The Association of Improved Overall Survival with NSAIDs in Non-Small Cell Lung Cancer Patients Receiving Immune Checkpoint Inhibitors

Non-steroidal anti-inflammatory drugs (NSAIDs) regimens enhance synergistic selective anticancer efficacy of chemotherapeutic agents on cultured cells

Background/purpose

Cancer incidences are rising, presenting challenges due to severe side effects and resistance of chemotherapeutic agents. To address these issues, we propose a strategy involving pharmaceutical compositions of PTM (Phytopolyphenols, Targeting drugs, Metals) regimens. This study aimed to investigate NSAIDs (Non-steroidal anti-inflammatory drugs)-PTM regimens enhancing anticancer selectivity and efficacy of chemotherapeutic agents on cultured cancer cells.

Materials and methods

Effects of drugs on proliferation of cultured cancer cells and pathogens was assessed using MTT assay and optical density at 600 nm (OD600) respectively. Synergistic effects of drug combinations were determined using combination index and efficacy index. ATPase activity was assayed using a colorimetric method.

Results

NSAIDs-PTM regimens demonstrated selective and synergistic anticancer effects. They also enhanced anticancer selectivity and efficacy of Cisplatin, 5-Fluorouracil, and Methotrexate. The most effective NSAIDs-PTM regimens increased anticancer efficacy by 16, 4, and 23 fold against oral, lung, and colon cancer cell lines, respectively. Additionally, these NSAIDs-PTM regimens enhanced selective anticancer efficacy of Cisplatin, 5-Fluorouracil, and Methotrexate by 8-21 fold on the three cancer cells. Furthermore, all regimens exhibited synergistic anti-efflux pump ATPase activity and antibacterial effects against four cultured pathogens.

Conclusion

The findings indicate that NSAIDs-PTM regimens not only possess synergistic and selective anticancer and antibacterial properties but also enhance anticancer selectivity and efficacy of Cisplatin, 5-Fluorouracil, and Methotrexate. Notably, all regimens exhibited anti-efflux pump ATPase, which may help overcome multidrug resistance in cancer treatment. Given that all components of PTM regimens are clinically effective and safe, further clinical studies are warranted.

The impact of cannabis on immune checkpoint inhibitor therapy: a systematic review of immunomodulatory effects of cannabis in patients with and without cancer

PURPOSE

Cannabis is commonly used among patients with cancer for palliative benefit. As the use of immune checkpoint inhibitors (ICIs) for cancer therapy increases, there is concern about potential interactions between ICIs and cannabis. Preclinical studies suggest that cannabis leads to immunosuppression, which could impair the function of ICIs. However, only a few clinical studies have investigated this relationship. The goal of this review is to synthesize reported immunomodulatory effects of cannabis in patients with and without cancer in order to better understand whether these preclinical findings translate to the clinical space.

METHODS

A database search was conducted through Ovid Medline to identify relevant articles. Clinical studies investigating cannabis use in humans and the immune system were included. Preclinical studies and case studies were excluded. Information pertaining to immune changes with cannabis exposure was abstracted.

RESULTS

Forty studies met inclusion criteria, including 9 randomized, placebo-controlled clinical trials. Analysis of immune-related markers demonstrated no change in cytokines, T-cell counts, and CRP in most studies with cannabis exposure. Among patients with autoimmune diseases, cannabis use showed improvements in clinical symptoms even while objective laboratory immune markers remained unchanged.

CONCLUSION

We did not find evidence of meaningful changes in immune parameters with cannabis use in the clinical setting across multiple diseases. In particular, immune markers relevant to ICI function did not appear to be associated with cannabis use. This evidence may provide some reassurance to patients and oncologists contemplating concomitant cannabis use with ICIs; however, additional well-controlled prospective studies are warranted in this setting.

Efficacy of timing‑dependent infusion of nivolumab in patients with advanced gastric cancer

Although an association exists between the timing of immune checkpoint inhibitor (ICI) administration and therapeutic efficacy in several types of cancer, to the best of our knowledge, no reports exist regarding this relationship in gastric cancer (GC). The present study aimed to evaluate the optimal timing of ICI (nivolumab) administration in patients with advanced GC. A total of 58 consecutive patients with advanced GC who received nivolumab monotherapy after ≥2 chemotherapy regimens were retrospectively evaluated. These patients were divided into two groups according to the median time of nivolumab administration: i) Early-timing and (ii) late-timing groups, and the efficacy was assessed in both groups. The early-timing group had significantly longer overall survival (OS) than the late-timing group [median OS 8.2 months; 95% confidence interval (CI), 4.2-12.9 vs. median OS 5.4 months; 95% CI, 3.6-6.1]. Moreover, patients in the early-timing group had significantly longer progression-free survival (PFS) than those in the late-timing group (median PFS 2.6 months; 95% CI, 1.3-3.9 months vs. median PFS 1.6 months; 95% CI, 0.9-2.1 months). Furthermore, univariate analysis showed that early timing, immune-related adverse events and nonsteroidal anti-inflammatory drug administration were associated with longer OS and PFS. Cutoff Finder analysis revealed that the optimal timing of nivolumab administration for achieving better outcomes was before 12:06 p.m. Nivolumab administration in the morning, especially before 12:06 p.m., had a better clinical impact on patients with advanced GC.

Impact of concurrent medications on the outcome of immunotherapy in non-small cell lung carcinoma

BACKGROUND

There have been reports on the impact of concurrent drugs on the outcome of immunotherapy for non-small cell lung carcinoma (NSCLC). However, the effect of some drugs, such as antibiotics and nonsteroidal anti-inflammatory drugs (NSAIDs), has not been clarified in patients with NSCLC. In the present study, we aimed to assess the association between concurrent drugs and the outcomes of immune checkpoint inhibitors (ICIs) alone or in combination with chemotherapy for patients with advanced NSCLC.

METHODS

We retrospectively assessed patients with advanced NSCLC who underwent ICI treatment between September 2017 and December 2021 at Kobe University Hospital. We evaluated the data regarding the use of antibiotics within 30 days before ICI initiation, as well as the use of proton pump inhibitors (PPIs) and NSAIDs during ICI initiation.

RESULTS

A total of 127 patients were assessed, among whom 28 (22.0%) patients received antibiotics, 39 (30.7%) PPIs, and 36 (28.3%) NSAIDs. No significant differences were observed between the patients with and without antibiotic use. However, patients using NSAIDs had significantly worse objective response rates (ORR) and progression-free survival (PFS) with ICI alone or in combination with chemotherapy compared to those who did not (ORR, 47.2% vs. 67.0%; p = 0.045. PFS, 6.3 months vs. 10.8 months; p = 0.02). Patients using PPIs demonstrated a worse ORR of ICI in combination with chemotherapy compared to those who did not (ORR, 45.2% vs. 72.6%; p = 0.013).

CONCLUSIONS

The unnecessary use of NSAIDs along with immunotherapy should be discouraged.

The relationship between nonsteroidal anti-inflammatory drugs and cancer incidence: An umbrella review

Several clinical and preclinical studies have shown that nonsteroidal anti-inflammatory drugs (NSAIDs), particularly aspirin, reduce the incidence of various cancer types. However, there is still a lack of literature evaluating the overall association between multiple cancer morbidities and NSAIDs. Thus, we conducted an umbrella review to evaluate the quality of evidence, validity, and biases of the existing systematic reviews and meta-analyses on the relationships between NSAIDS and multiple tumor incidence outcomes. We found that NSAIDs might be associated with a decreased risk of several cancers, including the central nervous system, breast, esophageal, gastric, head and neck, hepatocellular, cholangiocarcinoma, colorectal, endometrial, lung, ovary, prostate, and pancreatic cancers, but regular intake of any dose of non-aspirin NSAIDs (NA-NSAIDs) could increase the incidence of kidney cancer. However, most of included studies are evaluated as low quality according to our evidence assessment. Furthermore, due to the potential side effects, such as hemorrhage, digestive symptoms and peptic ulcer, it is still not recommend to use NSAIDs regularly to prevent cancers.

Readily available drugs and other interventions to potentially improve the efficacy of immune checkpoint blockade in cancer

To improve the efficacy of immune checkpoint inhibitors (ICIs) for cancer treatment, various strategies, including combination therapies with repurposed drugs, are being explored. Several readily available interventions with potential to enhance programmed death 1 (PD-1) blockade have been identified. However, these interventions often remain overlooked due to the lack of financial incentives for their development, making them financial orphans. This review summarizes current knowledge regarding off-label drugs, supplements, and other readily available interventions that could improve the efficacy of PD-1 blockade. The summary of each intervention includes the proposed mechanism of action for combination with checkpoint inhibitors and data from animal and human studies. Additionally, we include summaries of common interventions to be avoided by patients on PD-1 blockade. Finally, we present approaches for conducting further studies in patients, with the aim of expediting the clinical development of these interventions. We strive to increase awareness of readily available combination therapies that may advance cancer immunotherapy and help patients today.

First-line immunotherapy in non-small cell lung cancer: how to select and where to go

INTRODUCTION

Immunotherapy (IO) has established a new milestone in lung cancer treatment. Several registrational studies have approved immune checkpoint inhibitors (ICIs) in different settings, including the metastatic nonsmall cell lung cancer (NSCLC). As well known, responders are just a certain proportion of patients; therefore, their selection by using predictive factors has stood out as a crucial issue to address in tailoring a patient-centered care.

AREAS COVERED

In our review we propose a detailed yet handy cross section on ICIs as first-line treatment in metastatic NSCLC, regarding indications, histological, clinical, and blood-based biomarkers, other than their mechanisms of resistance and new immunological actionable targets. We performed a literature search through PubMed entering keywords complying with crucial features of immunotherapy.

EXPERT OPINION

IO represents the backbone of lung cancer treatment. Trials are currently testing novel immune blockade agents assessing combinatorial approaches with standard ICIs, or antibody drug conjugates (ADC), harboring immunological targets. Perfecting patients' selection is an ongoing challenge and a more and more urgent need in order to best predict responders who will consistently benefit from it.

Trial watch: beta-blockers in cancer therapy

Compelling evidence supports the hypothesis that stress negatively impacts cancer development and prognosis. Irrespective of its physical, biological or psychological source, stress triggers a physiological response that is mediated by the hypothalamic-pituitary-adrenal axis and the sympathetic adrenal medullary axis. The resulting release of glucocorticoids and catecholamines into the systemic circulation leads to neuroendocrine and metabolic adaptations that can affect immune homeostasis and immunosurveillance, thus impairing the detection and eradication of malignant cells. Moreover, catecholamines directly act on β-adrenoreceptors present on tumor cells, thereby stimulating survival, proliferation, and migration of nascent neoplasms. Numerous preclinical studies have shown that blocking adrenergic receptors slows tumor growth, suggesting potential clinical benefits of using β-blockers in cancer therapy. Much of these positive effects of β-blockade are mediated by improved immunosurveillance. The present trial watch summarizes current knowledge from preclinical and clinical studies investigating the anticancer effects of β-blockers either as standalone agents or in combination with conventional antineoplastic treatments or immunotherapy.

Relevance of Phytochemical Taste for Anti-Cancer Activity: A Statistical Inquiry

Targeting inflammation and the pathways linking inflammation with cancer is an innovative therapeutic strategy. Tastants are potential candidates for this approach, since taste receptors display various biological functions, including anti-inflammatory activity (AIA). The present study aims to explore the power different tastes have to predict a phytochemical's anti-cancer properties. It also investigates whether anti-inflammatory phytocompounds also have anti-cancer effects, and whether there are tastes that can better predict a phytochemical's bivalent biological activity. Data from the PlantMolecularTasteDB, containing a total of 1527 phytochemicals, were used. Out of these, only 624 phytocompounds met the inclusion criterion of having 40 hits in a PubMed search, using the name of the phytochemical as the keyword. Among them, 461 phytochemicals were found to possess anti-cancer activity (ACA). The AIA and ACA of phytochemicals were strongly correlated, irrespective of taste/orosensation or chemical class. Bitter taste was positively correlated with ACA, while sweet taste was negatively correlated. Among chemical classes, only flavonoids (which are most frequently bitter) had a positive association with both AIA and ACA, a finding confirming that taste has predictive primacy over chemical class. Therefore, bitter taste receptor agonists and sweet taste receptor antagonists may have a beneficial effect in slowing down the progression of inflammation to cancer.

Prostaglandin E2 and myocarditis; friend or foe?

This review article summarizes the role of prostaglandin E2 (PGE2) and its receptors (EP1-EP4) as it relates to the inflammatory cardiomyopathy, myocarditis. During the COVID-19 pandemic, the onset of myocarditis in a subset of patients prompted a debate on the use of nonsteroidal anti-inflammatory drugs (NSAIDs), like ibuprofen, which act to inhibit the actions of prostaglandins. This review aims to further understanding of the role of PGE2 in the pathogenesis or protection of the myocardium in myocarditis. Inflammatory cardiomyopathies encompass a broad spectrum of disorders, all characterized by cardiac inflammation. Therefore, for the purpose of this review, the authors have placed particular emphasis on etiologies of myocarditis where effects of PGE2 have been documented.

Effects of Acetaminophen Exposure on Outcomes of Patients Receiving Immune Checkpoint Inhibitors for Advanced Non-Small-Cell Lung Cancer: A Propensity Score-Matched Analysis

(1) Background: Several studies have investigated potential interactions between immune checkpoint inhibitors (ICIs) and commonly prescribed medications. Although acetaminophen (APAP) has not been considered susceptible to interaction with ICIs, recent research has shown that detectable plasma levels of this drug can hinder the efficacy of PD-1/PD-L1 blockade therapies. A reliable assessment of the potential interaction between APAP and ICIs in advanced non-small cell lung cancer (NSCLC) patients would be worthwhile since it is often prescribed in this condition. We sought to evaluate the impact of the concomitant use of APAP in patients with advanced NSCLC on PD-1/PD-L1 blockade using real-world evidence. (2) Methods: This study included consecutive patients with histologically proven stage IV NSCLC who underwent first-line therapy with pembrolizumab as a single agent or in combination with platinum-based chemotherapy, or second-line therapy with pembrolizumab, nivolumab, or atezolizumab. The intensity of APAP exposure was classified as low (therapeutic intake lasting less than 24 h or a cumulative intake lower than 60 doses of 1000 mg) or high (therapeutic intake lasting more than 24 h or a total intake exceeding 60 doses of 1000 mg). The favorable outcome of anti-PD-1/PD-L1 therapies was defined by durable clinical benefit (DCB). Progression-free survival (PFS) and overall survival (OS) were relevant to our efficacy analysis. Propensity score matching (PSM) methods were applied to adjust for differences between the APAP exposure subgroups. (3) Results: Over the course of April 2018 to October 2022, 80 patients were treated with first-line pembrolizumab either as single-agent therapy or in combination with platinum-based chemotherapy. During the period from June 2015 to November 2022, 145 patients were given anti-PD-1/PD-L1 blockade therapy as second-line treatment. Subsequent efficacy analyses relied on adjusted PSM populations in both treatment settings. Multivariate testing revealed that only the level of APAP and corticosteroid intake had an independent effect on DCB in both treatment lines. Multivariate Cox regression analysis confirmed high exposure to APAP and immunosuppressive corticosteroid therapy as independent predictors of shorter PFS and OS in both treatment settings. (4) Conclusions: Our findings would strengthen the available evidence that concomitant intake of APAP blunts the efficacy of ICIs in patients with advanced NSCLC. The detrimental effects appear to depend on the cumulative dose and duration of exposure to APAP. The inherent shortcomings of the current research warrant confirmation in larger independent series.