Gender Differences and Their Effects on Survival Outcomes in Lung Cancer Patients Treated With PD-1/PD-L1 Checkpoint Inhibitors: A Systematic Review and Meta-Analysis

Let's talk about sex: Survival among females and males in a real-world cohort treated with pembrolizumab for non-small cell lung cancer

Innate differences in the female and male immune systems and subgroup results from clinical trials have led researchers to hypothesize there could be sex-based disparities in the effectiveness of immune checkpoint inhibitors for anticancer treatment. This real-world study evaluated potential sex-based disparities in survival among non-small cell lung cancer (NSCLC) patients treated with pembrolizumab as monotherapy or in combination with chemotherapy. The population-based cohort included 1586 females and 1978 males diagnosed with advanced NSCLC in Norway, treated with first-line pembrolizumab (2017-2021) or platinum-based chemotherapy (2012-2016). Sex-based survival differences among pembrolizumab users, and survival benefits relative to chemotherapy users, were evaluated using lung-cancer specific survival adjusted for age, stage, histology, cardiovascular disease, education, and income. Results were presented for pembrolizumab mono- and combination therapy separately. We did not observe sex-based differences in survival among pembrolizumab monotherapy users. Among combination therapy users, females had higher survival than males (7 percentage points higher 18 months after treatment initiation); this effect persisted until the end of follow-up (36 months). When comparing the effect of pembrolizumab relative to chemotherapy, males derived a larger survival benefit from monotherapy than females. We did not observe any sex-based disparities in the survival benefit of combination therapy. Sex-based survival disparities in our study appeared to be associated with disparities in the effectiveness of chemotherapy, but could also indicate that pembrolizumab monotherapy is more effective for males. Framing the sex-based effectiveness of pembrolizumab as a survival difference versus benefit relative to chemotherapy affected whether a disparity was observed.

Combined Immune Checkpoint Blockade and Helixor® Therapy in Oncology: Real-World Tolerability and Subgroup Survival (ESMO GROW)

Real-world data (RWD) play a crucial role in identifying key subgroups and assessing multimodal oncology therapies, including integrative and palliative care. Immune checkpoint blockade (ICB) has improved survival, and its combination with complementary therapies like Viscum album L. extracts (VA) may enhance outcomes. This RWD study, based on the Network Oncology registry and ESMO-GROW guidelines, analyzed oncological patients receiving PD-1/PD-L1 inhibitors alone or with Helixor® VA (HVA) extracts. Primary and secondary objectives were tolerability and overall survival. Statistical analyses included Kaplan-Meier survival curves and Cox regression. Among 405 cancer patients, 344 received ICB alone (CTRL) and 61 received ICB + HVA (COMB). Lung cancer was predominant (78.6%). Adverse event-related discontinuation was lower in COMB (4.9% vs. 6.4%, p = 0.25). In non-small cell lung cancer (NSCLC) patients, the 3-year survival rate was significantly higher in COMB (34.3% vs. 17.2%, p = 0.02). In female NSCLC patients, COMB was significantly associated with a reduced death risk of 91.2% (aHR: 0.088; 95% CI: 0.009-0.783). Our RWD findings show the favorable tolerability of combinatorial ICB + HVA in several tumor entities and underscore its potential to improve survival in NSCLC particularly in female NSCLC patients, warranting further investigation.

Sex disparities in advanced non-small cell lung cancer survival: A Danish nationwide study

BACKGROUND

Historically, cancers often exhibit sexual dimorphism. However, following the introduction of immune checkpoint inhibitors and targeted therapies into routine clinical practice, the association of sex on patient and tumour characteristics, as well as survival remains largely unexplored in advanced NSCLC.

PATIENTS AND METHODS

In this observational study, we identified adults diagnosed with advanced NSCLC from January 1, 2017, to December 31, 2023, using Danish nationwide health registries and clinical databases. We compared females to males across demographic, social, socioeconomic, patient and tumour characteristics (including PDL-1 expression and driver mutations), treatments, and overall survival (OS) from diagnosis and initiation of the first line of treatment (LOT1). Cox proportional hazards regression was employed, adjusting for key covariates in the overall cohort and stratified by stage, histological subtype, PD-L1 expression level, and treatment type. Propensity score matching was conducted as a sensitivity analysis.

RESULTS

Among 14,635 included individuals, males comprised 50 % (n = 7,322). Patient and tumour characteristics differed between sexes. The crude and adjusted female-to-male mortality hazard ratio (HR) was 0·82 (95 % confidence interval [CI]: 0·79-0·85) and 0·84 (0·81-0·88) from diagnosis and 0·80 (0·76-0·84) and 0·80 (0·75-0·84) from initiation of LOT1. Median OS for females and males was 8·8 months (95 % CI 8·4-9·2) and 7·0 months (6·7-7·3) from diagnosis and 14·1 months (13·5-15·1) and 10·9 months (10·3-11·5) from initiation of LOT1. Stratified analyses revealed that across all strata, females consistently demonstrated either favourable or comparable outcomes compared to males.

CONCLUSIONS

This study increases our understanding of sex-based disparities in advanced NSCLC. Adjusted analyses addressing previously suggested explanations for sex disparities in survival still demonstrated a longer survival for females, indicating yet-unidentified sex differences with potential clinical implications. Our results underscore the critical role of acknowledging sex as a key variable in oncology trials, research, and clinical practice.

Camrelizumab-based therapies for the treatment of advanced lung cancer: a prospective, open-label, multicenter, observational, real-world study

Objective

Camrelizumab, a programmed death-1 inhibitor, is effective and safe for treating patients with advanced lung cancer according to previous phase 3 trials. However, relevant real-world clinical evidence is required. This study intended to explore the efficacy and safety of camrelizumab-based therapies in patients with advanced lung cancer.

Methods

Patients with advanced lung cancer who received camrelizumab-based therapies as first-line or above treatment were consecutively enrolled in this study. The median follow-up duration was 5 months.

Results

A total of 298 subjects were enrolled. Objective response rate (ORR) and disease control rate (DCR) were 27.2% and 82.2%. Multivariable logistic regression analysis showed that previous pulmonary surgery [odds ratio (OR)=0.440, P=0.024], previous radiotherapy (OR=0.410, P=0.010), and Eastern Cooperative Oncology Group Performance Status (ECOG PS) score (>1 vs. 0~1) (OR=0.414, P=0.046) were independently and negatively associated with ORR. The median progression-free survival (PFS) [95% confidence interval] was 10.0 (7.8-12.2) months. Median overall survival (OS) was not reached. Multivariable Cox regression analysis suggested that brain metastasis [hazard ratio (HR)=1.548, P=0.036] and liver metastasis (HR=1.733, P=0.035) were independently associated with shorter PFS. Previous chemotherapy (HR=2.376, P=0.022), brain metastasis (HR=2.688, P=0.006), and liver metastasis (HR=2.583, P=0.039) were independently associated with shorter OS. Most adverse events were grade I or II. Grade III and IV adverse events rarely occurred. The occurrence of adverse events was associated with a higher DCR (P=0.003).

Conclusions

Camrelizumab-based therapies may serve as potential treatments for patients with advanced lung cancer. However, further studies with an extended follow-up duration are warranted.

Effect of Gender on Patients with Non-Small-Cell Lung Cancer Treated with Immune Checkpoint Inhibitors: A Real-World Study

Objective: To evaluate the differences in overall survival (OS) and progression-free survival (PFS) between men and women with non-small-cell lung cancer (NSCLC) treated with immune checkpoint inhibitors (ICIs) in second-line and later treatments. Methods: A retrospective, single-center observational study was conducted on patients with advanced NSCLC treated with ICIs (nivolumab, pembrolizumab, and atezolizumab) from January 2015 to December 2019 (with follow-up until December 2021). Demographic, clinical, and treatment-related variables were collected. OSand PFSwere analyzed using the Kaplan-Meier method and compared between genders using the log-rank test.A multivariate Cox regression analysis was performed to adjust for confounders. Results: A total of 189 patients were included, and 47 (25%) were women. The most common histology was adenocarcinoma (61%). Women began treatment at a younger age (59.8 vs. 66 years, p < 0.001) and had higher rates of active smoking (46.8% vs. 38%, p = 0.001). The median OS was similar between men (9.5 months, 95% CI: 7.1-11.8) and women (9.2 months, 95% CI: 3.3-15.2; p = 0.382) while PFS was significantly higher in males (3.2 months, 95% CI: 2.5-4.0) than in females (2.1 months; 95% CI = 1.6-2.5) (p = 0.002).Women had higher rates of tumor cachexia (BMI < 20).Worse PFS was observed for women both in the <20 kg/m2 (median PFS: 1.8 vs. 2.7 months, p = 0.016) and 20-24.9 kg/m2 groups (median PFS: 2.2 vs. 3.3 months, p = 0.077), while in patients with a BMI >= 25 kg/m2, median OS was higher in women than in men (14.7 months vs. 10.1 months). Women had also a significantly worse PFS than men among those with a cumulative tobacco consumption of <30 packs-year (median PFS: 2.2 vs. 3.2, p = 0.038. In the multivariate analysis, the male sex was significantly associated with a better PFS(HR = 0.59; p = 0.009), without significant differences between sexes in OS (HR = 0.90; p = 0.618). Among the other variables analyzed, only an ECOG >= 2 was significantly associated with both worse OS (HR = 3.53; 95% CI = 1.93-6.47) and PFS (HR = 2.19; 95% CI = 1.23-3.89). Women who discontinued due to toxicity (n = 7) had a median OS of 41.4 months (95% CI: 14.7-68.1) after discontinuation, whereas men (n = 15) had a median OS of 8.8 months (95% CI: 6.9-10.8), (p = 0.045). Conclusions: Sex-based differences were observed in the ICI outcomes. Women had worse PFS, particularly with lower BMI and lower tobacco exposure, despite similar OS between sexes. Women discontinued ICIs due to toxicity earlier but showed longer OS after discontinuation. Poor ECOG status was linked to worse outcomes across all the patients.

The pregnancy-associated protein glycodelin as a potential sex-specific target for resistance to immunotherapy in non-small cell lung cancer

Lung cancer has been shown to be targetable by novel immunotherapies which reactivate the immune system and enable tumor cell killing. However, treatment failure and resistance to these therapies is common. Consideration of sex as a factor influencing therapy resistance is still rare. We hypothesize that the success of the treatment is impaired by the presence of the immunosuppressive pregnancy-associated glycoprotein glycodelin that is expressed in patients with non-small-cell lung cancer (NSCLC). We demonstrate that the glycan pattern of NSCLC-derived glycodelin detected by a lectin-based enrichment assay highly resembles amniotic fluid-derived glycodelin A, which is known to have immunosuppressive properties. NSCLC-derived glycodelin interacts with immune cells in vitro and regulates the expression of genes associated with inflammatory and tumor microenvironment pathways. In tumor microarray samples of patients, high glycodelin staining in tumor areas results in an impaired overall survival of female patients. Moreover, glycodelin colocalizes to tumor infiltrating CD8+ T cells and pro-tumorigenic M2 macrophages. High serum concentrations of glycodelin prior to immunotherapy are associated with a poor progression-free survival (p < 0.001) of female patients receiving PD-(L)1 inhibitors. In summary, our findings suggest that glycodelin not only is a promising immunological biomarker for early identification of female patients that do not benefit from the costly immunotherapy, but also represents a promising immunotherapeutic target in NSCLC to improve therapeutic options in lung cancer.

Tutorial: design, production and testing of oncolytic viruses for cancer immunotherapy

Oncolytic viruses (OVs) represent a novel class of cancer immunotherapy agents that preferentially infect and kill cancer cells and promote protective antitumor immunity. Furthermore, OVs can be used in combination with established or upcoming immunotherapeutic agents, especially immune checkpoint inhibitors, to efficiently target a wide range of malignancies. The development of OV-based therapy involves three major steps before clinical evaluation: design, production and preclinical testing. OVs can be designed as natural or engineered strains and subsequently selected for their ability to kill a broad spectrum of cancer cells rather than normal, healthy cells. OV selection is further influenced by multiple factors, such as the availability of a specific viral platform, cancer cell permissivity, the need for genetic engineering to render the virus non-pathogenic and/or more effective and logistical considerations around the use of OVs within the laboratory or clinical setting. Selected OVs are then produced and tested for their anticancer potential by using syngeneic, xenograft or humanized preclinical models wherein immunocompromised and immunocompetent setups are used to elucidate their direct oncolytic ability as well as indirect immunotherapeutic potential in vivo. Finally, OVs demonstrating the desired anticancer potential progress toward translation in patients with cancer. This tutorial provides guidelines for the design, production and preclinical testing of OVs, emphasizing considerations specific to OV technology that determine their clinical utility as cancer immunotherapy agents.

Non-Small Cell Lung Cancer Metastatic Without Oncogenic Alterations

This overview provides a thorough review of current treatment approaches for first-line management of nononcogenic addicted non-small cell lung cancer. We also address pertinent clinical decision-making queries encountered in everyday practice, such as the optimal treatment strategy for PD-L1-high patients, predictive factors for response to immune checkpoint inhibitors (ICI) both in terms of patient and cancer characteristics, the potential benefits of dual checkpoint blockade, and the unresolved issue of safe discontinuation strategies for long-term responders. Around one in five patients falls into this latter category while the majority develop either primary or acquired resistance to ICI-based first-line therapy, necessitating effective subsequent lines of treatment. Docetaxel, with or without combination of antiangiogenic agents, serves as the backbone of treatment, although evidence in the post-ICI setting is limited. Given that an inflamed tumor microenvironment (TME) is crucial for ICI responses, targeting the TME in cases of acquired resistance alongside continued ICI administration appears rational, although clinical trials so far have failed to confirm this hypothesis. Antibody-drug conjugates have emerged as a promising treatment modality, offering the potential for reduced toxicity and improved efficacy by targeting specific cancer antigens. Moreover, several chemotherapy-free approaches are currently under investigation for treatment-naïve patients, including alternative ICI and drugs targeting epitopes on both cancer and immune cells.

The predictive value of 18F-FDG PET/CT combined with inflammatory index for major pathological reactions in resectable NSCLC receiving neoadjuvant immunochemotherapy

OBJECTIVES

To investigate whether the combination of inflammatory biomarkers and metabolic parameters of 18F-FDG PET/CT could predict the major pathological reactions (MPR) in resectable NSCLC patients after neoadjuvant immunochemotherapy more accurately and screen out patients who may benefit from the neoadjuvant therapy.

MATERIALS AND METHODS

114 resectable NSCLC patients who underwent neoadjuvant immunochemotherapy and radical surgery were retrospectively enrolled. Detailed clinical characteristics, B-R and 18F-FDG PET/CT images were collected for analyzing their correlation with MPR. A metabolic-inflammation comprehensive prognostic index (MICPI) combined 18F-FDG PET/CT metabolic parameters and inflammatory index was proposed to predict MPR.

RESULTS

66.7 % patients achieved MPR. Smoking history, gender and ILO were influencing factors for MPR acquisition in NSCLC patients. High absolute neutrophils count (PreN ≥ 3.65), metabolic parameters (PreSUVmax ≥ 11.73) before treatment and ΔSUVmean (≥54.18) were significantly associated with MPR (P＜0.01, P＜0.05 and P＜0.001 respectively). MICPI-B based on PreN and PreSUVmax categorized NSCLC patients into three groups and among the groups of high, intermediate and low MICPI-B score, MPR accounted for 80.00 %, 51.72 % and 28.57 % respectively (P < 0.01). In high, intermediate and low MICPI-P groups which based on PreN and ΔSUVmean, MPR accounted for 92.31 %, 53.57 % and 11.11 %, respectively (P < 0.001).

CONCLUSION

PreN and metabolic parameter of 18F-FDG PET/CT may be an accurate alternative biomarker for predicting MPR in NSCLC patients after neoadjuvant immunochemotherapy. Moreover, MICPI can stratify patients into different groups based on their likelihood of obtaining MPR, allowing clinicians to identify patients who may most likely benefit from neoadjuvant immunochemotherapy.

Sex and anti-inflammatory treatment affect outcome of melanoma and non-small cell lung cancer patients with rheumatic immune-related adverse events

BACKGROUND

Rheumatic immune-related adverse events (R-irAEs) occur in 5-15% of patients receiving immune checkpoint inhibitors (ICI) and, unlike other irAEs, tend to be chronic. Herein, we investigate the factors influencing cancer and R-irAEs outcomes with particular focus on adverse effects of anti-inflammatory treatment.

METHODS

In this prospective, multicenter, long-term, observational study, R-irAEs were comprehensively analyzed in patients with malignant melanoma (MM, n=50) and non-small cell lung cancer (NSCLC, n=41) receiving ICI therapy who were enrolled in the study between August 1, 2018, and December 11, 2022.

RESULTS

After a median follow-up of 33 months, progressive disease or death occurred in 66.0% and 30.0% of MM and 63.4% and 39.0% of patients with NSCLC. Male sex (progression-free survival (PFS): p=0.013, and overall survival (OS): p=0.009), flare of a pre-existing condition (vs de novo R-irAE, PFS: p=0.010) and in trend maximum glucocorticoid (GC) doses >10 mg and particularly ≥1 mg/kg prednisolone equivalent (sex-adjusted PFS: p=0.056, OS: p=0.051) were associated with worse cancer outcomes. Patients receiving disease-modifying antirheumatic drugs (DMARDs) showed significantly longer PFS (n=14, p=0.011) and OS (n=20, p=0.018). Effects of these variables on PFS and/or OS persisted in adjusted Cox regression models. Additionally, GC treatment negatively correlated with the time from diagnosis of malignancy and the latency from ICI start until R-irAE onset (all p<0.05). R-irAE features and outcomes were independent of other baseline patient characteristics in both studied cancer entities.

CONCLUSION

Male sex, flare of pre-existing rheumatologic conditions and extensive GC treatment appeared to be linked with unfavorable cancer outcomes, while DMARD use had a favorable impact. These findings challenge the current dogma of restrictive DMARD use for R-irAE and thus may pave the way to better strategies and randomized controlled trials for the growing number of patients with R-irAE.

Sex Differences in Lung Cancer

Sex disparities in the incidence and mortality of lung cancer have been observed since cancer statistics have been recorded. Social and economic differences contribute to sex disparities in lung cancer incidence and mortality, but evidence suggests that there are also underlying biological differences that contribute to the disparity. This review summarizes biological differences which could contribute to the sex disparity. Sex hormones and other biologically active molecules, tumor cell genetic differences, and differences in the immune system and its response to lung cancer are highlighted. How some of these differences contribute to disparities in the response to therapies, including cytotoxic, targeted, and immuno-therapies, is also discussed. We end the study with a discussion of our perceived future directions to identify the key biological differences which could contribute to sex disparities in lung cancer and how these differences could be therapeutically leveraged to personalize lung cancer treatment to the individual sexes.

Factors Predictive of Primary Resistance to Immune Checkpoint Inhibitors in Patients with Advanced Non-Small Cell Lung Cancer

INTRODUCTION

Primary resistance to immune checkpoint inhibitors (ICI) is observed in routine clinical practice. We sought to determine factors predictive of primary resistance to ICI monotherapy, defined by the Society for Immunotherapy of Cancer (SITC) as progression within 6 months of ICI treatment with patients receiving at least 6 weeks of ICI monotherapy, in patients with advanced non-small-cell lung cancer (NSCLC).

METHOD

Patients with stage IV NSCLC treated with at least 6 weeks of single-agent ICI at two tertiary hospitals in Singapore were included. A multivariate logistic regression model was utilised to elucidate factors predictive of primary resistance to ICI.

RESULTS

Of the 108 eligible patients, 59 (54.6%) experienced primary resistance. The majority were male (65.7%), smokers (66.3%), Chinese (79.6%), had adenocarcinoma (76.9%), received Pembrolizumab (55.6%) and received immunotherapy treatment in the later line setting (≥2 lines) (61.1%). Female gender (aOR = 3.16, p = 0.041), a sixth-week neutrophil-to-lymphocyte ratio (NLR) of ≥3) (aOR = 3.454, p = 0.037) and a later line of immunotherapy treatment (≥2 lines) (aOR = 2.676, p = 0.040) were factors predictive of primary resistance to ICI monotherapy in patients with advanced NSCLC.

CONCLUSIONS

Using SITC criteria, an elevated NLR (≥3) at 6 weeks, female gender and a later line of immunotherapy treatment (≥2 lines) were predictive factors of developing primary resistance to ICI monotherapy in patients with advanced NSCLC.

Sarcoma Patients Admitted to the Intensive Care Unit (ICU): Predictive Relevance of Common Sepsis and Performance Parameters

Purpose

Prognosis of sarcoma patients is improving, with a better understanding of sarcomagenesis revealing novel therapeutic targets. However, aggressive chemotherapy remains an essential part of treatment, bearing the risk of severe side effects that require intensive medical treatment. Available data on the characteristics and clinical outcome of sarcoma patients admitted to intensive care units (ICU) are sparse.

Patients and Methods

We performed a retrospective analysis of sarcoma patients admitted to the ICU from 2005 to 2022. Patients ≥18 years with histologically proven sarcoma were included in our study.

Results

Sixty-six patients were eligible for analysis. The following characteristics had significant impact on overall survival: sex (p=0.046), tumour localization (p=0.02), therapeutic intention (p=0.02), line of chemotherapy (p<0.001), SAPS II score (p=0.03) and SOFA score (p=0.02).

Conclusion

Our study confirms the predictive relevance of established sepsis and performance scores in sarcoma patients. For overall survival, common clinical characteristics are also of significant value. Further investigation is needed to optimize ICU treatment of sarcoma patients.

Low on-treatment levels of serum soluble CD8 (sCD8) predict better outcomes in advanced non-small cell lung cancer patients treated with atezolizumab

BACKGROUND

Immunotherapy has changed the paradigm of treating non-small cell lung cancer (NSCLC). But, selecting patients who will achieve long-term benefits from treatment remains unsatisfactory. Here, we investigated the possible use of the soluble form of CD8 antigen (sCD8) in predicting durable disease control after PD-1/PD-L1 blockade. CD8 is a marker of the cytotoxic T lymphocytes. Its soluble form (sCD8) is secreted under activation of the immune system but also has immunosuppressive properties. The data about serum sCD8 in patients dosed with anti-PD-1/PD-L1 drugs are lacking.

METHODS AND RESULTS

We included 42 NSCLC patients and collected samples at baseline and for the first 3 months of atezolizumab immunotherapy. The serum sCD8 concentrations were measured with the ELISA kit and correlated with treatment outcomes. Patients with durable (≥ 12 months) disease control presented lower serum sCD8 than those without long-term benefits. The sCD8 levels measured at the end of cycle 2 (sCD8.2) were the earliest time point that successfully differentiated patients (3.76 vs. 9.68 ng/mL, respectively, p < 0.001). Individuals with low sCD8.2 (≤ 4.09 ng/mL) presented longer progression-free survival (HR = 0.061, p < 0.001) and overall survival (HR = 0.104, p < 0.05) compared to individuals with high sCD8.2 (median values unreached vs. 4.4 months and 14.4 months for PFS and OS, respectively).

CONCLUSIONS

Serum sCD8 could be an early biomarker of durable disease control after anti-PD-L1 treatment. Higher sCD8 in patients with worse outcomes could suggest the inhibitory effect of sCD8 on cytotoxic T-cells activation.