (NSCLC), bevacizumab plus platinum-based doublet chemotherapy remains a commonly used first-line regimen. This study was conducted to compare the efficacy and safety of pemetrexed-platinum with or without bevacizumab in Chinese chemo-naive advanced lung adenocarcinoma patients in a real-world setting. We retrospectively collected 100 patients who received pemetrexed-platinum with or without bevacizumab (PP, n = 46; Bev+PP, n = 54) until disease progression or unacceptable toxicity. Clinical characteristics of patients were balanced, except for the proportion of stage IV b+c (Bev+PP and PP: 67.4 vs. 37.0%, p = 0.0066). Bev+PP significantly improved the objective response rate (ORR, 65 vs. 30%, p = 0.0004) and progression-free survival (PFS, 7.4 vs. 6.8 months, p = 0.009), but not overall survival (OS, 17.5 vs. 15.0 months, p = 0.553) compared with PP. Treatment (p = 0.001), gender (p = 0.008), adrenal metastasis (p = 0.001), and liver metastasis (p = 0.013) were independent risk factors for PFS. Patients with adrenal metastasis tended to be at the highest risk of not benefiting from bevacizumab addition (HR [95% CI]: 2.244 [0.6495-7.753]). The safety profile was acceptable, and grade ≥3 toxicity occurred similarly. This study showed that pemetrexed-platinum plus bevacizumab was effective compared to chemotherapy alone in Chinese patients with advanced NSCLC.

Clinical evaluation of plasma coagulation parameters in patients with advanced-stage non-small cell lung cancer treated with palliative chemotherapy in China

AIMS OF THE STUDY

Blood coagulation parameters are colossally important for clinical evaluation of palliative chemotherapy; however, this niche was not explored earlier for advanced-stage non-small cell lung cancer (NSCLC). Study focuses to explore the clinical relevancy of Coagulation parameters; prothrombin time (PT), activated partial thromboplastin time (APTT), thrombin time (TT), fibrinogen (FIB), D-dimer and international normalised ratio (INR) and their response to palliative chemotherapy in advanced-stage NSCLC.

METHODS

A retrospective study was conducted between 2013 and 2019 in Jiangsu Cancer hospital, Nanjing, PR. China. Medical records of 5445 patients were succinctly reviewed and classified accordingly to the inclusion and exclusion criteria. A total of 216 advanced NSCLC patients who used a first-line chemotherapy and antiangiogenic therapy regimen were enrolled in this study under ethical approval (JSCH-2020C-009). Blood samples were collected from these patients to measure the response levels of these coagulation parameters at time of admission to hospital and at the beginning of 4 cycles of Palliative therapy. We find the clinical value of all these coagulation parameters by using SPSS 24. Univariate Cox regression and Multivariate Cox regression models were used to identify the factors that were associated with progression-free survival (PFS) and the response to palliative chemotherapy.

RESULTS

In the Kaplan-Meier survival analysis for overall median (95% CI) survival of high pre-treatment coagulation parameters showed shorter PFS compared with normal pre-treatment except TT and their overall median (95% CI) follow-up was 3.3 (3.12-3.47). Coagulation parameters have showed clinical relevance as a potential independent prognostic factor of PFS in the Univariate Cox regression. In multivariable model, Age (≥60 years vs < 60 years), cancer differentiation (Unknown vs Poor), PT (High vs Normal) range, FIB (High vs Normal) range and D-dimer (High vs Normal) range, (P = .025, P = .045, P = .029, P = .049 and P = .011, respectively) were associated as a prognostic factor of PFS in NSCLC. Patients on 3-drugs regimen found to have better PFS compared with the ones taking the 2-drugs treatment regimen (P = .043).

CONCLUSION

The high range of PT, FIB and D-dimers was associated with poor prognosis of advanced-stage NSCLC. Our findings also confirmed that patients on 3-drugs regimen showed longer PFS compared with 2-drugs regimen.

Drinking-water nitrate and cancer risk: A systematic review and meta-analysis

BACKGROUND

Nitrate is an inorganic compound that occurs naturally in all surface and groundwater, although higher concentrations tend to occur only where fertilizers are used on the land. The regulatory limit for nitrate in public drinking water supplies was set to protect against infant methemoglobinemia, but other health effects were not considered. Risk of specific cancers and congenital disabilities may be increased when the nitrate is ingested, and nitrate is reduced to nitrite, which can react with amines and amides by nitrosation to form N-nitroso compounds which are known animal carcinogens. This study aims to evaluate the association between nitrate ingested through drinking water and the risk of developing cancers in humans.

METHODS

We performed a systematic review following PRISMA and MOOSE guidelines. A literature search was performed using PubMed, EMBASE, the Cochrane Library databases, Web of Science and Google Scholars in the time-frame from their inception to January 2020, for potentially eligible publications. STATA version 12.0 was used to conduct meta-regression and a two-stage meta-analysis.

RESULTS

A total of 48 articles with 13 different cancer sites were used for analysis. The meta-regression analysis showed stomach cancer had an association with the median dosage of nitrate from drinking water (t = 3.98, p = 0.0001, and adjusted R-squared = 50.61%), other types of cancers didn't show any association. The first stage of meta-analysis showed there was an association only between the risk of brain cancer & glioma (OR = 1.15, 95% CI: 1.06, 1.24) and colon cancer (OR = 1.11, 95% CI: 1.04, 1.17) and nitrate consumption in the analysis comparing the highest ORs versus the lowest. The 2^nd stage showed there was an association only between the risk colon cancer (OR = 1.14, 95% CI: 1.04, 1.23) and nitrate consumption in the analysis comparing all combined higher ORs versus the lowest.

CONCLUSION

This study showed that there is an association between the intake of nitrate from drinking water and a type of cancer in humans. The effective way of controlling nitrate concentrations in drinking water is the prevention of contamination (water pollution). Further research work on this topic is needed.

Clinical Evaluation of Serum Tumor Markers in Patients With Advanced-Stage Non-Small Cell Lung Cancer Treated With Palliative Chemotherapy in China

Aim: This study aims to analyze the prognostic value of seven tumor makers and also investigate the response of palliative chemotherapy in advanced NSCLC patients with advanced disease.

Methods: Medical records of 278 advanced NSCLC Chinese patients who received six cycles of palliative chemotherapy were retrospectively reviewed under ethical approval (JSCH2019K-011). Univariate and multivariate Cox regression analyses were performed using SPSS 24 to find the clinical value of these tumor markers and to identify the factors that were associated with progression-free survival (PFS), as well as the response to palliative chemotherapy.

Results: In baseline characteristic, the high levels of CEA, CA-125, CA-199, AFP, NSE, CYFRA21-1, and CA15-3 were detected in 209 (75.18%), 139 (50.0%), 62 (22.30%), 18 (6.47%), 155 (55.75%), 176 (63.30%), and 180 (64.74%) patients, respectively. Univariate analysis revealed that patients with high vs. normal levels of all tumor markers had an increased risk of poor prognosis. In the multivariable Cox regression model, the patient with (high vs. normal) CYFRA21-1 levels (HR = 1.454, P = 0.009) demonstrated an increased poor PFS. However, patients with (high vs. normal) CA19-9 levels (HR = 0.524, P < 0.0001) and NSE levels (HR = 0.584, P < 0.0001) presented a decreased risk of PFS. Also, patients receiving 3-drugs regimen had better PFS compared to those on 2-drugs regimen (P = 0.043).

Conclusions: The high levels of CYFRA21-1 was correlated with a poor prognostic factor of PFS for Advanced NSCLC patients. However, the high levels of CA19-9 and NSE were associated with a better prognostic factor of PFS. Additionally, smoking habits and tumor status had a poor prognostic factor of PFS. Moreover, we found that antiangiogenic therapy has high efficacy with first-line chemotherapy and longer PFS of NSCLC patients.

Treatment with or without bevacizumab as a first-line and maintenance therapy for advanced non-squamous non-small cell lung cancer: A retrospective study

BACKGROUND

Pemetrexed and bevacizumab as monotherapies, or in combination, have been approved for maintenance therapy following platinum-based induction in patients with advanced nonsquamous non-small cell lung cancer (NSCLC). The differences in the benefits of bevacizumab for treatment during early or late NSCLC have not yet been characterized.

METHODS

We retrospectively analyzed data from 35 patients with advanced naïve NSCLC who had received pemetrexed/platinum with or without bevacizumab followed by maintenance therapy with pemetrexed alone or pemetrexed plus bevacizumab. The data were analyzed using the Kaplan-Meier method and Cox regression adjusted for risk factors. Patients were grouped according to treatment conditions. Group A received pemetrexed plus platinum followed by pemetrexed alone (Pem-Pt/Pem). Group B received pemetrexed plus platinum followed by pemetrexed and bevacizumab (Group B; Pem-Pt/Pem + Bev). Group C received pemetrexed, platinum, and bevacizumab during induction therapy, and pemetrexed as maintenance therapy (Group C; Pem-Pt + Bev/Pem + Bev). We assessed the significance of introduction of bevacizumab at different stages of treatment.

RESULTS

A total of 13 (37.1%) patients were included in Group A, nine patients (25.7%) were included in Group B, and 13 patients (37.1%) were included in Group C. Among the 35 patients, 69.2% were male, and the median age was 59 years (range 40-75). The median progression-free survival (PFS) was 7.7 months (231 days, range 134-410 days) in Group A, 9.3 months (280 days, range 84-565 days) in Group B, and 8.0 months (241 days, range 108-665 days) in Group C. The median PFS was not significantly different among the three groups (P = 0.233). Similarly, bevacizumab did not significantly affect PFS (P = 0.630).

CONCLUSIONS

The addition of bevacizumab into induction chemotherapy or maintenance therapy provided limited benefits to PFS in our study, but previous studies suggested that bevacizumab may improve disease control. In that way, we presume that early use of bevacizumab may provide a greater benefit.

MTAP-deficiency could predict better treatment response in advanced lung adenocarcinoma patients initially treated with pemetrexed-platinum chemotherapy and bevacizumab

To investigate the predictive value of methylthioadenosine phosphorylase (MTAP) on treatment response and survival in advanced lung adenocarcinoma. MTAP expression was detected by immunohistochemistry. Treatment response and survival were compared according to MTAP expression level. The results indicated MTAP-low expression was observed in 61.2% (101/165) of all patients. The objective response rate and disease control rate improved in the MTAP-low group (64.4% vs 46.9%, p = 0.035; 92.1% vs. 79.7%, p = 0.03; respectively). The median progression-free survival and survival time in the MTAP-low group were significantly lower than that in the MTAP-high group (8.1 vs. 13.1 months, p = 0.002; 22 vs. 32 months, p = 0.044). Multivariate analysis demonstrated that brain metastasis (HR 1.55, p = 0.046), thoracic radiation (HR 0.52, p = 0.026), and MTAP-low expression (HR 1.36, p = 0.038) were independent factors on survival. It is concluded that MTAP-low expression could predict improved treatment response but worsened survival in advanced lung adenocarcinoma.