Efficacy of immune checkpoint inhibitor monotherapy in elderly patients with non-small-cell lung cancer

Efficacy and safety of immune checkpoint inhibitors in elderly patients with advanced non-small cell lung cancer: a systematic review and meta-analysis

Background

Immune checkpoint inhibitors (ICIs) are the preferred treatments for advanced non-small cell lung cancer (NSCLC) without targetable oncogene alterations. However, evidence in the elderly population (aged ≥ 65 years) remains limited.

Methods

We searched PubMed, Embase, Cochrane Library, Web of Science, and Scopus databases for eligible publications until September 30, 2024. The primary outcome of interest was overall survival (OS). A random-effects model was used for the statistical analysis.

Findings

A total of 35 phase 3 randomized controlled trials (RCTs) involving 9788 patients and 64 real-world studies involving 37,111 patients were included. Results from phase 3 RCTs revealed that ICIs significantly improved OS (hazard ratio [HR] = 0.78, 95% confidence interval [CI]: 0.74-0.82) and progression-free survival (PFS) (HR = 0.67, 95% CI: 0.60-0.75) compared to chemotherapy. The association between ICIs and improved OS was independent of patient characteristics (race and histological type) or treatment-related factors (ICI drug type, treatment mode, and treatment line). However, significantly prolonged OS was not observed in subgroups of aged ≥ 75 years and PD-L1 < 1%. In real-world studies, the pooled median OS of ICIs were 11.8 months (95% CI: 11.2-12.4); Eastern Cooperative Oncology Group (EOCG) score, histological type, PD-L1 status, with immune-related adverse events (irAEs), and treatment mode were predictive for OS; rates of irAEs and discontinuation were numerically higher for combination therapy vs. monotherapy.

Interpretation

ICIs are associated with a significant improvement in OS and PFS compared to chemotherapy in elderly patients with advanced NSCLC. Nevertheless, some patient characteristics such as aged ≥ 75 years, ECOG score ≥ 2, and PD-L1 < 1% seem to have a negative impact on the efficacy of ICIs, while these findings require further validation in large RCTs.

Funding

None.

Clinical benefit of anti-PD-1/PD-L1 plus chemotherapy in first-line treatment for patients over the age of 65 or 75 with metastatic non-small cell lung cancer (NSCLC)

Anti-PD-1/PD-L1 plus chemotherapy (CT) is considered the standard of care in first line treatment of metastatic NSCLC. However, the clinical benefit of this combination in older patients is controversial. We performed a meta-analysis of phase III randomized trials that compared PD-1/PD-L1 inhibitor plus CT with CT alone in first line of treatment for older patients with advanced NSCLC. Subgroups of patients over 65 and over 75 were analyzed. The outcomes included overall survival (OS) and progression-free survival (PFS). A fixedeffect model was used. We analyzed ten trials with an anti-PD-1 (camrelizumab, cemiplimab, nivolumab, pembrolizumab, tislelizumab or toripalimab) and six trials with an anti-PD-L1 (atezolizumab, durvalumab or sugemalimab), including 3666 patients over the age of 65 (41%) and 282 patients over the age of 75 (<10%). For patients over 65 years of age, anti-PD- 1/PD-L1 + CT was significantly associated (hazard ratio [95% confidence interval]) with prolonged OS (0.79 [0.72-0.86]; p < 0.00001) and P FS (0.63 [0.58-0.68]; p < 0.00001) compared to CT alone. Survival benefits occurred in both anti-PD-1 and anti-PD-L1 trials. For patients over 75 years of age, OS benefit was not statistically significant (0.88 [0.67-1.16]; p = 0.37). For patients over the age of 65 with untreated NSCLC, the anti-PD-1/PD-L1 combination with CT, compared with CT alone, is associated with significantly improved OS and PFS. Due to the low number of patients, it is difficult to conclude for those over 75.

Immunotherapy for the elderly. Maybe the best option for lung cancer?

Lung cancer is usually diagnosed at advanced stage and systematic therapy is administered. New current diagnostic techniques such as the convex-endobronchial ultrasound, radial endobronchial ultrasound, cone beam ct, electromagnetic navigation and robotic bronchoscopy provide us with a high diagnostic yield. These techniques are minimal invasive and patients with comorbidities such as chronic obstructive pulmonary disease and heart failure can be diagnosed with minimal adverse effects. All these techniques provide sufficient sample for molecular investigation. Since immunotherapy was first administered, we have more and more information regarding the appropriate patient target group. Several published studies divided patients as elderly ≥75 and non-elderly ≤74 and investigated the adverse effects of different drugs and survival. In our current commentary we present information on patients receiving immunotherapy versus chemoimmunotherapy in two groups of elderly and non-elderly. Elderly patients can receive both combinations without differences between the two groups, however; more studies are needed to clarify certain aspects.