Immune Checkpoint Inhibitors as A Threat to Reproductive Function: A Systematic Review

Quality of life, neurocognitive functioning, psychological issues, sexuality and comorbidity more than 2 years after commencing immune checkpoint inhibitor treatment

BACKGROUND

Increasing numbers of patients diagnosed with advanced cancer survive long-term after treatment with immune checkpoint inhibitors (ICIs). To design adequate interventions for these survivors, knowledge regarding quality of life (QOL) and its association with long-term and late effects of ICI treatment is required. Therefore, this study aimed to evaluate QOL, neurocognitive function, psychological issues, sexuality, and comorbidities in patients surviving at least 2 years after commencing ICI treatment.

METHODS

We performed a cross-sectional study in patients with stage III-IV melanoma, non-small cell lung cancer (NSCLC), urothelial cell carcinoma (UCC), or renal cell carcinoma (RCC) who survived at least 2 years after the start of ICIs. We assessed QOL, neurocognitive function, psychological issues, sexual function and comorbidity in survivors. Additionally, we evaluated QOL of informal caregivers.

RESULTS

132 survivors (70 melanoma, 50 NSCLC, 12 UCC or RCC) and 80 caregivers were included. Median age was 65 years (range 30-85) and 50 survivors were women (38%). Median time since start and cessation of ICI treatment was 33 (range 21-91) and 18 (range 0-68) months, respectively. Average survivor QOL was comparable to the reference population, but 37 (28%) survivors had poor QOL. Depression and anxiety were negatively correlated with all QOL domains. Although immune-related adverse events were common, there was no association with lower QOL. Caregiver and survivor QOL were only weakly related. Neurocognitive concerns and formally tested neurocognitive impairment were present in 22 (17%) and 13 (15%) survivors, respectively, and were not associated with a diagnosis of brain metastases. Men had a high prevalence of erectile dysfunction and low sexual satisfaction. Half of the survivors met the criteria for the metabolic syndrome.

CONCLUSIONS

At least 2 years after the start of ICI treatment, one-quarter of cancer survivors had a clinically relevant lower QOL. This was associated with symptoms of depression and anxiety, but not with immune-related adverse events. Sexual issues and metabolic syndrome are prevalent. Survivorship care should address these issues in this population.

Resveratrol alleviates testicular toxicity induced by anti-PD-1 through regulating the NRF2-SLC7A11-GPX4 pathway

Background

Fertility preservation is a critical concern for reproductive-age cancer survivors, as conventional cytotoxic therapies can cause irreversible damage to the reproductive system, potentially depriving them of the ability to have children in the future. Immune checkpoint inhibitors (ICIs), including anti-programmed cell death protein 1 (anti-PD-1), have become a standard therapeutic approach for various malignancies. However, the impact of ICIs on reproductive function and fertility is not well understood and remains a largely unexplored domain. Resveratrol (RSV), a plant-derived compound, has shown potential as an nuclear factor erythroid 2-related factor 2 (NRF2) agonist to counteract reproductive toxicity induced by various diseases, drugs, and environmental toxins.

Methods

Male C57BL6/J mice with B16 melanoma were assigned into four groups. RSV and ICI/RSV groups received RSV (40 mg/kg) orally every other day for one month, while controls received the vehicle. ICI and ICI/RSV groups were injected with anti-PD-1 antibody (10 mg/kg) weekly, and controls received IgG2b kappa antibody. Parameters like body and testicular weight, sperm concentration, and western blot for ferroptosis markers were measured. Furthermore, oxidative stress biomarkers, lipid oxidation factors, and gonadal hormone levels were quantified using commercial kits.

Results

Anti-PD-1 therapy caused male reproductive dysfunction, as evidenced by reduced sperm concentration, altered gonadal hormone levels, and disruption of blood-testis barrier (BTB) integrity. Furthermore, ferroptosis was a key mechanism in anti-PD-1-induced testicular dysfunction, characterized by disrupted iron homeostasis, elevated lipid peroxidation, and suppression of the system Xc-/glutathione peroxidase 4 (GPX4) axis. Additionally, anti-PD-1 therapy diminished antioxidant defenses by inhibiting the NRF2 pathway, thereby increasing the susceptibility to ferroptosis. Crucially, RSV treatment ameliorated anti-PD-1-induced reproductive dysfunction. This was achieved by reducing T cell infiltration, lowering interferon-gamma levels, activating the NRF2 pathway, and maintaining iron and lipid homeostasis.

Conclusions

Our study demonstrates that anti-PD-1 triggers oxidative stress and ferroptosis in the testis, causing male reproductive dysfunction. RSV may offer protection against testicular toxicity associated with anti-PD-1, particularly through its antioxidant and anti-ferroptosis properties.

Pharmacovigilance analysis of immune checkpoint inhibitor-related reproductive adverse effects based on the FDA adverse event reporting system

This study aims to investigate the adverse effects of immune checkpoint inhibitors (ICIs) on the female and male reproductive systems. In the FDA Adverse Event Reporting System (FAERS) database, adverse reactions under the "Reproductive system and breast disorders" category in the System Organ Classes were included, covering a period from January 1, 2015, to June 30, 2023. We identified 133,512 patients treated with ICIs. Immune checkpoint inhibitor-related reproductive adverse effects (irRAEs) were reported in 568 (0.43%) patients. Spermatogenesis abnormality (ROR025 = 7.91) had the highest signal strength associated with ICI use in males. Genital tract fistula was the only significant irRAE (ROR025 = 2.72) in females. PD-1 inhibitors pose greater risk than CTLA-4 inhibitors (OR = 1.65 [1.05-2.79], p = 0.045). Gynecologic cancers in females (OR = 3.77 [2.82-4.99], p < 0.0001) and urogenital cancers in males (OR = 1.56 [1.17-2.06], p = 0.0018) carried the highest risk compared to other cancers. Additional targeted drugs (OR = 2.32 [1.76-3.02], p < 0.0001), particularly lenvatinib (OR = 3.50 [2.48-4.94], p < 0.0001) and cabozantinib (OR = 3.71 [1.96-7.03], p < 0.0001) significantly increased the risk for females. Additional use of chemotherapy drugs was associated with a significant reduction in the risk for males (OR = 0.65 [0.42-0.96], p = 0.042) except for doxorubicin (OR = 2.58 [1.22-5.47], p = 0.013) and cyclophosphamide (OR = 2.36 [1.05-5.29], p = 0.038). This study demonstrates that ICIs could potentially lead to a wide range of adverse effects in the reproductive system in both males and females.

The efficacy and safety of relatlimab/nivolumab combination therapy in patients with advanced melanoma: a systematic review

Finding a treatment approach with high efficacy and minimal adverse reactions for advanced melanoma is still challenging. This study aimed to review and summarize available evidence regarding the effectiveness of the newly FDA-approved combination therapy of Relatmlimab and Nivolumab in patients with advanced melanoma and its comorbidities. We searched MEDLINE, EMBASE, and Cochrane Library for studies published in any language till 29/11/2023. We used the following Mesh and Emtree words, "melanoma" AND "relatlimab" AND "nivolumab". We screened 398 articles and included two single-arm clinical trials (N = 2) and one randomized clinical trial (RCT) (N = 1). In conclusion, The relatlimab/nivolumab combination therapy showed promising results for advanced melanoma patients. However, further research and longer follow-up periods are needed to compare it with previous treatments and validate its long-term effectiveness and safety.

Carnitine traffic and human fertility

Carnitine is a vital molecule in human metabolism, prominently involved in fatty acid β-oxidation within mitochondria. Predominantly sourced from dietary intake, carnitine also derives from endogenous synthesis. This review delves into the complex network of carnitine transport and distribution, emphasizing its pivotal role in human fertility. Together with its role in fatty acid oxidation, carnitine modulates the acety-CoA/CoA ratio, influencing carbohydrate metabolism, lipid biosynthesis, and gene expression. The intricate regulation of carnitine homeostasis involves a network of membrane transporters, notably OCTN2, which is central in its absorption, reabsorption, and distribution. OCTN2 dysfunction, results in Primary Carnitine Deficiency (PCD), characterized by systemic carnitine depletion and severe clinical manifestations, including fertility issues. In the male reproductive system, carnitine is crucial for sperm maturation and motility. In the female reproductive system, carnitine supports mitochondrial function necessary for oocyte quality, folliculogenesis, and embryonic development. Indeed, deficiencies in carnitine or its transporters have been linked to asthenozoospermia, reduced sperm quality, and suboptimal fertility outcomes in couples. Moreover, the antioxidant properties of carnitine protect spermatozoa from oxidative stress and help in managing conditions like polycystic ovary syndrome (PCOS) and endometriosis, enhancing sperm viability and fertilization potential of oocytes. This review summarizes the key role of membrane transporters in guaranteeing carnitine homeostasis with a special focus on the implications in fertility and possible treatments of infertility and other related disorders.

Fertility Preservation in the Era of Immuno-Oncology: Lights and Shadows

In recent years, immuno-oncology has revolutionized the cancer treatment field by harnessing the immune system's power to counteract cancer cells. While this innovative approach holds great promise for improving cancer outcomes, it also raises important considerations related to fertility and reproductive toxicity. In fact, most young females receiving gonadotoxic anti-cancer treatments undergo iatrogenic ovarian exhaustion, resulting in a permanent illness that precludes the vocation of motherhood as a natural female sexual identity. Although commonly used, oocyte cryopreservation for future in vitro fertilization and even ovarian cortex transplantation are considered unsafe procedures in cancer patients due to their oncogenic risks; whereas, ovarian stem cells might support neo-oogenesis, providing a novel stemness model of regenerative medicine for future fertility preservation programs in oncology. Recent scientific evidence has postulated that immune checkpoint inhibitors (ICIs) might in some way reduce fertility by inducing either primary or secondary hypogonadism, whose incidence and mechanisms are not yet known. Therefore, considering the lack of data, it is currently not possible to define the most suitable FP procedure for young patients who are candidates for ICIs. In this report, we will investigate the few available data concerning the molecular regulation of ICI therapy and their resulting gonadal toxicity, to hypothesize the most suitable fertility preservation strategy for patients receiving these drugs.