Health-related quality of life in cancer patients treated with immune checkpoint inhibitors in randomised controlled trials: A systematic review and meta-analysis

Patient views on continued immune checkpoint inhibition following progression in advanced melanoma: A qualitative study

INTRODUCTION

Immune checkpoint inhibition has revolutionized the management of metastatic melanoma, including in the final stages of disease progression: because it is well tolerated, some teams do not discontinue it in hopes of slowing disease progression. The risks are that treatment may be continued unnecessarily, causing side effects, and reduce access to specialist palliative care, in addition to increasing the cost of treatment.

METHOD

We explored the experiences of 10 patients in a university hospital with metastatic melanoma under continued immune checkpoint inhibitors combined with specialist palliative care. Our goal was to gain a better understanding of the advantages and disadvantages perceived by patients. The comprehensive interviews were analysed using a method inspired by grounded theory that met the COREQ international recommendation criteria.

RESULTS

Receiving the information of disease progression, continued treatment and onset of palliative care impacts patients' lives: from this point onwards, death becomes a reality and takes on the image of a sword of Damocles. The experience is anxiety-provoking because of the uncertainty of tomorrow, and painful because of the physical suffering and successive bereavements. However, far from causing depression and despair, joint oncology-palliative management is well accepted and helps to improve patients' daily lives and well-being.

CONCLUSION

Our findings highlight patients' ambivalence. On the one hand, they recount their experiences of suffering in connection with the disease and the confrontation with death, and on the other hand, their need to continue to live and to hope. Joint care provided by oncology and palliative care teams, symbolically representing hope and death, may mirror patients' psychological mindset and provide just the support they need.

Identification of the PROMs used to assess ICI toxicities and HRQoL in patients receiving immune checkpoint inhibitor treatment in cancer care and their suitability: A systematic review

BACKGROUND

The implementation of patient-reported outcome measures (PROMs) in the clinical identification of immunotherapy toxicities is a complex intervention. There has been very little work evaluating the clinical utility and generalisability of PROMs used after immune checkpoint inhibitor (ICI) treatment to date. We reviewed evidence on the use of PROMs assessing toxicities and health-related quality of life in patients treated with ICIs.

METHODS

PubMed, EMBASE, MEDLINE, PsycInfo, CINAHL, Web of Knowledge, the Cochrane Library were searched (January 2008 - October 2024). Quantitative studies reporting the use of PROMs to identify, assess and manage toxicities at any timepoint and HRQoL associated with ICI treatment in adult patients with cancer were included. A narrative synthesis describes the key characteristics of the PROMs identified.

RESULTS

43 studies were included; 12 on melanoma/skin, 12 on lung and 19 on other cancers. Study designs included 20 randomised controlled trials, 14 cohort studies, six cross-sectional studies and three non-randomised interventional trials. The lack of ICI-specific PROMs was highlighted, particularly as the PROMs used lacked sufficient sensitivity for ICI treatments.

CONCLUSIONS

There is need for an ICI-specific PROM for effective assessment of toxicities and a tailored PROM for assessment of HRQoL. Some suggested key domains by certain studies for ICI-specific PROMs include: (a) ICI-specific items (e.g. certain USD-I and PRO-CTCAE items) to capture symptoms associated with ICI treatments such as rash, myalgia, (b) role, psychological, emotional and social functioning domains within HRQoL assessments and (c) additional patient-reported toxicities not included in existing PROMs. Findings emphasize the importance of using a disease-specific PROM that is applicable, acceptable and sufficiently sensitive to identify toxicities and HRQoL issues across all stages.

Immune Checkpoint Inhibitors and Cognition in Adults with Cancer: A Scoping Review

Cancer-related cognitive decline refers to a deterioration in cognitive function affecting adults with cancer at any stage of their cancer journey. Older adults are at increased risk of cognitive decline. As the indications for immune checkpoint inhibitors expand in the treatment of cancer, understanding the potential complicating cognitive issues experienced by those receiving this therapy will be important. The aim of this scoping review is to identify the literature regarding immune checkpoint inhibitors and subjective/objective decline, to identify evidence in older adults, differences between older and younger adults, and outline areas for further research. Four large electronic databases were searched. Records were screened using standardised methodology. Ten studies were identified that met the inclusion criteria for review. Six studies objectively evaluated cognitive function in adults receiving ICI treatment; eight studies performed subjective cognitive assessments. There were differences identified in the cognitive assessment tools used and the methodology between studies. Few studies reported on age-dependent findings. The results of this scoping review highlight the need for further research in this area using standardised methodology and testing, with a particular focus on the cognitive outcomes of older adults who may be at increased risk of developing cognitive decline while on treatment.

Changes in global quality of life after treatment with immune checkpoint inhibitors in patients receiving different treatment regimens for advanced stage lung cancer in the Netherlands: a 2015-2021 cohort study

BACKGROUND

The introduction of immune checkpoint inhibitors (ICIs) has modified treatment modalities for patients with lung cancer, offering new alternatives for treatment. Despite improved survival benefits, ICIs may cause side effects impacting patients' quality of life (QoL). We aim to study the changes in global QoL (gQoL) of patients with advanced-stage lung cancer up to 18 months after treatment with ICIs between 2015 and 2021.

METHODS AND ANALYSIS

A longitudinal cohort study was conducted using the Oncological Life Study: Living well as a cancer survivor data-biobank from the University Medical Center Groningen. Participants completed the European Organisation for Research and Treatment of Cancer QoL 30-item questionnaire, at the beginning of their ICI treatment (baseline) and then at 6, 12 and 18 months. Using joint modelling, changes in predicted mean gQoL were studied by treatment regimens from baseline to 18 months, while accounting for the competing risk of death and adjusting for prespecified covariates.

RESULTS

Of the 418 participants with median age of 66 years, 39% were women. Patients receiving first-line immuno-monotherapy with palliative intent had a small improvement in their gQoL within 6 months and no clinically significant change thereafter. Patients receiving first-line immune-chemotherapy with palliative intent had a small improvement in their gQoL within 12 months and no clinically significant change thereafter. Patients with second/further line immunotherapy with palliative intent or first-line chemoradiotherapy followed by durvalumab with curative intent had no clinically significant change in their gQoL over 18 months.

CONCLUSION

The changes in gQoL over time among patients with advanced-stage lung cancer may vary by treatment regimens based on drug intensity, line and intent of treatment, which will help clinicians and patients understand the potential dynamic of treatments on QoL. It may further influence treatment decisions and patient management strategies, reflecting the practical implications of different treatment regimens.

An evaluation of durvalumab across the spectrum of urothelial carcinoma

INTRODUCTION

Urothelial carcinoma is a common malignancy affecting the urinary system, with the spectrum of disease encompassing non-muscle invasive, muscle-invasive and metastatic disease. On a background of almost half a century of immunogenic management with BCG, various immune checkpoint inhibitors, including durvalumab, have now demonstrated clinical efficacy in the treatment of urothelial carcinoma.

AREAS COVERED

This article reviews the available literature on durvalumab in the treatment of urothelial carcinoma for all stages of the disease including mechanisms of action, pharmacokinetics, efficacy and safety and covers a broad portfolio of reported and ongoing trials.

EXPERT OPINION

The management of UC is rapidly evolving, which is reflected in the diverse range of upcoming pivotal trials incorporating durvalumab with additional immunomodulatory agents and therapeutics targeting key oncogenic pathways, each with the potential to change the standard of care. As the complexity of UC management increases, future efforts should be directed at identifying better predictive biomarkers and selecting rational synergistic combinations from the novel treatments available. This will allow the addressing of existing gaps, facilitate the exploitation of new techniques of treatment delivery and ultimately deliver more personalized and efficacious care to the individual patient.

Quality of life under treatment with the immune checkpoint inhibitors ipilimumab and nivolumab in melanoma patients. Real-world data from a prospective observational study at the Skin Cancer Center Kiel

PURPOSE

Combined immunotherapy (ipilimumab + nivolumab) has improved survival in stage IV melanoma patients, making Health-related Quality of Life (HrQoL) crucial due to potential immune-related adverse events (irAEs). Previous studies treated HrQoL as secondary/explorative endpoint, and no specific HrQoL questionnaire for melanoma patients on immune checkpoint inhibitor (ICI) therapy exists. This study aimed to gather specific HrQoL data during combined ICI therapy, tracking changes during and after treatment, and examining associations with gender, irAEs, and treatment response.

METHODS

35 melanoma patients (22 males, 13 females) undergoing combined ICI were surveyed using the Short-form 36 questionnaire (SF-36), the Inflammatory Bowel Disease Questionnaire - Deutsch (IBDQ-D), and the distress thermometer (DT). HrQoL was evaluated during treatment, after six months, and at the onset of autoimmune colitis.

RESULTS

irAEs occurred in 51.4% of patients, with colitis being the most common (26.1%). 45.7% had progressive disease. SF-36 showed stable HrQoL during treatment and follow-up. Women had worse HrQoL on the physical component scale than men (p = 0.019). Patients with progression showed worse HrQoL over time in physical (p = 0.015) and mental health scales (p = 0.04). IBDQ-D showed constant HrQoL throughout treatment and follow-up. Distress on DT remained constant, with women reporting higher levels of distress.

CONCLUSION

HrQoL remained stable during and after therapy. Female gender and disease progression negatively impacted HrQoL. The development of irAEs was not associated with HrQoL, though this may not apply to severe irAEs like colitis, which were not assessed.

The Impact of Immune Checkpoint Inhibitors-Induced Skin Toxicity on Patients Quality of Life and the Role of Dermatologic Intervention

INTRODUCTION

Data regarding quality of life (QoL) of oncologic patients experiencing dermatologic immune-related adverse events (dirAEs) and their course after dermatologic intervention are scarce.

OBJECTIVES

To assess the impact of dirAEs on patients QoL and to investigate the correlation between dermatologic and oncologic indexes used for estimating QoL.

METHODS

We enrolled oncologic patients with dirAEs managed in two supportive onco-dermatology outpatient clinics in Greece. Patient-reported outcomes included DLQI, EORTC-QLQ-C30 and Numerical Rating Scale for pruritus (pNRS).

RESULTS

Overall, 110 patients were enrolled in the study. Mean (standard deviation) DLQI and pNRS scores were 15.54 (5.44) and 7.25 (2.95), correspondingly, while functional, symptom and summary scores of EORTC-C30 were 79.17 (2.11), 17.66 (3.60) and 80.67 (3.08), respectively. After therapeutic interventions, there was a statistically significant decrease in DLQI scores after first intervention compared to baseline, and second intervention compared to first (mean decrease 4.38 (2.91), P < 0.001 and 5.16 (3.99), P < 0.001, respectively). DLQI showed no correlation with global health status/QoLs (rho 0.01, P = 0.90) of EORTC-C30.

CONCLUSIONS

DirAEs negatively affect QoL. Dermatologic intervention improves patients QoL, facilitating an unimpaired oncologic treatment. Poor correlation between DLQI and EORTC-QLQ-30 highlights the need for adapted QoL measurement tools in the context of immune checkpoint inhibitors treatment.

Guidelines for the diagnosis and treatment of cutaneous squamous cell carcinoma: a GRADE approach for evidence evaluation and recommendations by the Italian Association of Medical Oncology

Cutaneous squamous cell carcinoma (CSCC) accounts for ∼20%-25% of all skin tumors. Its precise incidence is often challenging to determine due to limited statistics and its incorporation with mucosal forms. While most cases have a favorable prognosis, challenges arise in patients presenting with locally advanced or metastatic forms, mainly appearing in immunocompromised patients, solid organ transplantation recipients, or those facing social difficulties. Traditionally, chemotherapy and targeted therapy were the mainstays for advanced cases, but recent approvals of immunotherapeutic agents like cemiplimab and pembrolizumab have revolutionized treatment options. These guidelines, developed by the Italian Association of Medical Oncologists (AIOM) using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach, aim to guide clinicians in diagnosing, treating, and monitoring patients with CSCC, covering key aspects from primitive tumors to advanced stages, selected by a panel of experts selected by AIOM and other national scientific societies. The incorporation of these guidelines into clinical practice is expected to enhance patient care and address the evolving landscape of CSCC management.

Effects of medical interventions on health-related quality of life in chronic disease - systematic review and meta-analysis of the 19 most common diagnoses

Introduction

The demographic shift leads to a tremendous increase in age-related diseases, which are often chronic. Therefore, a focus of chronic disease management should be set on the maintenance or even improvement of the patients' quality of life (QoL). One indicator to objectively measure QoL is the EQ-5D questionnaire, which was validated in a disease- and world region-specific manner. The aim of this study was to conduct a systematic literature review and meta-analysis on the QoL across the most frequent chronic diseases that utilized the EQ-5D and performed a disease-specific meta-analysis for treatment-dependent QoL improvement.

Materials and methods

The most common chronic disease in Germany were identified by their ICD-10 codes, followed by a systematic literature review of these ICD-10 codes and the EQ-5D index values. Finally, out of 10,016 independently -screened studies by two persons, 538 studies were included in the systematic review and 216 studies in the meta-analysis, respectively.

Results

We found significant medium to large effect sizes of treatment effects, i.e., effect size >0.5, in musculoskeletal conditions with the exception of fractures, for chronic depression and for stroke. The effect size did not differ significantly from zero for breast and lung cancer and were significantly negative for fractures.

Conclusion

Our analysis showed a large variation between baseline and post-treatment scores on the EQ-5D health index, depending on the health condition. We found large gains in health-related quality of life mainly for interventions for musculoskeletal disease.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020150936, PROSPERO identifier CRD42020150936.

The Symptom Experience of Patients with Advanced Melanoma Undergoing Immune Checkpoint Inhibitor (ICI) Therapy

OBJECTIVES

The advent of immune checkpoint inhibitor (ICI) therapy has vastly improved outcomes for patients with advanced melanoma. However, the symptom burden and intensity with their impact on quality-of-life (HRQoL) and functionality are heterogeneous and unpredictable. We used descriptive exploratory content analysis from interviews to capture the patient experience after they had completed quantitative data collection of their symptom burden and interference with the use of two patient-reported outcome (PRO) instruments.

DATA SOURCES

Participants from a single center with advanced melanoma (n = 19) who are undergoing ICI therapy completed the Modified MD Anderson Symptom Inventory and Functional Assessment of Cancer Therapy-Melanoma and recorded semistructured interviews. Interpretive description informed the inductive and iterative analysis approach.

CONCLUSION

Participants had a heterogenous experience of ICI and melanoma-related symptoms: distress (84%), fatigue (68%), rash or skin changes (53%), pain (30%), diarrhea (30%), itching (26%), and shortness of breath (21%), with varying interference within HRQoL domains, mood (47%), relations with other people (26%), and activity (21%). Some noted a lack of physical interference (79%). Uncertainty was a pervasive theme in the interviews (68%) despite the majority having positive thoughts about ICI therapy (58%) and expectations of the success of therapy (53%). The physical and emotional burden of a melanoma diagnosis, undergoing therapy, and the uncertainty of the outcomes are pervasive for patients.

IMPLICATIONS FOR NURSING PRACTICE

Communication surrounding the diagnosis, prognosis, treatment options, and outcomes need to be clear and acknowledge there are unknowns. Nurses may benefit from using a validated PRO instrument to help document and understand the patient's symptom experience while undergoing ICI therapy.

Clinical benefit of anti-PD-(L)1 immunotherapies in advanced cancer in France: a population-based estimate from 2014 to 2021

BACKGROUND

In France, the potential benefit of new treatments is initially evaluated by the Haute Autorité de Santé to determine reimbursement and pricing, but rarely afterwards. Although immunotherapies (ITs) have considerably improved the survival of patients, few data are available on their long-term benefit at a population-treated level. The present retrospective study aimed to assess the clinical benefit of ITs compared to the previous standards of care (SoCs) in France from 2014 to 2021.

MATERIALS AND METHODS

To do this, we analyzed all ITs from the anti-programmed cell death protein 1/programmed death-ligand 1 [anti-PD-(L)1] class used in monotherapy or in association with another treatment available in early access or reimbursed in France between 2014 and 2021, regardless of indication. The number of patients initiating an IT was retrieved by year, drug and indication. Using extrapolated Kaplan-Meier curves, utility scores and the population treated, the clinical benefit was expressed as the number of deaths prevented (DP), life-years (LYs) and quality-adjusted life years (QALYs) gained compared to previous SoC.

RESULTS

Across the period, five ITs were marketed in 21 indications related to eight primary tumor sites. Between 2014 and 2021, 132 924 patients initiated an IT. By December 2021, 16 173 (13 804-17 141) deaths were delayed compared to previous SoC, mainly in lung cancer. Compared to their SoC, ITs provided a gain of 37 316 (33 581-41 048) additional LYs and 27 709 (23 784-30 450) additional QALYs. Lung cancer was the driver indication with 70.6% of LYs and 68.4% of QALYs gained followed by melanoma with 18.7% and 20.4% of the gain, respectively.

CONCLUSIONS

Significant gains in DP, LYs and QALYs have been observed in France following the introduction of ITs.

Associations between age and patient-reported outcomes, emergency department visits, and hospitalizations among lung cancer patients receiving immune checkpoint inhibitors

OBJECTIVE

Immune checkpoint inhibitors (ICIs) for lung cancer (LC) treatment have a more favorable safety profile and improved patient reported outcomes (PROs) compared to chemotherapy, suggesting that ICIs are advantageous for older populations. The impact of ICIs on PROs, clinical outcomes, and age in LC patients remains to be established. We examined associations between age and PROs, emergency department (ED) visits, and hospitalizations in LC patients receiving ICIs.

METHODS

We performed retrospective analyses via My Wellness Check (MWC), an assessment and triage electronic medical record (EMR) integrated platform in LC patients receiving ICIs. Demographics, clinical characteristics, ED visits, and hospitalizations were extracted via EMR. Patient reported outcomes (PROMIS® anxiety, depression, fatigue, pain, physical function), and health-related quality of life (HRQOL; FACT-G7), were collected via MWC. We classified age into three categories (<65, 65-74, ≥75). Multiple regressions examined associations between PROs and age. Cox proportional hazards regressions assessed cumulative ED visits and hospitalizations.

RESULTS

Among LC patients (N = 190) receiving ICIs, patients ≥75 had lower depression (β = -5.80, p = 0.01) and higher HRQOL (β = 2.47, p = 0.05) compared with patients <65. Relative to patients <65, patients 65-74 had lower anxiety (β = -3.31, p = 0.05) and pain (β = -4.18, p = 0.03). Patients 65-74 and ≥ 75 had lower risk of an ED visit (adjusted hazards ratio [aHR] = 0.45, p = 0.05 and aHR = 0.21, p = 0.05, respectively) and patients 65-74 had lower risk of hospitalization (aHR = 0.36, p = 0.02) relative to patients <65.

CONCLUSIONS

Older LC patients (65-74; ≥75) have more favorable PROs and lower risk for negative clinical outcomes than younger (<65) patients.

Health-Related Quality of Life With Nivolumab Plus Chemotherapy Versus Chemotherapy in Patients With Advanced Gastric/Gastroesophageal Junction Cancer or Esophageal Adenocarcinoma From CheckMate 649

PURPOSE

In CheckMate 649, first-line nivolumab plus chemotherapy prolonged overall survival versus chemotherapy in patients with advanced/metastatic non-human epidermal growth factor receptor 2 (HER2)-positive gastric/gastroesophageal junction cancer (GC/GEJC) or esophageal adenocarcinoma (EAC). We present exploratory patient-reported outcomes (PROs).

METHODS

In patients (N = 1,581) concurrently randomly assigned 1:1 to nivolumab plus chemotherapy or chemotherapy and in those with tumor PD-L1 expression at a combined positive score (CPS) of ≥5, health-related quality of life (HRQoL) was assessed using the EQ-5D and Functional Assessment of Cancer Therapy-Gastric (FACT-Ga), which included the FACT-General (FACT-G) and Gastric Cancer subscale (GaCS). The FACT-G GP5 item assessed treatment-related symptom burden. Longitudinal changes in HRQoL were assessed using mixed models for repeated measures in the PRO analysis population (randomly assigned patients with baseline and ≥1 postbaseline assessments). Time to symptom or definitive deterioration analyses were also conducted.

RESULTS

In the PRO analysis population (n = 1,360), PRO questionnaire completion rates were mostly >80% during treatment. Patient-reported symptom burden was not increased with nivolumab plus chemotherapy versus chemotherapy. Mean improved changes from baseline were greater with nivolumab plus chemotherapy versus chemotherapy for FACT-Ga total, GaCS, and EQ-5D visual analog scale in patients with a CPS of ≥5; results were similar for the overall PRO analysis population. In CPS ≥5 and all randomly assigned populations, nivolumab plus chemotherapy reduced the risk of symptom deterioration versus chemotherapy, on the basis of FACT-Ga total score and GaCS; time to definitive deterioration was longer, and the risk of definitive deterioration in HRQoL was reduced with nivolumab plus chemotherapy across EQ-5D and most FACT-Ga measures (hazard ratio [95% CI] <1).

CONCLUSION

Compared with chemotherapy alone, first-line nivolumab plus chemotherapy showed stable or better on-treatment HRQoL in patients with advanced/metastatic non-HER2-positive GC/GEJC/EAC and also showed decreased risk of definitive HRQoL deterioration.

Impact of Immune Checkpoint Inhibitor Therapy on Quality of Life in Patients With Advanced Melanoma: A Systematic Review

BACKGROUND

Immune checkpoint inhibitors (ICIs) were approved to treat advanced melanoma (AM) because of meaningful clinical benefit. These early data reported that ICI therapy is generally well tolerated, and despite symptoms, patients reported a high global health-related quality of life (HRQOL).

OBJECTIVE

Immune checkpoint inhibitors are widely used in the oncology community; the aim of this systematic review was to evaluate current data on ICI therapy and its impact on HRQOL of patients with AM.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed during this systematic review to identify and select studies from the PubMed, OVID, EMBASE, and Cochrane databases. Selected studies were downloaded into Covidence and analyzed for trends in how ICI therapy impacts HRQOL in patients with AM. Multiple tools were used to assess the quality of the studies.

RESULTS

The 16 studies included 12 quantitative, 2 qualitative, and 2 mixed-methods studies. The quality of the studies was moderate (n = 7) or strong (n = 9). Symptoms that impacted HRQOL were fatigue, endocrine dysfunction, rash, diarrhea, cognitive impairment, emotional impact (anxiety and depression), and financial toxicity. Suicidal ideation and 1 attempt were reported in 2 studies, which had not been previously published.

CONCLUSION

Patient-reported symptoms due to ICI negatively impacted HRQOL. Anxiety and depression are prevalent. Current QOL instruments do not capture the entire patient experience.

IMPLICATIONS FOR PRACTICE

Patients need to be asked if their symptoms are impacting their HRQOL. Further prospective research is needed to develop or adjust current patient-reported outcome instruments to adequately capture the impact of ICIs on HRQOL.

Linkage between Psychological Factors and Response to Immune Checkpoint Inhibitor Therapy: A Preliminary Study

Substantial evidence has accumulated showing that psychological distress affects immune regulation, the response to cancer treatment, and survival. The effect of psychological parameters on the effectiveness of immune checkpoint inhibitor (ICI) treatment has not yet been studied. This preliminary study aimed to (a) examine the associations between psychological factors and responses to ICI treatment and (b) assess the associations between psychological factors and blood measures of sPD-1, sCTLA-4, and cytokines that may alter the effect of ICI treatment. The participants were 62 individuals with advanced cancer, aged 18 years or older, who were candidates for ICI treatment as a new line of treatment. The participants answered questionnaires and provided blood samples and medical data prior to the start of ICI treatment and 3 months after. Perceived health status was positively associated with better responses to ICI treatment. In the subsample of participants with biomarkers, worse health-related quality of life was associated with higher IL-6 and sCTLA-4; emotional distress and sleep difficulties were associated with higher sCTLA-4; and better perceived health was associated with lower IL-6 and TNFα. sPD-1 was not associated with psychological measures. This preliminary study found for the first time that some psychological measures could be linked to responses to cancer treatment, possibly via pro-inflammatory cytokines and sCTLA-4.

Quality of Life with Monoclonal Antibody Therapies for Locally Advanced or Metastatic Urothelial Carcinoma: A Systematic Review

CONTEXT

Monoclonal antibody (mAb) therapies have improved the prognosis for locally advanced or metastatic urothelial cancers (la/mUC) but little is known about health-related quality of life (HRQoL) with this mode of treatment.

OBJECTIVE

To conduct a systematic review of changes in HRQoL global health and domain scores in patients with la/mUC receiving mAb therapies.

EVIDENCE ACQUISITION

MEDLINE and the American Society of Clinical Oncology and European Society for Medical Oncology meeting databases were searched from January 2015 to June 18, 2022 in accordance with the Preferred Reported Items for Systematic Reviews and Meta-Analyses guidelines. Data were updated on February 3, 2023. Eligible studies were prospective trials assessing HRQoL in patients with la/mUC treated with mAbs. Patients treated for local disease or with radiotherapy or chemotherapy alone were excluded. Meta-analyses, reviews, and case reports were excluded. The validity of randomized trials was assessed using the Risk-of-Bias-2 (RoB2) tool and the strength of outcome evidence was rated using the Grading of Recommendations Assessment, Development and Evaluation approach. The data were analyzed via qualitative synthesis of the evidence.

EVIDENCE SYNTHESIS

Of the 1066 studies identified, nine were included (2364 patients); eight were interventional trials and one was an observational study. The mean change in global health score ranged from -2.8 to 1.9. Constipation, fatigue and pain symptoms, and emotional, physical, role and social functioning improved with treatment in at least two studies. No study demonstrated a significant improvement in global health score. Eight studies reported stability. In the RANGE trial, the global health score decreased. Only two studies had high internal validity according to RoB2 assessment. The HRQoL domain certainty was low, with moderate certainty only for the pain symptom domain. Disease- and treatment-related symptoms, tumor shrinkage, and disease recurrence were correlated to HRQoL.

CONCLUSIONS

Patient HRQoL with mAb therapies for la/mUC did not worsen over time. HRQoL is influenced by several factors related to treatment, tumor characteristics, and the patient's health condition. Evidence was moderate at best and further studies are needed.

PATIENT SUMMARY

We reviewed the evidence on health-related quality-of-life for patients with advanced bladder cancer treated with antibody therapies. We found that quality of life does not worsen on treatment, and sometimes improves. We conclude that these treatments do not negatively affect quality of life, but further studies are needed to draw solid conclusions.

Meta-analysis of quality of life in patients with cancer treated with antibody-drug conjugates in randomized controlled trials

Purpose: To evaluate the patient-reported outcomes of patients treated with commercially approved antibody-drug conjugates (ADC) reported in randomized controlled trials (RCT) published up to September 2023. Methods: A meta-analysis of 6430 patients from 12 randomized controlled trials was conducted. Results: No significant change was observed between the groups from baseline to end of treatment and end of follow-up, with a standardized mean difference of -0.08 (95% CI: -0.27-0.12) and 0.01 (95% CI: -0.11-0.12), respectively. Treatment with ADCs delayed the deterioration of patients' clinical condition compared with treatment with non-ADCs, with a hazard ratio of 0.78 (95% CI: 0.67-0.92). Conclusion: ADCs have a good correlation with delay of clinical deterioration in patients with cancer.

Pembrolizumab as first-line treatment for advanced NSCLC in older adults: A phase II clinical trial evaluating geriatric and quality-of-life outcomes

OBJECTIVES

Since specific data on immunotherapy in older adults with advanced non-small cell lung cancer (aNSCLC) are scarce, we designed this study to determine the overall survival (OS) at one year of first-line pembrolizumab in patients older than 70 years with aNSCLC expressing PD-L1. Secondary objectives included progression-free survival, disease-specific survival, response rate, tolerability, quality of life (QoL) changes, and geriatric assessments.

MATERIALS AND METHODS

A single-arm, open-label, phase II clinical trial was carried out by the Spanish Lung Cancer Group between February 2018 and November 2019 at ten active sites in Spain. We included patients 70 years old and older with histological or cytological documented stage IIIB or IV aNSCLC and PD-L1 expression ≥ 1%. Each subject received 200 mg of intravenous pembrolizumab every three weeks for a maximum of two years.

RESULTS

83 patients were recruited for the study and 74 were finally analysed. Most were male (N = 64, 86.5%) and former smokers (N = 51, 68.9%). 24 patients (32.4%) completed at least one year of treatment, 62 (83.7%) discontinued treatment, and 30 (40.5%) experienced disease progression. The median follow-up of our cohort was 18.0 months [range: 0.1-47.7] and 46 patients (62.2%) died during the period of study. The estimated OS at one year was 61.7% (95% CI: 49.6-71.8%) and the median OS of our cohort was 19.2 months (95% CI: 11.3-25.5). QoL tended to improve throughout the study, although the differences were not statistically significant. The main geriatric scores remained stable, except for a worsening in nutritional status (P = 0.004) and an improvement in frailty (P = 0.028).

CONCLUSION

Our results support treating older adults with aNSCLC expressing PD-L1 with pembrolizumab in monotherapy. The stability of most geriatric scores and the positive trend on the patients' QoL should be highlighted, although our results did not reach statistical significance.

Discontinuation of anti-PD1 in advanced melanoma: an observational retrospective study from the Italian Melanoma Intergroup

BACKGROUND

Immunotherapy has improved the survival of patients with stage IV melanoma. In responders, clinical benefits may be long-lasting and persist even after treatment discontinuation. The optimal duration of anti-PD1 (anti-Programmed cell death-1) therapy in metastatic melanoma patients remains to be elucidated. Moreover, limited data are available on clinical outcomes of patients that discontinued anti-PD1 immunotherapy in a real-life setting. The aim of this study was to evaluate the progression-free survival (PFS) in patients with metastatic melanoma who interrupted anti-PD-1 treatment in the in the absence of disease progression.

METHODS

We retrospectively reviewed patients with advanced/metastatic melanoma treated with anti-PD1 immunotherapy at 23 Italian Melanoma Intergroup (IMI) centres. The study investigated the risk of relapse in patients who stopped anti-PD1 therapy due to CR (Complete response), treatment-related toxicity, or by their own choice after a long period of treatment. Clinical and biological factors associated with or without recurrence were evaluated.

RESULTS

The study population included 237 patients. The median age of patients was 68.9 years (standard deviation: 13; range 33-95). The median time on treatment was 33 months (standard deviation: 18, 7; range 1-98). Among the 237 patients, 128 (54%) interrupted the anti-PD1 for CR, 74 patients (31.2%) for adverse events (37 patients in CR, 27 patients in partial response (PR), ten patients in stable disease (SD), and 35 patients (14.8%) by their own choice (12 patients in CR, 17 patients in PR, and 6 patients in SD). After a mean follow-up of 21 months (range 1-81), PFS after anti-PD1 discontinuation was 85.7%. Thirty-four patients (14.3%) developed disease progression after a median of 12 months (range 1-35): ten patients (29.4%) after discontinuation in CR, 17 patients (50%) after discontinuation for treatment-related toxicity (seven in CR, five in PR, five in SD), and seven (20.6%) after discontinuation due to the patient's decision (two in CR, four in PR, one in SD). Only 7.8% of patients who interrupted in CR (10/128), along with 23% of patients who interrupted for limiting toxicity (17/74) and 20% of patients who interrupted by their own choice (7/35), developed recurrence. Regarding patients who discontinued therapy because of CR, we observed a negative association between recurrence and site of primary melanoma, especially mucosal sites (p = <0.05, HR (Hazard ratio) 15.57 IC (confidence interval) 95% 2.64-91.73). Moreover, M1b patients who achieved a CR showed a lower number of relapses (p = <0.05, HR 3.84 IC 95% 1.40-8.48).

CONCLUSIONS

This study shows in a real-life setting that, with anti-PD-1 therapy, long-lasting responses, can be maintained after anti-PD1 interruption. In 70.6% of cases, recurrences were observed among patients who did not obtain a CR at treatment discontinuation.

Neuromuscular and cardiac adverse events associated with immune checkpoint inhibitors: pooled analysis of individual cases from multiple institutions and literature

BACKGROUND

Immune checkpoint inhibitors (ICIs) have revolutionized the management of multiple tumors, due to improved efficacy, quality of life, and safety. While most immune-related adverse events (irAEs) are mild and easily managed, in rare cases such events may be life-threatening, especially those affecting the neuromuscular and cardiac system. The management of neuromuscular/cardiac irAEs is not clear due to the lack of consistent data. Therefore, we carried out a pooled analysis of collected cases from selected Italian centers and individual data from published case reports and case series, in order to improve our understanding of these irAEs.

PATIENTS AND METHODS

We collected retrospective data from patients treated in six Italian centers with ICIs (programmed cell death protein 1 or programmed death-ligand 1 and/or cytotoxic T-lymphocyte antigen 4 inhibitor) for any solid tumor who experienced neuromuscular and/or cardiovascular toxicity. Then, we carried out a search of case reports and series of neuromuscular/cardiac irAEs from ICIs with any solid tumor.

RESULTS

This analysis includes cases from Italian institutions (n = 18) and the case reports identified in our systematic literature search (n = 120), for a total of 138 patients. Among these patients, 50 (36.2%) had complete resolution of their neuromuscular/cardiac irAEs, in 21 (15.2%) cases there was a clinical improvement with mild sequelae, and 53 (38.4%) patients died as a result of the irAEs. Factors significantly associated with worse outcomes were early irAE onset, within the first two cycles of ICI (Fisher P < 0.0001), clinical manifestation of both myositis and myocarditis when compared with patients who developed only myositis or myocarditis (chi-square P = 0.0045), and the development of arrhythmia (Fisher P = 0.0070).

CONCLUSIONS

To the best of our knowledge, this is the largest collection of individual cases of immune-related myocarditis/myositis. Early irAE onset, concurrent development of myositis and myocarditis, as well as occurrence of arrhythmias are associated with worse outcomes and should encourage an aggressive immunomodulatory treatment.

Immune Checkpoint Inhibitors Related to Cardiotoxicity

Immune checkpoint inhibitors (ICIs) have now emerged as a mainstay of treatment for various cancers. Along with development of ICIs, immune-related adverse effects (irAEs) have aroused wide attention. The cardiac irAE, one of the rare but potentially fatal effects, have been reported recently. However, the clinical comprehension of cardiac irAEs remains limited and guidelines are inadequate for cardio-oncologists to tackle the problem. In this review, we have summarized current classifications of, manifestations of, potential mechanisms of, and treatment for ICI-related myocardial injury in order to provide some clues for the understanding of cardiac irAEs in clinical work.

End-of-life impact of concurrent diabetes mellitus and adrenal insufficiency as immune-related adverse events in an advanced non-small cell lung cancer patient

A 49-year-old man diagnosed with metastatic non-small cell lung cancer was treated with immune checkpoint inhibitor (ICI) combination therapy (nivolumab + ipilimumab) as first-line therapy. During the treatment course, the patient developed ICI-associated diabetes mellitus and adrenal insufficiency, and insulin and hydrocortisone replacement therapy (10 mg/day) were initiated for endocrine toxicity. Despite systemic treatment, the disease progressed. Near the end of the patient's life, he was repeatedly hospitalized for diabetic ketoacidosis and adrenal crisis because he could not physically administer insulin subcutaneously or self-administer oral hydrocortisone due to the deterioration of his general condition as a result of disease progression. This case report demonstrates that it is necessary to evaluate not only the impact of immune-related adverse events on short-term quality of life during ICI treatment but also on the patient's end-of-life care.

Quality of life in patients with non-small cell lung cancer treated with PD-1/PD-L1 inhibitors: a systematic review and meta-analysis

Background

Immune checkpoint inhibitors (ICIs) have dramatically prolonged survival in non-small cell lung cancer (NSCLC) patients, but little research had focused on its impact on quality of life (QoL). The purpose of our study was to compare the QoL in patients with NSCLC treated with programmed cell death protein-1/programmed cell death-ligand 1 (PD-1/PD-L1) inhibitors versus chemotherapy.

Methods

We searched for randomized controlled trials utilizing the Quality of Life Questionnaire Core 30 items (QLQ-C30) and the EuroQol Five Dimensions Questionnaire-3L (EQ-5D-3L) to assess the QoL of NSCLC treated with PD-1/PD-L1 inhibitors versus chemotherapy. We collected hazard ratios (HRs) for the time from baseline to the first clinically significant deterioration (TTD) and effect size as the difference in mean change between and within treatment groups in patients’ reported outcomes (PROs). (PROSPERO registration number: CRD42022296680).

Results

In the five trials reported by QLQ-C30, TTD was longer in PD-1/PD-L1 inhibitors compared with control groups (HR = 0.86; 95% CI = 0.76, 0.97; P = 0.013), with similar results in terms of physical function, role function, and pain. The difference in mean change between the PD-1/PD-L1 inhibitors group and the chemotherapy group in QLQ-C30 and EQ-5D VAS was 3.64 (95% CI = 1.62, 5.66; P = 0.001) and 4.74 (95% CI = 2.65, 6.83; P = 0.001), which supported PD-1/PD-L1 inhibitors. However, for the EQ-5D utility index, there was no statistically significant difference between the two groups, with a mean change difference of 0.03 (95% CI = −0.01, 0.07; P = 0.094). The mean change from baseline to follow-up in PD-1/PD-L1 inhibitors group was 2.57 (95% CI = 0.43, 4.71; P = 0.019), and chemotherapy group was −1.31 (95% CI = −3.71, 1.09; P = 0.284), correspondingly. The subgroup analysis showed that no difference was observed between open-label and double-blind trials in patients treated with chemotherapy or PD-1/PD-L1 inhibitors.

Conclusion

In conclusion, PD-1/PD-L1 inhibitors could improve the QoL of patients with NSCLC compared to chemotherapy and reduce unfavorable symptoms during treatment.

Analysis of patient reported outcomes included in the registrational clinical trials of nivolumab for advanced non-small cell lung cancer

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Patients’ perspectives are at the center of value-based oncology care.

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Patient reported outcomes (PROs) guide clinical and regulatory decisions.

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PRO instruments do not capture immune-related adverse events in clinical trials.

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Studies did not accurately report PROs after treatment discontinuation.

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Precise analyses of longitudinal effects of nivolumab on PROs were lacking.

In the era of value-based oncology care, stakeholders are increasingly using patient reported outcomes (PROs) to guide clinical and regulatory decisions. PROs are also included in health technology assessments to guide patient access, drug reimbursement and pricing. We reviewed PROs collected in the United States Food and Drug Administration approved indications of nivolumab in advanced NSCLC. We analyzed the PRO data reported in the CheckMate 9LA (NCT03215706), CheckMate 227 (NCT02477826), CheckMate 057 (NCT01673867), and CheckMate 017 (NCT01642004) registrational clinical trials, and concluded that nivolumab alleviated symptom burden and improved health status of patients in this setting. However, inability of the included PRO instruments to measure immune-related adverse events, differences in the timing of PRO evaluation between treatment groups, incomplete patient participation at all time points, limited patient participation in the later time points, and interpretation of the longitudinal data are key challenges that impede accurate analysis and validation of PROs.

Efficacy of Immune Checkpoint Inhibitors in Patients with Mismatch Repair-Deficient or Microsatellite Instability-High Metastatic Colorectal Cancer: Analysis of Three Phase-II Trials

Programmed cell death ligand 1 (PD-L1) and programmed cell death protein 1 (PD-1) inhibitors are increasingly used in a variety of solid tumors. In patients with DNA mismatch repair-deficient (dMMR)/microsatellite instability-high (MSI-H) metastatic colorectal cancer, their efficacy has been demonstrated in recently published phase-II trials. However, an indirect comparison of effectiveness between pembrolizumab, nivolumab, and nivolumab+ipilimumab is not yet available.

After a standard literature search, we analyzed four overall survival (OS) curves from three phase-II trials. Individual patient data were reconstructed from each curve using a specific web-based technique (Shiny method). Indirect statistical comparisons were made based on hazard ratio (HR) and restricted mean survival time (RMST).

Nivolumab+ipilumumab had a better HR compared with pembrolizumab (0.65, 95% confidence interval [CI], 0.43 to 1.002, p=0.051); the difference being close to statistical significance. In the analysis based on RMST, the combination of nivolumab+ipilimumab showed a significantly longer OS than pembrolizumab (improvement in RMST, 1.08 mos; 95%CI, 0.11 to 2.06; p=0.029). The other two pairwise differences in RMST (nivolumab vs. pembrolizumab and nivolumab+ ipilimumab vs. nivolumab) had a smaller magnitude (0.25 mos, 95%CI, -0.99 to 1.48, and 0.84 mos, 95%CI, -0.40 to 2.07, respectively) and were far from statistical significance.

Our results favoring the combination of nivolumab+ipilimumab in metastatic colorectal cancer must be viewed with caution owing to the indirect nature of our statistical comparisons. With this limitation in mind, the magnitude of the incremental benefit for the above combination treatment was estimated to be around one month over a follow-up of 15 months.