Asian Ethnicity Is a Favorable Prognostic Factor for Overall Survival in Non-small Cell Lung Cancer (NSCLC) and Is Independent of Smoking Status

Survivorship Care for People Affected by Advanced or Metastatic Cancer: Building on the Recent Multinational Association of Supportive Care in Cancer-ASCO Standards and Practice Recommendations

Although there is a growing number of people living with advanced or metastatic cancer, primarily because of more effective treatment regimens, there are limited estimates of the actual number of people living with advanced or metastatic cancer. Many people will have treatable but not curable cancers, may have survival measured in years, and may have periods on and off therapy. People with advanced or metastatic disease, as well as their families and caregivers, may experience significant unmet needs, overlapping yet distinct to those with potentially curable cancer. Recently, the Multinational Association of Supportive Care in Cancer and ASCO developed standards and practice recommendations relevant to the delivery of quality survivorship care for people living with advanced or metastatic cancer. The recommendations included seven domains: (1) person-centered care; (2) coordinated and integrated care; (3) evidence-based and comprehensive care; (4) evaluated and communicated care; (5) accessible and equitable care; (6) sustainable and resourced care; and (7) research and data-driven care. Immediate priorities to improve clinical care include focusing on (1) discussions regarding prognosis and goals of care; (2) routinely assessing physical, psychological, and social unmet needs with referral to appropriate supportive care services; and (3) creating blended models of care, incorporating elements of palliative care and survivorship services. Additional areas for focus include (1) advocacy and policy; (2) system design and health care delivery; (3) defining, measuring, and managing quality; (4) addressing inequity; and (5) research specifically focused on these cancer populations.

Molecular subtyping dictates therapeutic response to anti-PD-L1 immunotherapy in ES-SCLC

Anti-PD-L1 immunotherapy is recommended as standard of care for patients with extensive stage small cell lung cancer (ES-SCLC); however, there are no reliable biomarkers guiding patient selection and the survival benefit of PD-L1 inhibitors in the overall population is limited. In this study, we retrospectively analyzed a total number of 61 cases of ES-SCLC who underwent anti-PD-L1 immunotherapy. Patient demographic characteristics and laboratory findings were processed for univariate and multivariate analysis. Subgrouping of SCLC was performed on IHC platform using antibodies against ASCL1, NEUROD1 and POU2F3. The tumor microenvironment (TME) of ES-SCLC was evaluated by CD8 + T cell infiltration, granzyme B production and PD-L1 expression. We found limited efficacy of defined variable factors conferring therapeutic outcomes of anti-PD-L1 immunotherapy in patients with ES-SCLC. Intriguingly, there was a profound difference in TME and response to anti-PD-L1 immunotherapy when classifying SCLC into A/N/P/I subgroups. Although accounted for a small proportion of SCLC, the SCLC-P and SCLC-I subtypes manifested as T cell-enriched "hot" tumor and elicited more favorable response to immunotherapy, whereas the SCLC-A and SCLC-N subgroups were T cell-absent "cold" tumor. There was also a significant difference in progression free survival and overall survival across these subsets. Moreover, we found the SCLC-P and SCLC-I tumors revealed features of low neuroendocrine (NE) differentiation and showed clinicopathologic features overlapping with the SCLC non-NE lineage. These findings may aid clinicians to select ES-SCLC patients who were more likely to gain higher response rate and longer survival to anti-PD-L1 immunotherapy. Revisiting SCLC according to A/N/P/I subtyping and NE/non-NE differentiation is a reliable approach to guide therapeutic strategy in patients with ES-SCLC.

Minimally Invasive Pneumonectomy vs Open Pneumonectomy: Outcomes and Predictors of Conversion

BACKGROUND

In the modern era, whether minimally invasive pneumonectomy for non-small cell lung cancer (NSCLC) provides a survival advantage over open pneumonectomy is unknown.

METHODS

Patients who underwent pneumonectomy for NSCLC between 2015 and 2020 were queried from the National Cancer Database. Surgical approach was categorized as robot-assisted thoracoscopic surgery (RATS), video-assisted thoracoscopic surgery (VATS), or open pneumonectomy on an intention-to-treat basis. Propensity score matching was performed to balance patient cohorts. Univariate and multivariate regression analyses were used to examine the association between surgical approach and 30- and 90-day mortality, and a Cox proportional hazards model was used to assess overall survival.

RESULTS

We identified 3784 patients, including 73% open (n = 2776), 19% VATS (n = 725), and 8% RATS (n = 283). The overall conversion rate from minimally invasive to open was 29.5% (n = 298). After propensity matching 212 patients per cohort, there were no differences between open, VATS, and RATS 30-day (9.4% vs 8.5% vs 7.5%, respectively; P = .807) or 90-day mortality (14.2% vs 12.3% vs 10.4%, respectively; P = .516). Median overall survival was similar among open (48 months; 95% CI, 35.6-64.1 months), VATS (51.0 months; 95% CI, 34.9-72.3 months), and RATS approaches (50 months; 95% CI, 42.6-NA months; P = .560). Multivariate analysis of the matched cohort found no association between approach and overall survival. RATS (odds ratio, 0.67; 95% CI, 0.47-0.94; P = .020) and neoadjuvant chemotherapy (odds ratio, 0.52, 95% CI, 0.27-0.98; P = .045) were found to be protective against conversion to open.

CONCLUSIONS

Minimally invasive pneumonectomy can be performed with short-term and long-term survival that are equivalent to open pneumonectomy.

Patterns of Treatment and Real-World Outcomes of Patients With Non-small Cell Lung Cancer With EGFR Exon 20 Insertion Mutations Receiving Mobocertinib: The EXTRACT Study

BACKGROUND

Real-world data regarding patients with non-small cell lung cancer (NSCLC) with EGFR exon 20 insertion (ex20ins) mutations receiving mobocertinib are limited. This study describes these patients' characteristics and outcomes.

METHODS

A chart review was conducted across three countries (Canada, France, and Hong Kong), abstracting data from eligible patients (NCT05207423). The inclusion criteria were: ≥ 18 years old; diagnosis of stage IIIB-IV NSCLC with EGFR ex20ins between January 1, 2017 and November 30, 2021; received mobocertinib. Data on demographics, clinical parameters, treatment patterns, mobocertinib exposure, real-world outcomes, and adverse events (AEs) were collected. Results are also reported by Asian/Non-Asian races.

RESULTS

Overall, 105 patients were enrolled (median [IQR] age at initial diagnosis: 64.0 years [56, 71]; women: 62.9%). The most common first-line of therapy (LoT) was chemotherapy; the most common second LoT was EGFR tyrosine kinase inhibitors. Most patients received mobocertinib during LoT two and three (74.3%); the maximum dose was 160 mg/day for 67.6% of the cohort (mean [SD] daily dose: 130.6 mg [36.68]). The median real-world progression-free survival (PFS) on mobocertinib was 4.76 months (95% CI: 3.98, 6.21). The overall response rate and disease control rate were 20.0% and 48.6%, respectively (median duration of response: 8.34 months [95% CI: 3.61, 9.49]). The median overall survival (OS) was 26.28 months (95% CI: 20.21, 36.44). Asian patients had numerically superior PFS and OS compared with non-Asian patients. Regarding safety analysis, 73 patients (69.5%) experienced any AE. The most common AE was diarrhea (any grade) (52 patients; 49.5%).

CONCLUSIONS

These data illustrate the real-world effectiveness of mobocertinib.

Assessment of NSCLC disease burden: A survival model-based meta-analysis study

We present a meta-analytics approach to quantify NSCLC disease burden by integrative survival models. Aggregated survival data from public sources were used to parameterize the models for early as well as advanced NSCLC stages incorporating chemotherapies, targeted therapies, and immunotherapies. Overall survival (OS) was predicted in a heterogeneous patient cohort based on various stratifications and initial conditions. Pharmacoeconomic metrics (life years gained (LYG) and quality-adjusted life years (QALY) gained), were evaluated to quantify the benefits of specialized treatments and improved early detection of NSCLC. Simulations showed that the introduction of novel therapies for the advanced NSCLC sub-group increased median survival by 8.1 months (95 % CI: 5.9, 10.0), with corresponding gains of 2.9 months (95 % CI: 2.2, 3.6) in LYG and 1.65 months (95 % CI: 1.2, 2.0) in QALY. Scenarios representing improved detection of early cancer in the whole patient cohort, revealed up to 17.6 (95 % CI: 16.5, 19.0) and 15.7 months (95 % CI: 14.8, 16.6) increase in median survival, with respective gains of 6.2 months (95 % CI: 5.9, 6.4) and 5.2 months (95 % CI: 4.9, 5.4) in LYG and 6.6 months (95 % CI: 6.4, 6.7) and 6.0 months (95 % CI: 5.9, 6.2) in QALY for conventional and optimal treatment. This integrative modeling platform, aimed at characterizing cancer burden, allows to precisely quantify the cumulative benefits of introducing specialized therapies into the treatment schemes and survival prolongation upon early detection of the disease.

Stage-Specific Guideline Concordant Treatment Impacts on Survival in Nonsmall Cell Lung Cancer: A Novel Quality Indicator

BACKGROUND

Lung cancer in Australia contributes 9% of all new cancer diagnoses and is the leading cause of cancer death and burden. Clinical practice guidelines provide evidence-based treatment recommendations for best practice management. We aimed to determine the extent of delivery of guideline-concordant treatment (GCT) and to identify modifiable variables influencing receipt of GCT and survival.

METHODS

Data was sourced from the Victorian Lung Cancer Registry (VLCR) in Victoria, Australia. Descriptive statistics were used to summarize patient and disease characteristics according to treatment type: GCT versus non-GCT versus no/declined treatment. Statistical analyses included multiple logistic regression, multiple COX regression and Kaplan-Meier survival estimates.

RESULTS

52% of patients were treated with GCT, 32.8% non-GCT and 15.2% declined or received no treatment. GCT treated patients were younger, never smoked, had no comorbidities, had better performance status, had early stage cancer, were discussed at a multidisciplinary meeting or had treatment at a higher volume hospital. Overall, patients that received GCT had a 24% lower risk of mortality compared to patients that received non-GCT.

CONCLUSION

Modifiable variables impacting likelihood of receiving GCT included age, smoking status and treating hospital characteristics. Several modifiable variables were identified with positive impacts on survival including increased treatment of the elderly, smoking cessation, delivery of GCT, and treatment in higher volume hospitals. The measurement and reporting of delivery of GCT has positive impacts on survival and therefore merits consideration as an evidence-based quality indicator in the reporting of lung cancer quality and safety outcomes.

Tislelizumab plus chemotherapy versus chemotherapy alone as first-line treatment for advanced squamous non-small-cell lung cancer: final analysis of the randomized, phase III RATIONALE-307 trial

PURPOSE

First-line tislelizumab plus chemotherapy significantly improved progression-free survival (PFS) versus chemotherapy alone in advanced squamous non-small-cell lung cancer (sq-NSCLC) at the interim analysis of the phase III RATIONALE-307 trial. We present the final analysis of this trial.

PATIENTS AND METHODS

Patients with treatment-naive, stage IIIB/IV, sq-NSCLC were randomized (1 : 1: 1) to 21-day cycles of i.v.: tislelizumab plus paclitaxel and carboplatin (arm A); tislelizumab plus nab-paclitaxel and carboplatin (arm B); or paclitaxel and carboplatin (arm C). The primary endpoint was independent review committee-assessed PFS; overall survival was a secondary endpoint.

RESULTS

In total, 360 patients were randomized; 355 received treatment. At the final analysis (median study follow-up: 16.7 months), tislelizumab plus chemotherapy had a manageable safety profile, consistent with that at the interim analysis. Improvement in PFS was maintained for arms A and B versus C {hazard ratio (HR) 0.45 [95% confidence interval (CI) 0.33-0.62] and 0.43 (95% CI 0.31-0.60), respectively}. Overall survival HRs for arms A and B versus C were 0.68 (95% CI 0.46-1.01) and 0.75 (95% CI 0.50-1.12), respectively.

CONCLUSIONS

The RATIONALE-307 final analysis demonstrated superior clinical benefit with addition of tislelizumab to chemotherapy, and a manageable safety profile, as first-line treatment of advanced sq-NSCLC.

Histopathological Patterns of Lung Cancer in Iran: A Single-Center Study

BACKGROUND

Lung cancer (LC) is one of the leading causes of cancer-related deaths worldwide. In Iran, it is the second most common cause of cancer-related deaths for men and the third most common for women. This study aimed to examine the clinicopathological characteristics of Iranian patients with LC.

METHODS

Clinicopathological data of 1382 patients with primary LC diagnosed over 11 years (2012‒2023) at the "National Institute of Tuberculosis and Lung Disease" (NRITLD), Tehran, Iran, were retrospectively reviewed.

RESULTS

Adenocarcinoma was the most common type of cancer found in the patients (42.44%). The median age was 59.69 years (mean: 60.41 years) ranging 24-88 years. The mean male-to-female ratio was 3.65. Additionally, 65.84% of patients were smokers. The majority of patients (82.69 %) were diagnosed at an advanced stage (stage IV) of cancer.

CONCLUSION

Although some of our findings are consistent with those of previous LC studies, there are some discrepancies, especially concerning the smoking status and median age of the Iranian patients. Therefore, additional clinical and epidemiological studies are needed to determine the impact of non-smoking factors, such as environmental exposure and genetic predisposition, on the development of LC.

Identifying Asian American lung cancer disparities: A novel analytic approach

Objective

Asian Americans include heterogeneous subpopulations with unique burden as the only racial group with cancer as the leading cause of death. The purpose of the study was to identify differences in clinical stage and survival of patients with lung cancer between Asian Americans and its subgroups relative to other racial groups.

Methods

Patients with lung cancer from 2016 National Cancer Database were divided into East Asian, Southeast Asian, South Asian subgroups based on geographic origins, and a composite Asian American group with White non-Hispanic, Black, and Hispanic comparison groups. Columnar z score analysis with adjusted residuals was employed and the terms underrepresented and overrepresented were utilized to describe significant statistical findings.

Results

A total of 825,448 patients were analyzed. Asian Americans were underrepresented relative to White non-Hispanics in all clinical stages except IIIB and IV. In clinical stage IV, Asian Americans (51.0%), East Asians (47.2%), Southeast Asians (57.4%), and South Asians (52.2%) were overrepresented relative to White non-Hispanics (42.2%) and Southeast Asians were overrepresented relative to East Asians and South Asians. For survival across all stages, Asian Americans were overrepresented relative to White non-Hispanics and Blacks, but in clinical stage IV, Southeast Asians (17.9%) were underrepresented relative to East Asians (26.0%) and South Asians (26.6%).

Conclusions

This is the first study to address lung cancer disparity in Asian American subgroups employing a novel analytical approach. Asian American subgroups demonstrated more advanced lung cancer diagnosis yet higher survival compared with White non-Hispanics, Blacks, and/or Hispanics with differences between subgroups. Interplay of complex factors may contribute to Asian American health disparities.

Racial Disparities in Cancer Stage at Diagnosis and Survival for Adolescents and Young Adults

Importance

There are limited studies assessing stage at diagnosis and risk of death among all 5 federally defined races in the US among adolescent and young adult (AYA) patients with cancer.

Objective

To identify racial disparities in stage at diagnosis and survival among AYA patients with cancer.

Design, Setting, and Participants

This retrospective cohort study used data from a US national hospital-based oncology database on AYA patients, aged 15 to 39 years, with the 10 deadliest cancers among AYA patients who received a diagnosis from January 1, 2004, to December 31, 2017, with 6 months or more of follow-up. Analyses by race were categorized by the 5 federally defined races in the US: American Indian or Alaska Native, Asian, Black, Native Hawaiian or Other Pacific Islander, and non-Hispanic White (hereafter, White). White patients served as the majority reference group. Statistical analysis was performed from November 2022 to September 2023.

Main Outcomes and Measures

The primary end points were late stage at diagnosis (logistic regression with adjusted odds ratios [AORs] and 95% CIs) and overall survival (log-rank tests and Cox proportional hazards regression with adjusted hazard ratios [AHRs] and 95% CIs).

Results

A total of 291 899 AYA patients (median age, 33 years [IQR, 28-37 years]; 186 549 female patients [64%]; 189 812 [65%] with stage I or II cancers) were evaluated. The cohort included 1457 American Indian or Alaska Native patients (1%), 8412 Asian patients (3%), 40 851 Black patients (14%), 987 Native Hawaiian or Other Pacific Islander patients (0.3%), and 240 192 White patients (82%). Cancers included breast (n = 79 195 [27%]), lymphoma (n = 45 500 [16%]), melanoma (n = 36 724 [13%]), testis (n = 31 413 [11%]), central nervous system (n = 26 070 [9%]), colon or rectum (n = 22 545 [8%]), cervix (n = 20 923 [7%]), sarcoma (n = 14 951 [5%]), ovary (n = 8982 [3%]), and lung (n = 5596 [2%]). Risk of late-stage diagnosis was higher for Asian (AOR, 1.20; 95% CI, 1.14-1.26), Black (AOR, 1.40; 95% CI, 1.36-1.43), and Native Hawaiian or Other Pacific Islander (AOR, 1.34; 95% CI, 1.16-1.55) patients compared with White patients. Overall survival differed by race for all cancer sites, except cancers of the central nervous system and ovary. Risk of death was higher for American Indian or Alaska Native (AHR, 1.15; 95% CI, 1.02-1.30), Black (AHR, 1.22; 95% CI, 1.19-1.26), and Native Hawaiian or Other Pacific Islander (AHR, 1.25; 95% CI, 1.09-1.44) patients but lower for Asian patients (AHR, 0.90; 95% CI, 0.85-0.95) compared with White patients.

Conclusions and Relevance

This cohort study of AYA patients suggests that stage at diagnosis and survival varied across races for the 10 deadliest AYA cancers. These results support the need for tailored interventions and informed public policy to achieve cancer care equity for all races.

Use of quantitative bias analysis to evaluate single-arm trials with real-world data external controls

PURPOSE

Use of real-world data (RWD) for external controls added to single-arm trials (SAT) is increasingly prevalent in regulatory submissions. Due to inherent differences in the data-generating mechanisms, biases can arise. This paper aims to illustrate how to use quantitative bias analysis (QBA).

METHODS

Advanced non-small cell lung cancer (NSCLC) serves as an example, where many small subsets of patients with molecular tumor subtypes exist. First, some sources of bias that may occur in oncology when comparing RWD to SAT are described. Second, using a hypothetical immunotherapy agent, a dataset is simulated based on expert input for survival analysis of advanced NSCLC. Finally, we illustrate the impact of three biases: missing confounder, misclassification of exposure, and outcome evaluation.

RESULTS

For each simulated scenario, bias was induced by removing or adding data; hazard ratios (HRs) were estimated applying conventional analyses. Estimating the bias-adjusted treatment effect and uncertainty required carefully selecting the bias model and bias factors. Although the magnitude of each biased and bias-adjusted HR appeared moderate in all three hypothetical scenarios, the direction of bias was variable.

CONCLUSION

These findings suggest that QBA can provide an intuitive framework for bias analysis, providing a key means of challenging assumptions about the evidence. However, the accuracy of bias analysis is itself dependent on correct specification of the bias model and bias factors. Ultimately, study design should reduce bias, but QBA allows us to evaluate the impact of unavoidable bias to assess the quality of the evidence.

Asian, regional, and national burdens of respiratory tract cancers and associated risk factors from 1990 to 2019: A systematic analysis for the global burden of disease study 2019

Background

Respiratory cancer is the leading cause of cancer-related deaths worldwide, but its statistics vary between the East and West. This study aimed to estimate the burdens of tracheal, bronchus, and lung (TBL) cancer and larynx cancer and their attributable risks from 1990 to 2019 in Asia, and at regional and national levels.

Methods

This research evaluated the incidence, mortality, years lived with disability, years of life lost, and disability-adjusted life years (DALYs) for respiratory tract cancers using the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 database. Age-standardized rates were calculated for TBL cancer from 1990 to 2019, adjusted for smoking and socio-demographic index (SDI). Deaths from TBL cancer and larynx cancer attributable to each risk factor were estimated for 33 Asian countries.

Results

The age-standardized incidence and death rates for TBL cancer in Asia declined from 2010 to 2019, while the incidence rate of larynx cancer increased. Smoking was the leading specific risk factor for deaths from both TBL and larynx cancers. The burden of TBL cancer in Asian countries was influenced by SDI and smoking, particularly among males in Central Asia. Deaths, DALYs, and incidences of larynx cancer in East Asia had not changed significantly over the past 30 years, but showed slight downward trends in males and both sexes combined, and an upward trend in females in recent years.

Conclusions

The past decade saw increases in numbers of incident cases and deaths from TBL cancer and larynx cancer in Asia. SDI and smoking were the main factors influencing the disease burden of TBL cancer in Asian countries. This study highlights the need for tailored cancer control programs to address the burden of respiratory tract cancers in different Asian countries.

Lung Cancer in Never Smokers: Delving into Epidemiology, Genomic and Immune Landscape, Prognosis, Treatment, and Screening

Lung cancer in never smokers (LCINS) represents a growing and distinct entity within the broader landscape of lung malignancies. This review provides a comprehensive overview of LCINS, encompassing its epidemiologic trends, risk factors, distinct genomic alterations, clinical outcomes and the ongoing initiative aimed at formulating screening guidelines tailored to this unique population. As LCINS continues to gain prominence, understanding its intricate genomic landscape has become pivotal for tailoring effective therapeutic strategies. Moreover, LCINS does not meet the criteria for lung cancer screening as per the current guidelines. Hence, there is an urgent need to explore its heterogeneity in order to devise optimal screening guidelines conducive to early-stage detection. This review underscores the vital importance of detailed research to elucidate the multifaceted nature of LCINS, with the potential to shape future clinical management and screening recommendations for this unique and growing patient cohort.

Nomograms integrating CT radiomic and deep learning signatures to predict overall survival and progression-free survival in NSCLC patients treated with chemotherapy

OBJECTIVES

This study aims to establish nomograms to accurately predict the overall survival (OS) and progression-free survival (PFS) in patients with non-small cell lung cancer (NSCLC) who received chemotherapy alone as the first-line treatment.

MATERIALS AND METHODS

In a training cohort of 121 NSCLC patients, radiomic features were extracted, selected from intra- and peri-tumoral regions, and used to build signatures (S1 and S2) using a Cox regression model. Deep learning features were obtained from three convolutional neural networks and utilized to build signatures (S3, S4, and S5) that were stratified into over- and under-expression subgroups for survival risk using X-tile. After univariate and multivariate Cox regression analyses, a nomogram incorporating the tumor, node, and metastasis (TNM) stages, radiomic signature, and deep learning signature was established to predict OS and PFS, respectively. The performance was validated using an independent cohort (61 patients).

RESULTS

TNM stages, S2 and S3 were identified as the significant prognosis factors for both OS and PFS; S2 (OS: (HR (95%), 2.26 (1.40-3.67); PFS: (HR (95%), 2.23 (1.36-3.65)) demonstrated the best ability in discriminating patients with over- and under-expression. For the OS nomogram, the C-index (95% CI) was 0.74 (0.70-0.79) and 0.72 (0.67-0.78) in the training and validation cohorts, respectively; for the PFS nomogram, the C-index (95% CI) was 0.71 (0.68-0.81) and 0.72 (0.66-0.79). The calibration curves for the 3- and 5-year OS and PFS were in acceptable agreement between the predicted and observed survival. The established nomogram presented a higher overall net benefit than the TNM stage for predicting both OS and PFS.

CONCLUSION

By integrating the TNM stage, CT radiomic signature, and deep learning signatures, the established nomograms can predict the individual prognosis of NSCLC patients who received chemotherapy. The integrated nomogram has the potential to improve the individualized treatment and precise management of NSCLC patients.

Survival differences between the USA and an urban population from China for all cancer types and 20 individual cancers: a population-based study

BACKGROUND

The systematic comparison of cancer survival between China and the USA is rare. Here we aimed to assess the magnitude of survival disparities and disentangle the impact of the stage at diagnosis between a Chinese metropolitan city and the USA on cancer survival.

METHODS

We included 11,046 newly diagnosed cancer patients in Dalian Cancer Registry, China, 2015, with the follow-up data for vital status until December 2020. We estimated age-standardised 5-year relative survival and quantified the excess hazard ratio (EHR) of death using generalised linear models for all cancers and 20 individual cancers. We compared these estimates with 17 cancer registries' data from the USA, using the Surveillance, Epidemiology, and End Results database. We further estimated the stage-specific survival for five major cancers by region.

FINDINGS

Age-standardised 5-year relative survival for all patients in Dalian was lower than that in the USA (49.9% vs 67.9%). By cancer types, twelve cancers with poorer prognosis were observed in Dalian compared to the USA, with the largest gap seen in prostate cancer (Dalian: 55.8% vs USA: 96.0%). However, Dalian had a better survival for lung cancer, cervical cancer, and bladder cancer. Dalian patients had a lower percentage of stage Ⅰ colorectal cancer (Dalian: 17.9% vs USA: 24.2%) and female breast cancer (Dalian: 40.9% vs USA: 48.9%). However, we observed better stage-specific survival among stage Ⅰ-Ⅱ lung cancer patients in Dalian than in the USA.

INTERPRETATION

This study suggests that although the overall prognosis for patients was better in the USA than in Dalian, China, survival deficits existed in both countries. Improvement in cancer early detection and cancer care are needed in both countries.

FUNDING

National Key R&D Program (2021YFC2501900, 2022YFC3600805), Major State Basic Innovation Program of the Chinese Academy of Medical Sciences (2021-I2M-1-010, 2021-I2M-1-046), and Talent Incentive Program of Cancer Hospital of Chinese Academy of Medical Sciences.

Stereotactic body radiation therapy and thermal ablation for treatment of NSCLC: A systematic literature review and meta-analysis

RATIONALE

Stereotactic body radiation therapy (SBRT) is the standard of care for inoperable early stage non-small cell lung cancer (NSCLC). Use of image guided thermal ablation (IGTA; including microwave ablation [MWA] and radiofrequency ablation [RFA]) has increased in NSCLC, however there are no studies comparing all three.

OBJECTIVE

To compare the efficacy of IGTA (including MWA and RFA) and SBRT for the treatment of NSCLC.

METHODS

Published literature databases were systematically searched for studies assessing MWA, RFA, or SBRT. Local tumor progression (LTP), disease-free survival (DFS), and overall survival (OS) were assessed with single-arm pooled analyses and meta-regressions in NSCLC patients and a stage IA subgroup. Study quality was assessed with a modified methodological index for non-randomized studies (MINORS) tool.

RESULTS

Forty IGTA study-arms (2,691 patients) and 215 SBRT study-arms (54,789 patients) were identified. LTP was lowest after SBRT at one and two years in single-arm pooled analyses (4% and 9% vs. 11% and 18%) and at one year in meta-regressions when compared to IGTA (OR = 0.2, 95%CI = 0.07-0.63). MWA patients had the highest DFS of all treatments in single-arm pooled analyses. In meta-regressions at two and three-years, DFS was significantly lower for RFA compared to MWA (OR = 0.26, 95%CI = 0.12-0.58; OR = 0.33, 95%CI = 0.16-0.66, respectively). OS was similar across modalities, timepoints, and analyses. Older age, male patients, larger tumors, retrospective studies, and non-Asian study region were also predictors of worse clinical outcomes. In high-quality studies (MINORS score ≥ 7), MWA patients had better clinical outcomes than the overall analysis. Stage IA MWA patients had lower LTP, higher OS, and generally lower DFS, compared to the main analysis of all NSCLC patients.

CONCLUSIONS

NSCLC patients had comparable outcomes after SBRT and MWA, which were better than those with RFA.

Recurrence Patterns and Patient Outcomes in Resected Lung Adenocarcinoma Differ according to Ground-Glass Opacity at CT

Background Although lung adenocarcinoma with ground-glass opacity (GGO) is known to have distinct characteristics, limited data exist on whether the recurrence pattern and outcomes in patients with resected lung adenocarcinoma differ according to GGO presence at CT. Purpose To examine recurrence patterns and associations with outcomes in patients with resected lung adenocarcinoma according to GGO at CT. Materials and Methods Patients who underwent CT followed by lobectomy or pneumonectomy for lung adenocarcinoma between July 2010 and December 2017 were retrospectively included. Patients were divided into two groups based on the presence of GGO: GGO adenocarcinoma and solid adenocarcinoma. Recurrence patterns at follow-up CT examinations were investigated and compared between the two groups. The effects of patient grouping on time to recurrence, postrecurrence survival (PRS), and overall survival (OS) were evaluated using Cox regression. Results Of 1019 patients (mean age, 62 years ± 9 [SD]; 520 women), 487 had GGO adenocarcinoma and 532 had solid adenocarcinoma. Recurrences occurred more frequently in patients with solid adenocarcinoma (36.1% [192 of 532 patients]) than in those with GGO adenocarcinoma (16.2% [79 of 487 patients]). Distant metastasis was the most common mode of recurrence in the group with solid adenocarcinoma and all clinical stages. In clinical stage I GGO adenocarcinoma, all regional recurrences appeared as ipsilateral lung metastasis (39.2% [20 of 51]) without regional lymph node metastasis. Brain metastasis was more frequent in patients with clinical stage I solid adenocarcinoma (16.5% [16 of 97 patients]). The presence of GGO was associated with time to recurrence and OS (adjusted hazard ratio [HR], 0.6 [P < .001] for both). Recurrence pattern was an independent risk factor for PRS (adjusted HR, 2.1 for distant metastasis [P < .001] and 3.9 for brain metastasis [P < .001], with local-regional recurrence as the reference). Conclusion Recurrence patterns, time to recurrence, and overall survival differed between patients with and without ground-glass opacity at CT, and recurrence patterns were associated with postrecurrence survival. © RSNA, 2023 Supplemental material is available for this article.

Indirect comparison of mobocertinib and real-world therapies for pre-treated non-small cell lung cancer with EGFR exon 20 insertion mutations

OBJECTIVES

Mobocertinib, a novel oral epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor, is available for the treatment of non-small cell lung cancer (NSCLC) with EGFR exon 20 insertion (ex20ins) mutations after platinum chemotherapy. We performed an indirect comparison of clinical trial data and real-world data (RWD) to determine the relative efficacy of mobocertinib vs. other treatments for these patients.

MATERIALS AND METHODS

Data on the efficacy of mobocertinib from a phase I/II trial (NCT02716116) were compared to RWD from a retrospective study in 12 German centers using inverse probability of treatment weighting to adjust for age, sex, Eastern Cooperative Oncology Group score, smoking status, presence of brain metastasis, time from advanced diagnosis, and histology. Tumor response assessment was based on RECIST v1.1.

RESULTS

The analysis included 114 patients in the mobocertinib group and 43 in the RWD group. The confirmed overall response rate (cORR) according to investigator assessment was 0% for standard treatments and 35.1% (95% confidence interval [CI], 26.4-44.6) for mobocertinib (p < 0.0001). Compared to standard regimens in the weighted population, mobocertinib prolonged overall survival (OS, median [95% CI] = 9.8 [4.3-13.7] vs. 20.2 [14.9-25.3] months; hazard ratio [HR] = 0.42 [0.25-0.69], p = 0.0035), progression-free survival (PFS, median [95% CI] = 2.6 [1.5-5.7] vs. 7.3 [5.6-8.8] months; HR = 0.28 [0.18-0.44], p < 0.0001), and time to treatment discontinuation (median [95% CI] = 2.1 [1.2-3.1] vs. 7.4 [6.4-8.5] months; HR = 0.34 [0.18-0.65], p = 0.0004).

CONCLUSION

Mobocertinib was associated with an improved cORR and prolonged PFS and OS compared to standard treatments for patients with EGFR ex20ins-positive NSCLC previously treated with platinum-based chemotherapy.

Real-world clinical practice and outcomes in treating stage III non-small cell lung cancer: KINDLE-Asia subset

Introduction

Stage III non-small cell lung cancer (NSCLC) is a heterogeneous disease requiring multimodal treatment approaches. KINDLE-Asia, as part of a real world global study, evaluated treatment patterns and associated survival outcomes in stage III NSCLC in Asia.

Methods

Retrospective data from 57 centers in patients with stage III NSCLC diagnosed between January 2013 and December 2017 were analyzed. Median progression free survival (mPFS) and median overall survival (mOS) estimates with two sided 95% confidence interval (CI) were determined by applying the Kaplan-Meier survival analysis.

Results

Of the total 1874 patients (median age: 63.0 years [24 to 92]) enrolled in the Asia subset, 74.8% were men, 54.7% had stage IIIA disease, 55.7% had adenocarcinoma, 34.3% had epidermal growth factor receptor mutations (EGFRm) and 50.3% had programmed death-ligand 1 (PD-L1) expression (i.e. PD-L1 ≥1%). Of the 31 treatment approaches as initial therapy, concurrent chemoradiotherapy (CRT) was the most frequent (29.3%), followed by chemotherapy (14.8%), sequential CRT (9.5%), and radiotherapy (8.5%). Targeted therapy alone was used in 81 patients of the overall population. For the Asia cohort, the mPFS and mOS were 12.8 months (95% CI, 12.2–13.7) and 42.3 months (95% CI, 38.1–46.8), respectively. Stage IIIA disease, Eastern Cooperative Oncology Group ≤1, age ≤65 years, adenocarcinoma histology and surgery/concurrent CRT as initial therapy correlated with better mOS (p &lt; 0.05).

Conclusions

The results demonstrate diverse treatment patterns and survival outcomes in the Asian region. The high prevalence of EGFRm and PD-L1 expression in stage III NSCLC in Asia suggests the need for expanding access to molecular testing for guiding treatment strategies with tyrosine kinase inhibitors and immunotherapies in this region.

Investigation of racial differences in survival from non-small cell lung cancer with immunotherapy use: A Texas study

Background

The use of immunotherapy is associated with improved survival among patients with Non-Small Cell Lung Cancer (NSCLC) and has gained widespread use in its management. However, there is limited information on whether the survival benefits associated with immunotherapy differ among races and ethnicities.

Objective

This study aimed to investigate racial differences in survival amongst patients with NSCLC who received immunotherapy as the first-line treatment in Texas.

Methods

Patients with NSCLC who received immunotherapy between October 2015 to December 2018 were identified from the Texas Cancer Registry (TCR). Disease-specific survival was evaluated and compared among patients across racial/ethnic categories using the Kaplan-Meier survival analysis, log-rank test, and a multivariable Cox proportional hazard regression model following an inverse probability treatment weighting (IPTW) propensity score analysis.

Results

A total of 1453 patients were included in the analysis. Median survival (in months) was longest among Asians (34, 95% CI: 15-Not Estimable), followed by African Americans (AAs) (23, 95% CI: 15-34), Hispanics (22, 95% CI: 16-26), and Whites (19, 95% CI: 17-22). The adjusted regression estimates had no statistically significant differences in survival among AAs (aHR = 0.97; 95% CI = 0.78-1.20; P =0.77) and Hispanics (aHR = 0.96; 95% CI = 0.77-1.19, P =0.73) when compared to White patients. Asians on the other hand, had 40% reduction in mortality risk compared to Whites (aHR = 0.60; 95% CI = 0.39-0.94, P = 0.03).

Conclusions

Our study indicated that African Americans and Hispanics do not have poorer survival compared to White patients when receiving immunotherapy as first-line treatment. Asians however had longer survival compared to Whites. Our findings suggest that existing racial disparity in NSCLC survival might be mitigated with the use of immunotherapy and should be considered in providing care to these minority groups.

Usage of epidermal growth factor mutation testing and impact on treatment patterns in non-small cell lung cancer: An international observational study

OBJECTIVES

Epidermal growth factor receptor (EGFR) mutations (EGFRm) are common oncogene drivers in non-small cell lung cancer (NSCLC). This real-world study explored treatment patterns and time to receive EGFRm test results in patients with advanced EGFRm NSCLC.

METHODS

A cross-sectional medical chart review was completed May-August 2020 in Australia, Canada, Germany, Italy, South Korea, Taiwan, UK, and USA. Eligible patients had advanced NSCLC and a positive EGFRm test result January-December 2017. Data were abstracted from NSCLC diagnosis to end of follow-up (31 March 2020) or patient's death whichever occurred earlier. The index date was the date of EGFRm confirmation.

RESULTS

223 physicians provided data for 1,793 patients. Patients' mean age was 64.7 years, 54 % were male, 30.7 % had no history of smoking. Overall, 78 % of EGFRm test results were received ≤ 2 weeks after request (range of median 7-14 days across countries). Median time from advanced NSCLC diagnosis to EGFRm test result was 18 days (median range 10-22 days across countries). Over a third (37 %) of patients received a systemic treatment prior to EGFRm result; chemotherapy (25 %) and EGFR-TKI (15 %) were most commonly prescribed; post-EGFR test-result was EGFR-TKI (68 %); 80 % of patients initiated EGFR-TKI at any time point post-NSCLC diagnosis. Of those receiving a first-line EGFR-TKI post-EGFRm testing, 84 % received a TKI alone, 12 % in combination with chemotherapy, and 3 % with other treatments. Median time from first-line EGFR-TKI initiation post-EGFRm testing to first subsequent treatment was 19.8 months.

CONCLUSION

Over one-fifth of patients wait >14 days for their EGFRm test results, affecting their likelihood of receiving first-line EGFR-TKI with 20 % of patients never receiving EGFR TKI treatment. There was significant inter-country variability in the proportion of patients receiving EGFR TKIs. Our study highlights the need to improve EGFRm testing turnaround times and treatment initiation across countries.

Generalizability of ORIENT-11 trial results to a US standard of care cohort with advanced non-small-cell lung cancer

Aim: This retrospective study estimated efficacy and safety of sintilimab + pemetrexed + platinum (SPP) versus placebo + pemetrexed + platinum (PPP) in untreated locally advanced/metastatic, nonsquamous non-small-cell lung cancer (NSCLC), after adjusting each ORIENT-11 trial patient's contribution to ORIENT-11 data based on characteristics of a target US population. Materials & methods: The target US population (n = 557) was selected from a real-world deidentified advanced NSCLC database based on key ORIENT-11 eligibility criteria. Inverse probability weights for ORIENT-11 patients (n = 397) relative to US patients were calculated. Efficacy and safety of SPP versus PPP were adjusted by inverse probability weights. Results: After adjustment, progression-free survival remained superior for SPP. Other efficacy and safety outcomes were consistent. Conclusion: These results provide evidence on how the effects observed with SPP in ORIENT-11 could translate to a US population with untreated locally advanced/metastatic nonsquamous NSCLC.

Differences in the prognostic implication of ground-glass opacity on CT according to pathological nodal status in lung cancers treated with lobectomy or pneumonectomy

OBJECTIVES

To clarify the prognostic significance of a ground-glass opacity (GGO) component according to T category and pathological nodal status in patients with resectable non-small cell lung cancer (NSCLC).

METHODS

Patients who underwent lobectomy or pneumonectomy for NSCLC between July 2010 and December 2017 were retrospectively included. Patients were divided into GGO and solid groups based on the presence of a GGO component on CT. The effects on survival of interactions between GGO and (a) pathological nodal status (pN) and (b) cT category were evaluated using Cox regression.

RESULTS

Out of 1545 patients, 548 were classified into the GGO group (pN0: 457, pN1/2: 91) and 997 into the solid group (pN0: 660, pN1/2: 337). There were interactions between the presence of GGO and pathological nodal status on 5-year disease-free survival (DFS; p = .006) and 5-year overall survival (OS; p = .02). In multivariate analysis, better survival of patients in the GGO group than in the solid group was observed only in pN0 category (adjusted hazard ratio [HR], 0.63 for 5-year DFS; p = .002 and 0.47 for 5-year OS; p = .002), but not in pN1/2 category. Moreover, in those with pN0 category, the favorable prognostic value of GGO was limited to those with cT1 category for 5-year DFS (adjusted HR, 0.48; p < .001) and those with cT1/2 category for 5-year OS (adjusted HR, 0.37; p = .002).

CONCLUSIONS

GGO was a favorable predictor of survival only in patients with pN0 category, showing an advantage in DFS for those with cT1 category and OS for those with cT1/2 category.

KEY POINTS

• The presence of ground-glass opacity was associated with a favorable prognosis, only in pathological node-negative patients (5-year disease-free survival, p = .002; 5-year overall survival, p = .002). • Within pathological node-negative patients, the effect of ground-glass opacity on 5-year disease-free survival was valid in patients with cT1 category (adjusted hazard ratio, 0.48; 95% confidence interval, 0.32-0.72; p < .001), but not in patients with cT2 or above category. • Within pathological node-negative patients, the effect of ground-glass opacity on 5-year overall survival was valid in patients with cT1/2 category (adjusted hazard ratio, 0.37; 95% confidence interval, 0.20-0.68; p = .002), but not in patients with cT3/4 category.

Racial disparities in bone metastasis patterns and targeted screening and treatment strategies in newly diagnosed lung cancer patients

Objective: Race disparities exist in bone metastasis (BM) development and survival in lung cancer (LC) patients. The Surveillance, Epidemiology, and End Results (SEER) database was used to investigate different patterns of BM development and survival in different races.Design: LC patients with BM were identified from the database from 2010 to 2014. Risk factors were investigated by univariable and multivariable logistic regression. Potential factors for prognosis were evaluated by univariable and multivariable Cox regression.Results: Asian and Pacific Islander (API) patients presented the highest prevalence of BM (24.6%), followed by white (20.7%) and black patients (19.9%) (χ2 = 78.74; p < .001). After adjusting for the demographic and clinical factors, API race was independently associated with a high risk of BM development. The median survival times for the API, white and black LC patients with BM were 16 months (95% CI: 15.2-16.8), 11 months (95% CI: 10.9-11.1) and 10 months (95% CI: 9.7-10.3), respectively, with significant differences (p < .001). Multivariable Cox regression showed that API race was positively associated with greater overall survival compared with white and black patients. Male gender, larger tumor size, lymph node involvement, lower tumor differentiated grade, and the presence of lung, liver and brain metastases were independently associated with a high risk of developing BM and worse survival with LC across all races. Age, income, insurance and histological types had different impacts on BM among different races.Conclusion: Homogeneous and heterogeneous associated factors for BM were revealed among different races. Individualized screening and treatment should be performed race-specifically.

Disparities in clinical and demographic characteristics among Asian/Pacific Islander and Non-Hispanic White newly diagnosed lung cancer patients

PURPOSE

Racial disparities persist among lung cancer patients but have not been adequately studied among Asian/Pacific Islander (API) subgroups, which are heterogeneous. This study compared clinical and demographic characteristics at diagnosis of API subgroups and NHW patients.

METHODS

NHW and API adults diagnosed with lung cancer were identified from the Surveillance, Epidemiology, and End Results database (1990-2015). API was divided into eight subgroups: Chinese, Japanese, Filipino, Hawaiian/Pacific Islander, Korean, Vietnamese, Asian Indian/Pakistani, and Other. Multivariable multinomial logistic regression models were used to assess adjusted associations of clinical and demographic factors with API/subgroups.

RESULTS

There were 522,702 (92.6%) NHW and 41,479 (7.4%) API lung cancer patients. API were less likely to be diagnosed at the age of ≥ 80 years (OR_adj 0.53, 95% CI 0.48-0.58 for ≥ 80 vs. ≤ 39 years) than NHW. However, Japanese patients were more often diagnosed at ≥ 80 years compared to other ethnic subgroups. API were less often female (OR_adj 0.85, 95% CI 0.83-0.86), and unmarried (OR_adj 0.71, 95% CI 0.68-0.74); however, among API, Japanese, Hawaiian/Pacific Islander, Korean, and Vietnamese were more often unmarried, compared to Chinese patients. API were more frequently diagnosed at stage IV, compared to stage I (OR_adj 1.31, 95% CI 1.27-1.35). API had significantly less squamous cell carcinoma (OR_adj 0.54, 95% CI 0.52-0.56, compared to adenocarcinoma); among API, Japanese, Filipino, Hawaiian/Pacific Islander, Korean, Asian Indian/Pakistani, and Other were more likely than Chinese patients to present with squamous cell histology (range: OR_adj[Other] 1.24, 95% CI 1.09-1.41; OR_adj[Hawaiian/Pacific Islander] 2.47, 95% CI 2.22-2.75).

CONCLUSION

At diagnosis, there are significant differences in demographic and clinical characteristics between NHW, API, and API subgroups. Treating API patients as a single population may overlook biological, environmental, and behavioral differences that might be beneficial in designing prevention strategies and treatment.

Estradiol-mediated inhibition of Sp1 decreases miR-3194-5p expression to enhance CD44 expression during lung cancer progression

BACKGROUND

Sp1, an important transcription factor, is involved in the progression of various cancers. Our previous studies have indicated that Sp1 levels are increased in the early stage of lung cancer progression but decrease during the late stage, leading to poor prognosis. In addition, estrogen has been shown to be involved in lung cancer progression. According to previous studies, Sp1 can interact with the estrogen receptor (ER) to coregulate gene expression. The role of interaction between Sp1 and ER in lung cancer progression is still unknown and will be clarified in this study.

METHODS

The clinical relevance between Sp1 levels and survival rates in young women with lung cancer was studied by immunohistochemistry. We validated the sex dependence of lung cancer progression in EGFRL858R-induced lung cancer mice. Wound healing assays, chamber assays and sphere formation assays in A549 cells, Taxol-induced drug-resistant A549 (A549-T24) and estradiol (E2)-treated A549 (E2-A549) cells were performed to investigate the roles of Taxol and E2 in lung cancer progression. Luciferase reporter assays, immunoblot and q-PCR were performed to evaluate the interaction between Sp1, microRNAs and CD44. Tail vein-injected xenograft experiments were performed to study lung metastasis. Samples obtained from lung cancer patients were used to study the mRNA level of CD44 by q-PCR and the protein levels of Sp1 and CD44 by immunoblot and immunohistochemistry.

RESULTS

In this study, we found that Sp1 expression was decreased in premenopausal women with late-stage lung cancer, resulting in a poor prognosis. Tumor formation was more substantial in female EGFRL858R mice than in male mice and ovariectomized female mice, indicating that E2 might be involved in the poor prognosis of lung cancer. We herein report that Sp1 negatively regulates metastasis and cancer stemness in E2-A549 and A549-T24 cells. Furthermore, E2 increases the mRNA and protein levels of RING finger protein 4 (RNF4), which is the E3-ligase of Sp1, and thereby decreases Sp1 levels by promoting Sp1 degradation. Sp1 can be recruited to the promoter of miR-3194-5p, and positively regulate its expression. Furthermore, there was a strong inverse correlation between Sp1 and CD44 levels in clinical lung cancer specimens. Sp1 inhibited CD44 expression by increasing the expression of miR-3194-5p, miR-218-5p, miR-193-5p, miR-182-5p and miR-135-5p, ultimately resulting in lung cancer malignancy.

CONCLUSION

Premenopausal women with lung cancer and decreased Sp1 levels have a poor prognosis. E2 increases RNF4 expression to repress Sp1 levels in premenopausal women with lung cancer, thus decreasing the expression of several miRNAs that can target CD44 and ultimately leading to cancer malignancy.

Systemic Inflammation Index and Tumor Glycolytic Heterogeneity Help Risk Stratify Patients with Advanced Epidermal Growth Factor Receptor-Mutated Lung Adenocarcinoma Treated with Tyrosine Kinase Inhibitor Therapy

Simple Summary

Patients with advanced epidermal growth factor receptor (EGFR)-mutated lung adenocarcinoma have been known to respond to first-line tyrosine kinase inhibitor (TKI) treatment. However, a subgroup of patients are non-responsive to the treatment, with poor survival outcomes, and those who are initially responsive may still experience resistance. A reliable prognostic tool may provide a valuable direction for tailoring individual treatment strategies in this clinical setting. With this aim, the present study explores the prognostic power of the combination of the systemic inflammation index (portrayed by hematological markers) and tumor glycolytic heterogeneity (characterized by ¹⁸F-fluorodeoxyglucose positron emission tomography images). The model integrating these two biomarkers could be used to improve risk stratification, and the subsequent personalized management strategy in patients with advanced EGFR-mutated lung adenocarcinoma.

Abstract

Tyrosine kinase inhibitors (TKIs) are the first-line treatment for patients with advanced epidermal growth factor receptor (EGFR)-mutated lung adenocarcinoma. Over half of patients failed to achieve prolonged survival benefits from TKI therapy. Awareness of a reliable prognostic tool may provide a valuable direction for tailoring individual treatments. We explored the prognostic power of the combination of systemic inflammation markers and tumor glycolytic heterogeneity to stratify patients in this clinical setting. One hundred and five patients with advanced EGFR-mutated lung adenocarcinoma treated with TKIs were retrospectively analyzed. Hematological variables as inflammation-induced biomarkers were collected, including the neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR), platelet-to-lymphocyte ratio (PLR), and systemic inflammation index (SII). First-order entropy, as a marker of heterogeneity within the primary lung tumor, was obtained by analyzing ¹⁸F-fluorodeoxyglucose positron emission tomography images. In a univariate Cox regression analysis, sex, smoking status, NLR, LMR, PLR, SII, and entropy were associated with progression-free survival (PFS) and overall survival (OS). After adjusting for confounders in the multivariate analysis, smoking status, SII, and entropy, remained independent prognostic factors for PFS and OS. Integrating SII and entropy with smoking status represented a valuable prognostic scoring tool for improving the risk stratification of patients. The integrative model achieved a Harrell’s C-index of 0.687 and 0.721 in predicting PFS and OS, respectively, outperforming the traditional TNM staging system (0.527 for PFS and 0.539 for OS, both p < 0.001). This risk-scoring model may be clinically helpful in tailoring treatment strategies for patients with advanced EGFR-mutated lung adenocarcinoma.

Phase 3 Trial of BI 695502 Plus Chemotherapy Versus Bevacizumab Reference Product Plus Chemotherapy in Patients With Advanced Nonsquamous NSCLC

Introduction

Biological therapies such as bevacizumab have improved survival in patients with NSCLC. This study was conducted to confirm the equivalent efficacy of the biosimilar candidate BI 695502 to the bevacizumab reference product (RP).

Methods

In this phase 3, multicenter, randomized, double-blind trial of adult patients with recurrent or metastatic NSCLC received up to 18 weeks of induction treatment with BI 695502 or bevacizumab RP 15 mg/kg plus paclitaxel and carboplatin. Subsequent maintenance therapy comprised BI 695502 or bevacizumab RP monotherapy until disease progression or unacceptable toxicity. The primary end point was the best overall response rate (ORR) per Response Evaluation Criteria in Solid Tumors version 1.1 assessed by central imaging review, until 18 weeks after the start of treatment.

Results

In total, 671 patients were randomized at one-to-one ratio to BI 695502 or bevacizumab RP, of whom 335 and 328, respectively, received treatment. Of these, 228 (68.1%) and 256 (78.0%), respectively, proceeded to maintenance monotherapy. A manufacturing issue led to a small number of patients treated with BI 695502 switching to bevacizumab RP late in the study. The primary end point, best ORR, was 54.0% in the BI 695502 group and 63.1% in the bevacizumab RP group. The 90% confidence interval for the between-group ratio of best ORR (0.770 to 0.951) was within the prespecified range for equivalence (0.736–1.359). Adverse events were class-related and similar between the two treatment arms.

Conclusions

This study revealed equivalent ORR after 18 weeks of treatment with BI 695502 or bevacizumab RP, with similar adverse event profiles.

Durvalumab After Concurrent Chemoradiotherapy in Elderly Patients With Unresectable Stage III Non-Small-Cell Lung Cancer (PACIFIC)

BACKGROUND

The PACIFIC trial demonstrated that consolidation durvalumab significantly improved PFS and OS (the primary endpoints) vs. placebo in patients with unresectable, stage III NSCLC whose disease had not progressed after platinum-based, concurrent chemoradiotherapy (CRT). We report exploratory analyses of outcomes from PACIFIC by age.

PATIENTS AND METHODS

Patients were randomized 2:1 (1-42 days post-CRT) to receive 12-months' durvalumab (10 mg/kg intravenously every-2-weeks) or placebo. We analyzed PFS and OS (unstratified Cox-proportional-hazards models), safety and patient-reported outcomes (PROs: symptoms, functioning, and global-health-status/quality-of-life) in subgroups defined by a post-hoc 70-year age threshold. Data cut-off for PFS was February 13, 2017 and for OS, safety and PROs was March 22, 2018.

RESULTS

Overall, 158 of 713 (22.2%) and 555 of 713 (77.8%) randomized patients were aged ≥70 and <70 years, respectively. Durvalumab improved PFS and OS among patients aged ≥70 (PFS: hazard ratio [HR], 0.62 [95% CI, 0.41-0.95]; OS: HR, 0.78 [95% CI, 0.50-1.22]) and <70 (PFS: HR, 0.53 [95% CI, 0.42-0.67]; OS: HR, 0.66 [95% CI, 0.51-0.87]), although the estimated HR-95% CI for OS crossed one among patients aged ≥70. Durvalumab exhibited a manageable safety profile and did not detrimentally affect PROs vs. placebo, regardless of age; grade 3/4 (41.6% vs. 25.5%) and serious adverse events (42.6% vs. 25.5%) were more common with durvalumab vs. placebo among patients aged ≥70.

CONCLUSION

Durvalumab was associated with treatment benefit, manageable safety, and no detrimental impact on PROs, irrespective of age, suggesting that elderly patients with unresectable, stage III NSCLC benefit from treatment with consolidation durvalumab after CRT. However, small subgroup sizes and imbalances in baseline factors prevent robust conclusions.

RELAY, ramucirumab plus erlotinib versus placebo plus erlotinib in patients with untreated, EGFR-mutated, metastatic non-small cell lung cancer: Europe/United States subset analysis

BACKGROUND

In EGFR mutation-positive NSCLC, dual EGFR/VEGFR inhibition compared to EGFR alone increases anti-tumor efficacy. The Phase III RELAY trial demonstrated superior PFS for ramucirumab plus erlotinib (RAM + ERL) over placebo plus erlotinib (PBO + ERL) (HR 0.591 [95% CI 0.461-0.760], p<0.0001). EGFR mutated NSCLC is less prevalent in Western versus Asian patients. This prespecified analysis evaluates efficacy and safety of RAM + ERL in EU and US patients enrolled in RELAY.

PATIENTS AND METHODS

Patients were randomized 1:1 to ERL + RAM (10 mg/kg IV) or PBO Q2W. Treatment continued until unacceptable toxicity or progressive disease. Patients were stratified by geographic region (East Asia vs "other" [EU/US and Canada (EU/US)]). Objectives included PFS, ORR, DoR, OS, PFS2, safety and biomarker analysis.

RESULTS

EU/US subset included 113/449 (25.9%) patients (58 RAM + ERL, 55 PBO + ERL). RAM + ERL improved PFS (20.6 vs 10.9 months, HR 0.605 [95% CI: 0.362-1.010]). ORR and DCR were similar, but median DoR was longer with RAM + ERL (18.0 vs 10.1 months, HR 0.527 [95% CI: 0.296-0.939]). OS and PFS2 were immature at data cut-off (censoring rates 81.0-81.8% and 67.3-79.3%, respectively). Most commonly reported Grade ≥3 TEAE for RAM + ERL was hypertension (17 [29.8%]) and for PBO + ERL, dermatitis acneiform (5 [9.1%]).

CONCLUSION

EU/US subset analysis showed improved efficacy outcomes for RAM + ERL and a safety profile consistent with the overall population. Ramucirumab is a safe and effective addition to standard-of-care EGFR-TKI for EGFR mutation-positive metastatic NSCLC.

Association of Immune Related Adverse Events With Efficacy of Immune Checkpoint Inhibitors and Overall Survival in Cancers: A Systemic Review and Meta-analysis

Objectives

Immune checkpoint inhibitors (ICIs) have brought impressive benefits to cancer patients, however often accompanied with immune-related adverse events (irAEs). We aimed to investigate the association of irAEs with efficacy and overall survival in cancer patients treated by ICIs, and further quantify the association by stratifying subgroups.

Methods

PubMed, EMBASE and Cochrane library from database inception to 29 August 2019 were systematically searched. Articles reporting association of objective response rate (ORR), progression-free survival (PFS), overall survival (OS) with irAEs in cancer patients treated with approved ICIs were included. Adjusted odds ratios (OR) with 95% confidential intervals (CIs) were calculated for ORR, and hazard ratios (HR) were used for PFS and OS.

Results

A total of 52 articles comprising 9,156 patients were included. Pooled data demonstrated a statistically significant greater probability of achieving objective tumor response for patients with irAEs compared to those without (OR 3.91, 95% CI 3.05-5.02). In overall meta-analysis, patients who developed irAEs presented a prolonged PFS (HR 0.54; 95% CI 0.46-0.62) and OS (HR 0.51; 95% CI 0.41-0.59). More specifically, irAEs in certain cancer types (NSCLC and melanoma) and organs (skin and endocrine) were robustly associated with better clinical outcomes, while this association needs further verification regarding other tumors. High grade toxicities (G3-5) were not associated with a significantly favorable PFS or OS. Additionally, the association between irAEs and clinical benefit seemed to be more definite in patients receiving PD-(L)1 blockade than CTLA-4 blockade. Pooled data from landmark analyses displayed consistent results.

Conclusions

The occurrence of irAEs predicted improved tumor response and better survival in overall cancer patients treated with ICIs. Notably, the association stayed robust in certain cancer types (NSCLC and melanoma) and organ-specific irAEs (skin and endocrine).

Immune-Based Cancer Treatment: Addressing Disparities in Access and Outcomes

Avoidable differences in the care and outcomes of patients with cancer (i.e., cancer care disparities) emerge or worsen with discoveries of new, more effective approaches to cancer diagnosis and treatment. The rapidly expanding use of immunotherapy for many different cancers across the spectrum from late to early stages has, predictably, been followed by emerging evidence of disparities in access to these highly effective but expensive treatments. The danger that these new treatments will further widen preexisting cancer care and outcome disparities requires urgent corrective intervention. Using a multilevel etiologic framework that categorizes the targets of intervention at the individual, provider, health care system, and social policy levels, we discuss options for a comprehensive approach to prevent and, where necessary, eliminate disparities in access to the clinical trials that are defining the optimal use of immunotherapy for cancer, as well as its safe use in routine care among appropriately diverse populations. We make the case that, contrary to the traditional focus on the individual level in descriptive reports of health care disparities, there is sequentially greater leverage at the provider, health care system, and social policy levels to overcome the challenge of cancer care and outcomes disparities, including access to immunotherapy. We also cite examples of effective government-sponsored and policy-level interventions, such as the National Cancer Institute Minority-Underserved Community Oncology Research Program and the Affordable Care Act, that have expanded clinical trial access and access to high-quality cancer care in general.

Detection of programmed cell death-ligand 1 using 22C3 antibody in patients with unresectable stage III non-small cell lung cancer receiving chemoradiotherapy

BACKGROUND

The expression of programmed cell death-ligand 1 (PD-L1) is a biomarker for administering immune check point inhibitors in patients with advanced stage non-small cell lung cancer. Although the consolidation therapy of durvalumab after definitive chemoradiotherapy has become the new standard of care for patients with unresectable stage III non-small cell lung cancer, the prevalence and prognostic role of PD-L1 expression in this population remain unclear.

METHODS

We retrospectively reviewed data from patients with unresectable stage III non-small cell lung cancer who received definitive chemoradiotherapy at our institution between 2012 and 2017. Levels of PD-L1 were assessed using 22C3 antibody, and associations of progression-free and overall survival rates with PD-L1 statuses at a tumor proportion score cutoff of 1% were analyzed.

RESULTS

Among the 104 patients enrolled, PD-L1 statuses were as follows: tumor proportion score < 1%, 73 (70.2%); 1-49%, 21 (20.2%); and ≥ 50%, 10 (9.6%). The number of patients with stage III non-small cell lung cancer with pretreatment PD-L1 tumor proportion score ≥ 1% was less than the number with advanced stage disease. There was no association between patient characteristics and PD-L1 status, and no significant differences were observed in progression-free and overall survival rates relative to PD-L1 status.

CONCLUSION

Expression of PD-L1 in patients with stage III non-small cell cancer before chemoradiotherapy should be assessed because of the low prevalence of tumors with tumor proportion scores ≥ 1%. Further studies are needed to clarify whether durvalumab improves survival after definitive chemoradiotherapy, irrespective of tumor PD-L1 expression.

Role of immunotherapy and co-mutations on KRAS-mutant non-small cell lung cancer survival

Background

KRAS mutations reported in non-small cell lung cancer (NSCLC) represent a significant percentage of patients diagnosed with NSCLC. However, there still remains no therapeutic option designed to target KRAS. In an era with immunotherapy as a dominant treatment option in metastatic NSCLC, the role of immunotherapy in

KRAS

mutated patients is not clear.

Methods

Eligible patients diagnosed with NSCLC and found to have a KRAS mutation were identified in an institutional lung cancer database. Demographic, clinical, and molecular data was collected and analyzed.

Results

A total of 60 patients were identified for this retrospective analysis. Majority of patients were Caucasian (73%), diagnosed with stage IV (70%) adenocarcinoma (87%), and had a KRAS codon 12 mutation (78%). Twenty percent of patients were treated with immunotherapy. Median overall survival was 28 months in the cohort and patients who received immunotherapy were found to have better survival versus those who did not (33 vs. 22 months, P=0.31). Furthermore, there was an association between high survival and patients who received immunotherapy (P=0.007).

Conclusions

Patients with KRAS mutations have a unique co-mutation phenotype that requires further investigation. Immunotherapy seems to be an effective choice of treatment for KRAS positive patients in any treatment-line setting and yields better outcomes than conventional chemotherapy. The relationship between immunotherapy and KRAS mutations requires further studies to confirm survival advantage.

Thoracic radiotherapy plus Durvalumab in elderly and/or frail NSCLC stage III patients unfit for chemotherapy - employing optimized (hypofractionated) radiotherapy to foster durvalumab efficacy: study protocol of the TRADE-hypo trial

BACKGROUND

Non-small cell lung cancer is the most common cause of cancer death worldwide, highlighting the need for novel therapeutic concepts. In particular, there is still a lack of treatment strategies for the group of elderly and frail patients, who are frequently not capable of receiving standard therapy regimens. Despite comprising the majority of lung cancer patients, this group is underrepresented in clinical trials. This applies also to elderly and frail patients suffering from unresectable stage III NSCLC, who are unfit for chemotherapy, and, therefore, cannot receive the standard therapy comprising of radiochemotherapy and the recently approved subsequent durvalumab consolidation therapy. These patients often receive radiotherapy only, which raises the concern of undertreatment. The TRADE-hypo trial aims at optimizing treatment of this patient group by combining radiotherapy with concomitant durvalumab administration, thereby employing the immune-promoting effects of radiotherapy, and determining safety, feasibility, and efficacy of this treatment.

METHODS/ DESIGN

In this prospective phase II clinical trial, durvalumab therapy will be combined with either conventionally fractionated (CON-group) or hypofractionated (HYPO-group) thoracic radiotherapy. A safety stop-and-go lead-in phase will assess safety of hypofractionated radiotherapy with respect to severe pneumonitis in small patient cohorts before opening full enrollment. Tumor tissue, blood and stool samples will be collected before and during the study period to investigate the immunological mechanisms responsible for checkpoint inhibitor efficacy and immune-promoting effects of radiotherapy.

DISCUSSION

Preclinical data suggests that irradiation-induced immunogenicity can be further increased if applied in a hypofractionated setting, potentially boosting the expected synergistic effect with immune checkpoint inhibition in restoring the immune anti-tumor response. If proven safe and efficient, a hypofractionated radiation schedule can provide a considerably more practicable option for the patient. Taking into consideration the intend to develop a combination treatment strategy that can be made available to patients soon after proving to be efficient and the potentially elevated toxicity of a hypofractionated radiotherapy approach, this trial was designed as a two-trials-in-one design. An accompanying translational research program is planned striving to gain insights into the tumor-host biology and to identify suitable biomarkers to predict therapy response.

TRIAL REGISTRATION

Clinicaltrials.gov , NCT04351256 . Registered 17 April 2020, Eudra-CT, 2019-002192-33 . Registered 24 October 2019.

Different treatment efficacies and side effects of cytotoxic chemotherapy

Differences in efficacy and toxicity between Asian and Caucasian patients with lung cancer treated with systemic chemotherapy is increasingly recognised. This is a major concern in the clinical setting as it influences outcomes and affect international harmonization of drug development. Interindividual variability of pharmacokinetics, where different genetic polymorphisms affect drug metabolism, transport, and receptor binding may account for the ethnic differences. Treatment efficacy and outcomes may also be explained by differences in diet and lifestyle, access to healthcare, cultural barriers and environmental exposure. Efforts made to design prospective studies investigating ethnic specific determinants to systemic therapy and individualise lung cancer treatment based on genetic makeup of patient are important.

Lung cancer in women in 21th century

Lung cancer is the first cause of death from malignant disease. The distressing epidemiological data show the increasing female to male incidence ratio for this tumor. A high incidence of lung cancer in never smokers with importance of environmental agents makes a problem among women. Adenocarcinoma (ADC) is noted in women with increasing rate and ethnic background impacts female lung cancer with differences in the incidence of genetic aberrations. The conception of different hormonal status is taken into consideration as potential explanation of variant cancer biology and clinical manifestation in women and men. The impact of 17-β-estradiol, estrogen receptors, aromatase expression, pituitary sex hormones receptors in carcinogenesis with relation between estrogens and genetic aberrations are investigated. The response to newest therapies among female is also different than in men. This overview summarizes currently available evidence on the specificity of female lung cancer and presents the direction of necessary studies.

Development, internal validation and calibration of a risk score to predict survival in patients with EGFR-mutant non-small cell lung cancer

AIMS

EGFR tyrosine kinase inhibitors (TKIs) are first-line molecularly targeted therapies in patients with advanced non-small cell lung cancer (NSCLC) who carry sensitising EGFR mutations, due to its superior survival outcomes compared with conventional chemotherapy regimens. In this study, we sought to identify clinical, immune and biochemical variables with prognostic significance in this patient subgroup and incorporate them into a nomogram-based risk score.

METHODS

A total of 199 patients with EGFR mutation-positive, advanced NSCLC (defined as stage IV at initial diagnosis or incurable disease recurrence) treated with first-line EGFR TKI therapy were retrospectively profiled. Univariable and multivariable survival analyses were conducted, with variables from the multivariable model with the highest Harrell's Concordance (C) Index selected for inclusion in the subsequent survival nomogram. Internal validation and internal calibration of our prognostic nomogram were also performed.

RESULTS

Serum lactate dehydrogenase (LDH) and lung/pleural metastasis were independent predictors of unfavourable overall survival in all three multivariable models. A survival nomogram was generated based on the multivariable model with the highest Harrell's C Index, incorporating the following 11 variables: white cell count, haemoglobin, LDH, neutrophil/lymphocyte ratio, ethnicity (Chinese vs non-Chinese), Karnofsky-Performance Status (score of '90-100' or '70-80' vs '0-60'), Charlson Comorbidity Index (≥3, or 2, or 1 vs 0), neurological symptoms, brain, lung/pleural and adrenal metastases.

CONCLUSION

We identified serum LDH as an independent predictor of unfavourable clinical outcomes in patients with advanced, EGFR mutation-positive NSCLC. We further developed a robust nomogram-based risk score that incorporates clinical, biochemical and immune variables that can provide more targeted prognostication and management in this patient subgroup.

Sub-solid lung adenocarcinoma in Asian versus Caucasian patients: different biology but similar outcomes

Background

Asian and Caucasian patients with lung cancer have been compared in several database studies, with conflicting findings regarding survival. However, these studies did not include proportion of ground-glass opacity or mutational status in their analyses. Asian patients commonly develop sub-solid lung adenocarcinomas that harbor EGFR mutations, which have a better prognosis. We hypothesized that among patients undergoing surgery for sub-solid lung adenocarcinomas, Asian patients have better survival compared to Caucasian patients.

Methods

We identified Asian and Caucasian patients who underwent surgical resection for a sub-solid lung adenocarcinoma from 2002 to 2015 at our institution. Sub-solid was defined as ≥10% ground-glass opacity on preoperative CT scan or ≥10% lepidic component on surgical pathology. Time-to-event multivariable analysis was performed to determine which characteristics were associated with recurrence and survival.

Results

Two hundred twenty-four patients were included with median follow up 48 months. Asian patients were more likely to be never smokers (76.3% vs. 29.0%, P<0.01) and have an EGFR mutation (69.4% vs. 25.6% of those tested, P<0.01), while Caucasian patients were more likely to have a KRAS mutation (23.5% vs. 4.9% of those tested, P<0.01). There was a trend towards Asian patients having a higher proportion of ground-glass opacity (38.8% vs. 30.5%, P=0.11). Time-to-event multivariable analysis showed that higher proportion of ground-glass opacity was significantly associated with better recurrence-free survival (HR 0.76 per 20% increase, P=0.02). However, mutational status and race did not have a significant impact on recurrence-free or overall survival.

Conclusions

Asian and Caucasian patients with sub-solid lung adenocarcinoma have different tumor biology, but recurrence-free and overall survival after surgical resection is similar.

Asian Thoracic Oncology Research Group Expert Consensus Statement on Optimal Management of Stage III NSCLC

Stage III NSCLC represents a heterogeneous disease for which optimal treatment continues to pose a clinical challenge. Recent changes in the American Joint Commission on Cancer staging to the eighth edition has led to a shift in TNM stage grouping and redefined the subcategories (IIIA-C) in stage III NSCLC for better prognostication. Although concurrent chemoradiotherapy has remained standard-of-care for stage III NSCLC for almost 2 decades, contemporary considerations include the impact of different molecular subsets of NSCLC, and the roles of tyrosine kinase inhibitors post-definitive therapy and of immune checkpoint inhibitors following chemoradiotherapy. With rapid evolution of diagnostic algorithms and expanding treatment options, the need for interdisciplinary input involving multiple specialists (medical oncologists, radiation oncologists, pulmonologists, radiologists, pathologists and thoracic surgeons) has become increasingly important. The unique demographics of Asian NSCLC pose further challenges when applying clinical trial data into clinical practice. This includes differences in smoking rates, prevalence of oncogenic driver mutations, and access to health care resources including molecular testing, prompting the need for critical review of existing data and identification of current gaps. In this expert consensus statement by the Asian Thoracic Oncology Research Group, an interdisciplinary group of experts representing Hong Kong, Korea, Japan, Taiwan, Singapore, Thailand, Malaysia, and Mainland China was convened. Standard clinical practices for stage III NSCLC across different Asian countries were discussed from initial diagnosis and staging through to multi-modality approaches including surgery, chemotherapy, radiation, targeted therapies, and immunotherapy.

Racial and Ethnic Disparities in Lung Adenocarcinoma Survival: A Competing-Risk Model

BACKGROUND

Race/ethnicity-specific disparities in lung cancer survival have been investigated extensively. However, more studies concentrating on lung adenocarcinoma (ADC), especially those using a competing-risk model, are needed. We examined race/ethnicity-specific differences in lung ADC survival.

PATIENTS AND METHODS

Patients with ADC diagnosed from 2004 to 2015 were identified from the Surveillance, Epidemiology, and End Results program. Race/ethnicity was categorized into 4 groups: non-Hispanic white (NHW), non-Hispanic black (NHB), non-Hispanic Asian/Pacific Islander (NHAPI), and Hispanic. Lung cancer-specific mortality (LCSM) and other cause-specific mortality (OCSM) were evaluated using a competing-risk model.

RESULTS

On multivariate analysis, NHB patients experienced slightly lower LCSM (subdistribution hazard ratio, 0.96; 95% confidence interval, 0.94-0.98) and higher OCSM (subdistribution hazard ratio, 1.16; 95% confidence interval, 1.11-1.22) compared with NHW patients in the stage IV group. No significant differences were found in LCSM and OCSM between the NHB and NHW patients with early-stage ADC (stage I or II). Both NHAPI and Hispanic patients experienced lower OCSM and LCSM compared with the NHW patients. Additionally, NHB patients with stage IV tumors had a greater mortality risk of cardiovascular disease and a lower risk of chronic obstructive pulmonary disease than NHW patients.

CONCLUSIONS

The source of racial/ethnic survival disparities that exist between NHB and NHW patients was mainly found in patients with stage IV ADC. Reducing the greater mortality rate of cardiovascular disease among NHB patients and chronic obstructive pulmonary disease among NHW patients would be conducive to narrowing the racial/ethnic gaps. Further research is warranted to determine additional influencing factors, especially among patients with stage IV ADC.

Characteristics and Predictive Value of PD-L1 Status in Real-World Non-Small Cell Lung Cancer Patients

Immunotherapy targeting the programmed cell death-1 (PD-1) and programmed cell death-ligand 1 (PD-L1) pathway has emerged as an effective treatment for lung cancer patients. It is important to evaluate the practicality of PD-L1 testing in real-world practice. A total of 211 non-small cell lung cancer patients were enrolled to detect 5 driver mutations and PD-L1 status (22C3 and SP263 assays) and to evaluate the characteristics of PD-L1 expression and its predictive value of immunotherapy. The PD-L1 positive (≥1%) and strong positive (≥50%) rate by SP263 assay was 27.0% and 12.8%. The concordance rates between 2 PD-L1 assays while using 1%, 10%, 25%, and 50% positive tumor cells as the cutoffs were 76.8%, 81.5%, 90.5%, and 94.3%, respectively. Smokers and patients without known actionable driver mutation were more likely to present strong positive PD-L1 [adjusted hazard ratio, 5.00 (95% confidence interval-CI, 1.60-15.64); P=0.006 and 3.59 (95% CI, 1.25-10.33); P=0.018, respectively]. Higher levels of smoking were associated with higher PD-L1 expressions. None of the EGFR, ALK, HER2, or BRAF-mutant nonsmokers displayed strong positive PD-L1 expression by SP263 assay. Among patients undergoing PD-1 checkpoint inhibitors therapy, high PD-L1 expression by SP263 was associated with a longer progression-free survival [adjusted hazard ratio, 0.15 (95% CI, 0.03-0.71); P=0.017]. In conclusion, our results suggest that PD-L1 status remains an important predictor of immunotherapy efficacy. The concordance between 22C3 and SP263 assays was greater at a higher cutoff level of positivity. Patients without known actionable driver mutation, along with smokers, particularly those having high smoking pack-years, were more likely to have strong PD-L1 expression.

Impact of Asian ethnicity on outcome in metastatic EGFR-mutant non-small cell lung cancer

AIM

To determine factors associated with survival in de novo stage IV, non-small cell lung cancer (NSCLC) patients possessing epidermal growth factor receptor mutations (EGFRmut⁺ ) receiving tyrosine kinase inhibitors (TKI) in the first-line setting.

METHODS

The Glans-Look Lung Cancer Database was used to retrospectively review stage IV EGFRmut⁺ NSCLC patients diagnosed 2010-2016 receiving first-line TKI. Patients with overall survival times in the upper quartile (≥34 months) were designated "long-term survivors" (LTS), the remaining deemed "average-term survivors" and characteristics between these groups were compared in univariate analysis, and multivariable models constructed to determine predictors of outcome.

RESULTS

Of 170 eligible patients, median overall survival was 21 months. LTS were significantly more likely to be of Asian ethnicity, be never-smokers and not possess brain or bone metastases at diagnosis. Asian and non-Asian patients were comparable, save for an increased propensity of Asian patients to be never smokers and have normal-range BMI. Multivariable analysis revealed Asian ethnicity [hazard ratio (HR) = 0.65; P = 0.016] and never-smoking history (HR = 0.65; P = 0.034) as indicators of improved outcome, and presence of brain metastasis at diagnosis an indicator of poor outcome (HR = 2.21; P < 0.001).

CONCLUSIONS

Analysis of this population-based cohort identifies never-smoking history and absence of brain metastasis along with Asian ethnicity as an independent prognosticators of favorable outcome, and reveals Asian patients to be clinicopathologically similar to non-Asian patients. These findings suggest Asian patients represent a unique subpopulation within EGFRmut⁺ NSCLC who may possess different biological underpinnings of NSCLC.

Comparative efficacy of brigatinib versus ceritinib and alectinib in patients with crizotinib-refractory anaplastic lymphoma kinase-positive non-small cell lung cancer

OBJECTIVE

Brigatinib, ceritinib, and alectinib are approved to treat crizotinib-refractory anaplastic lymphoma kinase-positive (ALK+) non-small cell lung cancer (NSCLC), but no trial has compared them head-to-head. A matching-adjusted indirect comparison (MAIC) was conducted to estimate the relative efficacy of these agents in the crizotinib-refractory setting.

METHODS

MAIC is a propensity score-type method that adjusts for differences in baseline characteristics between trials to estimate relative efficacy. Analyses were based on patient-level data from the ALTA trial for brigatinib and published summary-level trial data from ASCEND-1 and ASCEND-2 for ceritinib and NP28761 and NP28673 for alectinib. Objective response rate (ORR), progression-free survival (PFS), and overall survival (OS) were compared.

RESULTS

After matching, all key baseline characteristics were balanced between trials. Compared with ceritinib, brigatinib was associated with longer PFS (ASCEND-1: median 15.7 vs 6.9 months, hazard ratio (HR) [95% confidence interval] = 0.38 [0.26-0.57]; ASCEND-2: median = 18.3 vs 7.2 months, HR = 0.33 [0.20-0.56]) and OS (ASCEND-1: not available; ASCEND-2: median 27.6 vs 14.9 months, HR = 0.33 [0.17-0.63]). Versus alectinib, brigatinib was associated with longer PFS (NP28761: median = 17.6 vs 8.2 months, HR = 0.56 [0.36-0.86]; NP28673: median = 17.6 vs 8.9 months, HR = 0.61 [0.40-0.93]); results for OS were inconclusive (NP28761: median = 27.6 vs 22.7 months, HR = 0.70 [0.42-1.16]; NP28673: median = 27.6 vs 26.0 months, HR = 0.66 [0.39-1.09]). ORR was similar.

CONCLUSION

In crizotinib-refractory ALK + NSCLC patients, relative efficacy estimates suggest brigatinib may have prolonged PFS and OS vs ceritinib and prolonged PFS vs alectinib.

Variable impact of prior cancer history on the survival of lung cancer patients

INTRODUCTION

Non-Small Cell Lung Cancer (NSCLC) is commonly diagnosed in patients who have survived a prior malignancy. However, it is currently unclear whether NSCLC patient survival is impacted by the potential for previously-treated malignancies to recur. Understanding the impact of a prior cancer history on NSCLC survival could not only enhance decision making but could affect eligibility for NSCLC studies.

METHODS

The National Cancer Database (NCDB) was queried for NSCLC patients (stage I-IV) diagnosed between 2004-2014. Kaplan-Meier survival curves and multivariable Cox proportional hazards regression models were estimated to analyze overall survival across a variety of treatment approaches and stages in the presence and absence of a prior cancer history.

RESULTS

A total of 821,323 patients with a newly diagnosed NSCLC were identified including 179,512 (21.9%) with a prior history of cancer. The unadjusted 5-year overall survival of patients with a prior cancer history (9.8%) was slightly better to those without a cancer history (9.5%, 95% CI 11.76-11.84, P < 0.0001). However, adjusted analyses revealed the impact of prior cancer history was extremely heterogenous across stage and treatment approach. Ultimately, 51.4% of patients fell into a subgroup in which prior cancer history appeared to compromise survival, 16.3% in which the difference was not significant, and 32.3% in which prior cancer was associated with increased survival. Patients with earlier-staged tumors were the most negatively NSCLC impacted by prior cancer history.

CONCLUSIONS

The association between prior cancer history and survival of newly diagnosed NSCLC patients is highly variable and to some degree reflects a patient's potential for cure.

Avelumab versus docetaxel in patients with platinum-treated advanced non-small-cell lung cancer (JAVELIN Lung 200): an open-label, randomised, phase 3 study

BACKGROUND

Antibodies targeting the immune checkpoint molecules PD-1 or PD-L1 have demonstrated clinical efficacy in patients with metastatic non-small-cell lung cancer (NSCLC). In this trial we investigated the efficacy and safety of avelumab, an anti-PD-L1 antibody, in patients with NSCLC who had already received platinum-based therapy.

METHODS

JAVELIN Lung 200 was a multicentre, open-label, randomised, phase 3 trial at 173 hospitals and cancer treatment centres in 31 countries. Eligible patients were aged 18 years or older and had stage IIIB or IV or recurrent NSCLC and disease progression after treatment with a platinum-containing doublet, an Eastern Cooperative Oncology Group performance status score of 0 or 1, an estimated life expectancy of more than 12 weeks, and adequate haematological, renal, and hepatic function. Participants were randomly assigned (1:1), via an interactive voice-response system with a stratified permuted block method with variable block length, to receive either avelumab 10 mg/kg every 2 weeks or docetaxel 75 mg/m² every 3 weeks. Randomisation was stratified by PD-L1 expression (≥1% vs <1% of tumour cells), which was measured with the 73-10 assay, and histology (squamous vs non-squamous). The primary endpoint was overall survival, analysed when roughly 337 events (deaths) had occurred in the PD-L1-positive population. Efficacy was analysed in all PD-L1-positive patients (ie, PD-L1 expression in ≥1% of tumour cells) randomly assigned to study treatment (the primary analysis population) and then in all randomly assigned patients through a hierarchical testing procedure. Safety was analysed in all patients who received at least one dose of study treatment. This trial is registered with ClinicalTrials.gov, number NCT02395172. Enrolment is complete, but the trial is ongoing.

FINDINGS

Between March 24, 2015, and Jan 23, 2017, 792 patients were enrolled and randomly assigned to receive avelumab (n=396) or docetaxel (n=396). 264 participants in the avelumab group and 265 in the docetaxel group had PD-L1-positive tumours. In patients with PD-L1-positive tumours, median overall survival did not differ significantly between the avelumab and docetaxel groups (11·4 months [95% CI 9·4-13·9] vs 10·3 months [8·5-13·0]; hazard ratio 0·90 [96% CI 0·72-1·12]; one-sided p=0·16). Treatment-related adverse events occurred in 251 (64%) of 393 avelumab-treated patients and 313 (86%) of 365 docetaxel-treated patients, including grade 3-5 events in 39 (10%) and 180 (49%) patients, respectively. The most common grade 3-5 treatment-related adverse events were infusion-related reaction (six patients [2%]) and increased lipase (four [1%]) in the avelumab group and neutropenia (51 [14%]), febrile neutropenia (37 [10%]), and decreased neutrophil counts (36 [10%]) in the docetaxel group. Serious treatment-related adverse events occurred in 34 (9%) patients in the avelumab group and 75 (21%) in the docetaxel group. Treatment-related deaths occurred in four (1%) participants in the avelumab group, two due to interstitial lung disease, one due to acute kidney injury, and one due to a combination of autoimmune myocarditis, acute cardiac failure, and respiratory failure. Treatment-related deaths occurred in 14 (4%) patients in the docetaxel group, three due to pneumonia, and one each due to febrile neutropenia, septic shock, febrile neutropenia with septic shock, acute respiratory failure, cardiovascular insufficiency, renal impairment, leucopenia with mucosal inflammation and pyrexia, infection, neutropenic infection, dehydration, and unknown causes.

INTERPRETATION

Compared with docetaxel, avelumab did not improve overall survival in patients with platinum-treated PD-L1-positive NSCLC, but had a favourable safety profile.

FUNDING

Merck and Pfizer.

Sex-Dependent Staging in Non-Small-Cell Lung Cancer; Analysis of the Effect of Sex Differences in the Eighth Edition of the Tumor, Node, Metastases Staging System

INTRODUCTION

Non-small-cell lung cancer (NSCLC) has disproportionately negative outcomes in men compared with women. The importance of the relationship between sex and tumor, node, metastases (TNM) staging system remains unknown. The objective of this study was to investigate the effect of sex on NSCLC survival for each stage in the eighth edition of the TNM staging system in NSCLC.

PATIENTS AND METHODS

Two cohorts treated surgically with curative intent between 2000 and 2010 were analyzed. The primary cohort was from Australia with a second population set from the Surveillance, Epidemiology, and End Results (SEER) database. Univariate and multivariate analyses of putative and validated prognostic factors were undertaken to investigate sex-dependent prognostication with detailed analyses of sex differences in each TNM stage. The primary outcome was disease-specific survival (DSS) at 5 years.

RESULTS

Inclusion criteria were met by 555 patients in the Australian cohort, 335 men (60.4%) and 220 (39.6%) women; and 47,706 patients from the SEER cohort, 24,671 men (51.7%) and 23,035 women (48.3%). Five-year DSS was significantly worse for men in multivariate analyses for the Australian (hazard ratio [HR], 1.44; 95% confidence interval [CI], 1.04-1.98; P = .026) and SEER (HR, 1.24; 95% CI, 1.20-1.28; P < .001) cohorts. Detailed analysis of TNM stage sex differences revealed a consistent pattern of men having worse survival than women across stages in both cohorts.

CONCLUSION

The poorer survival in men with NSCLC presents research and clinical communities with an important challenge. This study's findings suggest that for men and women diagnosed with NSCLC, and managed surgically, stage-specific outcomes should be quoted separately and consideration to a rapid prognostic score with sex combined with staging as a key element.