Efficacy and safety of immunochemotherapy, immunotherapy, chemotherapy, and targeted therapy as first-line treatment for advanced and metastatic esophageal cancer: a systematic review and network meta-analysis

Efficacy and safety of PD-1 inhibitors as second-line treatment for advanced squamous esophageal cancer: a systematic review and network meta-analysis with a focus on PD-L1 expression levels

Background

PD-1 inhibitors have shown promising efficacy in enhancing OS and AEs as second-line therapies for patients with advanced esophageal squamous cell carcinoma (ESCC). However, there remains no clear consensus on which PD-1 inhibitor provides the best balance between efficacy and safety. To address this key issue in the second-line treatment of ESCC, we conducted a network meta-analysis (NMA) with a focus on OS benefits, particularly in patients with different levels of PD-L1 expression.

Methods

A systematic search of relevant literature was conducted in Web of Science, Embase, PubMed, and Cochrane Library, covering publications from the inception of these database to June 2024. The evaluated endpoints included OS, progression-free survival (PFS), objective response rate (ORR), AEs, and Grade ≥ 3 adverse events (Grade ≥ 3 AEs). A systematic review and Bayesian network meta-analysis were performed to assess the efficacy and safety of various immunotherapy regimens in patients with advanced ESCC. To ensure transparency, novelty, and reliability, this study was prospectively registered in the systematic review registry (CRD42024540581).

Results

Five randomized controlled trials (RCTs), encompassing 2,078 patients and six treatment regimens, were included in this study. Among advanced ESCC patients not selected based on PD-L1 expression, Sintilimab demonstrated the greatest OS benefit (HR = 0.70, 95% CI: 0.50-0.98). Camrelizumab showed the most favorable improvement in PFS compared to chemotherapy (HR = 0.64, 95% CI: 0.47-0.87) and also achieved the best ORR benefit (OR = 3.72, 95% CI: 1.98-6.99). In terms of safety, Nivolumab (OR = 0.10, 95% CI: 0.05-0.19) and Tislelizumab (OR = 0.18, 95% CI: 0.10-0.33) exhibited significant safety advantages over chemotherapy concerning AEs. Moreover, Nivolumab (OR = 0.13, 95% CI: 0.08-0.20) was associated with a markedly lower risk of Grade ≥ 3 AEs compared to chemotherapy. Subgroup analysis based on PD-L1 expression revealed that Tislelizumab (HR = 0.53, 95% CI: 0.37-0.76) offered the greatest OS benefit for patients with PD-L1 ≥ 10%, while Camrelizumab (HR = 0.71, 95% CI: 0.57-0.89) was the most likely regimen to provide an OS advantage for patients with PD-L1 < 10%.

Conclusion

Compared to chemotherapy, PD-1 inhibitors may provide improved survival outcomes for patients with advanced ESCC. Among patients not selected based on PD-L1 expression, Sintilimab is most likely to deliver the best survival benefit. For patients with PD-L1 expression ≥ 10%, Tislelizumab is expected to offer the greatest efficacy, while Camrelizumab appears to be the most effective for those with PD-L1 < 10%.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42024540581.

Retrospective analysis of disease characteristics and treatment patterns among patients with esophageal cancer across 14 surgically represented centers

OBJECTIVE

Esophageal cancer (EC) ranks eighth among cancers in cancer-related deaths globally, and ~44% of new cases occur in China. We sought to describe the clinical characteristics and treatment landscape of EC in China before the approval of immunotherapy in 2020.

METHODS

CHANNEL was a large, retrospective study using patient-level data from 14 hospitals/cancer centers across China, including adults initiating therapy for newly diagnosed EC (January to December 2018). Demographics, clinicopathologic characteristics, and treatment patterns over 6 months were descriptively summarized.

RESULTS

Of 3,493 patients, 75.7% were men, the mean age was 64.1 years, and 75.0% had no family history of cancer. Most (92.8%) had squamous cell carcinoma, with a primary lesion in the middle esophagus (56.4%). Among patients with resectable EC, 92.9% received initial surgery, and 7.1% received neoadjuvant therapy, primarily chemotherapy (85.5% platinum-taxane). Among patients with unresectable early or locally advanced EC, 50.8% and 49.2% received palliative and radical therapy, respectively, as the initial treatment, primarily chemotherapy (66.5% platinum-taxane) and chemoradiotherapy (50.8% platinum-taxane), respectively. Adjuvant therapy was administered to 22.9% of patients undergoing initial surgery, and 2.4% receiving neoadjuvant therapy and surgery. Among patients with advanced EC, 84.6% received systemic therapy as an initial treatment, primarily chemotherapy (61.5% platinum-taxane).

CONCLUSIONS

Before the approval of immunotherapy in China, most patients with resectable early or locally advanced EC underwent radical surgery without preoperative treatment, whereas most patients with advanced EC received platinum-taxane chemotherapy. These findings highlight the need for novel EC treatments before immunotherapy was introduced, and provide a baseline for evaluating the benefits of immunotherapy, now that this treatment is widely used in this setting.

From tumor microenvironment to emerging biomarkers: the reshaping of the esophageal squamous cell carcinoma tumor microenvironment by neoadjuvant chemotherapy combined with immunotherapy

Esophageal squamous cell carcinoma is a cancer with high morbidity and mortality. The advent of immune checkpoint inhibitors has significantly increased complete response rates and postoperative R0 resection rates after neoadjuvant therapy. These drugs can largely reverse the suppression of the immune system caused by the tumor microenvironment, allowing the reactivation of anti-tumor immune infiltrating cells, significantly improving the patient's tumor microenvironment, and thus preventing tumor development. However, there are still some patients who respond poorly to neoadjuvant combined immunotherapy and cannot achieve the expected results. It is now found that exploring changes in the tumor microenvironment not only elucidates patient responsiveness to immunotherapy and identifies more reliable biomarkers, but also addresses the limitations of prediction with imaging examination such as CT and the instability of existing biomarkers. In light of these considerations, this review aims to delve into the alterations within the tumor microenvironment and identify potential predictive biomarkers ensuing from neoadjuvant immunotherapy in the context of esophageal squamous cell carcinoma.

Prospective multicenter study of camrelizumab in real-world settings for asian patients with esophageal squamous cell carcinoma

BACKGROUND

In this study, we aimed to evaluate the real-world efficacy and safety of camrelizumab and identify clinicolaboratory factors that predict treatment outcomes in patients with unresectable advanced, recurrent, or metastatic esophageal squamous cell carcinoma (ESCC) receiving camrelizumab.

METHODS

Herein, 174 patients with unresectable advanced, recurrent, or metastatic ESCC treated with camrelizumab monotherapy (n = 30), camrelizumab + chemotherapy (CT; n = 91), and camrelizumab + radiotherapy (RT; n = 53) between October 1, 2019 and October 1, 2022 were included.

RESULTS

The median follow-up time was 20 months (range, 1-34 months). The median progression-free survival (PFS) and overall survival (OS) of the whole cohort were 8 months [95% confidence interval (CI), 6.5-9.5 months] and 14 months (95% CI, 11.2-16.8 months), respectively. After multivariate analysis, receiving > 4 cycles of camrelizumab was identified as an independent predictor of better PFS [hazard ratio (HR), 0.56; 95% CI, 0.38-0.827; P = 0.004] and OS (HR, 0.532; 95% CI, 0.341-0.83; P = 0.005). An intermediate-to-poor lung immune prognostic index (LIPI) was identified as an independent predictor of worse PFS (HR, 1.505; 95% CI, 1.032-2.196; P = 0.034) and OS (HR, 1.657; 95% CI, 1.094-2.51; P = 0.017). The disease control rate of patients in the camrelizumab monotherapy group, camrelizumab + CT group, and camrelizumab + RT group was 92.3% (95% CI, 74.9-99.1%), 90.6% (95% CI, 82.3-95.9%), and 96.1% (95% CI, 86.8-99.5%), respectively. The treatment-related adverse events (AEs) of grade 3 or higher were reported in 67 patients (38.5%). The most common treatment-related AEs were decreased neutrophil count (23.0%), decreased white blood cell count (19.5%), anemia (7.5%), and pneumonitis (4.6%). One patient (0.6%) died from a treatment-related AE of immune checkpoint inhibitor-induced myocarditis.

CONCLUSION

Camrelizumab was safe and effective as both monotherapy and part of a combination therapy. Longer PFS and OS were associated with receiving > 4 cycles of camrelizumab and having a good LIPI. LIPI can be used as a prognostic biomarker for ESCC patients receiving camrelizumab + RT.

TRIAL REGISTRATION

ClinicalTrial.gov Identifier: CHICTR2000039499. Registered: 19th October 2020.

Prediction of Survival in Patients With Esophageal Cancer After Immunotherapy Based on Small-Size Follow-Up Data

Esophageal cancer (EC) poses a significant health concern, particularly among the elderly, warranting effective treatment strategies. While immunotherapy holds promise in activating the immune response against tumors, its specific impact and associated reactions in EC patients remain uncertain. Precise prognosis prediction becomes crucial for guiding appropriate interventions. This study, based on data from the First Affiliated Hospital of Xiamen University (January 2017 to May 2021), focuses on 113 EC patients undergoing immunotherapy. The primary objectives are to elucidate the effectiveness of immunotherapy in EC treatment and to introduce a stacking ensemble learning method for predicting the survival of EC patients who have undergone immunotherapy, in the context of small sample sizes, addressing the imperative of supporting clinical decision-making for healthcare professionals. Our method incorporates five sub-learners and one meta-learner. Leveraging optimal features from the training dataset, this approach achieved compelling accuracy (89.13%) and AUC (88.83%) in predicting three-year survival status, surpassing conventional techniques. The model proves efficient in guiding clinical decisions, especially in scenarios with small-size follow-up data.

Efficacy and safety of PD-1 Monoclonal antibodies in the treatment of esophageal squamous cell carcinoma: Systematic review and meta Regression

Background

Esophageal Squamous Cell Carcinoma (ESCC) contributes to the global burden of disease. Conventional treatments such as surgical resection and chemotherapy offer limited long-term survival rates. Recently, immunotherapies targeting PD-1 have shown promise in other cancers, but their efficacy in ESCC remains unclear.

Methods

The 31 studies eligible for this study included a total of 10,681 patients who were subjected to immunotherapy, either alone or in combination with traditional chemotherapy. A comprehensive search was conducted on September 1, 2023, across databases including CENTRAL, PubMed, MEDLINE, Web of Science, Embase, and Scopus.

Results

For OSR, results indicate a significantly improved survival at different time points (6, 12, and 24 months), with an odds ratio of 0.636 (95 % CI 0.595-0.680; Z = -13.292; p < 0.00001). In terms of PFS, PD-1 inhibitors demonstrated improvements at different time points; pooled odds ratio was 0.568 (95 % CI 0.511-0.633; Z = -10.357; p < 0.00001). Regarding ORR, the pooled analysis showed an overall odds ratio of 1.724 (95 % CI 1.554-1.913; Z = 10.289; p < 0.00001), indicating improved treatment response. DCR did not suggest a significant advantage for PD-1 inhibitors over chemotherapy, with an odds ratio of 0.904 (95 % CI 0.784-1.043; Z = -1.381; p = 0.167).

Conclusions

There is compelling evidence reinforcing the efficacy and safety of PD-1 inhibitors, as monotherapy or in combination with chemotherapy, for the treatment of ESCC. PD-1 inhibitors demonstrate a significant advantage in terms of OSR, PFS, and ORR.

Immune checkpoint inhibitors versus chemotherapy as second-line therapy for advanced oesophageal squamous cell carcinoma: a systematic review and economic evaluation

Background

Recently, several novel programmed cell death protein 1 (PD-1) inhibitors have been approved for second-line treating advanced or metastatic oesophageal squamous cell carcinoma (OSCC), including camrelizumab, nivolumab, pembrolizumab, sintilimab and tislelizumab. However, the optimal treatment regimen remained ambiguous.

Objectives

The purpose of this study was to investigate the efficacy, safety and economy of available PD-1 inhibitors to determine the optimal treatment from the Chinese healthcare system perspective.

Design

A systematic review and economic evaluation.

Data sources and methods

A systematic review was undertaken utilizing PubMed, Web of Science, Cochrane Library, Embase and Scopus databases to identify eligible studies until 31 August 2023. Primary outcomes were progression-free survival (PFS), overall survival (OS) and adverse events (AEs). We also developed a partitioned survival model at 3-week intervals based on five clinical trials to predict long-term costs, quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios for various treatment options. Direct medical costs and utility values were obtained from public drug bidding databases, clinical trials or published literature. The parameter uncertainties within the model were determined via one-way and probabilistic sensitivity analyses.

Results

Five randomized controlled trials involving 2837 patients were included in the analysis. Compared with other treatments examined, camrelizumab provided the best PFS benefits [hazard ratio (HR): 0.69, 95% confidence interval (CI): 0.56-0.86], and pembrolizumab provided the best OS benefits (HR: 0.55, 95% CI: 0.37-0.82). Nivolumab caused a relatively lower incidence of treatment-related AEs (HR: 0.10, 95% CI: 0.05-0.20) and grade 3-5 AEs (HR: 0.13, 95% CI: 0.08-0.21) than other immunotherapy regimens. In the economic evaluation, average 10-year costs ranged from $5,433.86 (chemotherapy) to $50,617.95 (nivolumab) and mean QALYs ranged from 0.55 (chemotherapy) to 0.82 (camrelizumab). Pembrolizumab was eliminated because of dominance. Of the remaining strategies, when the willingness-to-pay thresholds were 1, 2 and 3 times GDP per capita in 2022, sintilimab, tislelizumab and camrelizumab were the most cost-effective treatment options, respectively.

Conclusion

Sintilimab might be the optimal treatment alternative for second-line therapy of advanced OSCC in China, followed by tislelizumab and camrelizumab.

Trial registration

This study has been registered on the PROSPERO database with the registration number CRD42023495204.

Impacts of systemic treatments on health-related quality of life for patients with metastatic colorectal cancer: a systematic review and network meta-analysis

OBJECTIVE

There is limited evidence of comparative results among different treatments regarding impacts of Health-Related Quality of Life (HRQoL) for patients with metastatic colorectal cancer (mCRC). We aimed to compare efficacy of systemic treatments on HRQoL among patients with mCRC.

METHODS

We collected randomized controlled trials (RCTs) reported in English up until July 2023, from databases including PubMed, Embase, Cochrane Library, ClinicalTrials.gov, and prominent conference databases, for this Bayesian network meta-analysis. Phase 2 or 3 trials that evaluated at least two therapeutic regimens were included. Primary outcomes were short-term and long-term mean changes in EORTC QLQ-C30 global health status/quality of life (GHS/QoL) scores. Secondary outcome was mean change in EQ-5D health utility scores. Mean differences (MDs) with 95% confidence intervals (CIs) were used as effect size. Subgroup analysis was performed based on whether patients received systemic treatments before. We conducted various sensitivity analyses, including differentiating between chemotherapy types, and analyzed patient cohorts with non-specified gene expression levels as well as those with target KRAS expression statuses. The current systematic review protocol was registered on PROSPERO (CRD42023453315 and CRD42023420498).

RESULTS

Immunotherapy and targeted therapy significantly improved HRQoL over chemotherapy, with MDs of 9.27 (95% CI: 3.96 to 14.6) and 4.04 (95% CI: 0.11 to 7.94), respectively. Monotherapy significantly outperformed both combination therapy (MD 5.71, 95%CI 0.78 to 10.63) and no active treatment (MD 3.7, 95%CI 1.41 to 6.01) regarding GHS/QoL in the short-term. Combining targeted therapy with chemotherapy did not improve HRQoL. Focusing on HRQoL, cetuximab excelled when gene expression baselines were unspecified. Subgroup and sensitivity analyses upheld these robust findings, unaffected by model or patient baseline characteristics. Evidence from clinical trials without specific gene level data suggested that monotherapies, especially targeted therapies such as cetuximab, demonstrated superiority in HRQoL. For KRAS wild-type patients, no significant HRQoL differences emerged between chemotherapy, targeted therapy, or their combination..

CONCLUSIONS

Targeted therapies and immunotherapy demonstrate superior HRQoL benefits, monotherapy such as cetuximab is associated with significant improvements as compared to combination therapy. However, tailoring these results to individual gene expression profiles requires more evidence.