Association of Programmed Cell Death Ligand 1 Expression Status With Receipt of Immune Checkpoint Inhibitors in Patients With Advanced Non-Small Cell Lung Cancer

IMPORTANCE

Initial approval for immune checkpoint inhibitors (ICIs) for treatment of advanced non-small cell lung cancer (NSCLC) was limited to patients with high levels of programmed cell death ligand 1 (PD-L1) expression. However, in the period after approval, it is not known how new evidence supporting efficacy of these treatments in patients with low or negative PD-L1 expression was incorporated into real-world practice.

OBJECTIVE

To evaluate the association between PD-L1 testing and first-line ICI use.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study (January 1, 2011, to December 31, 2018) used a deidentified nationwide electronic health record-derived database reflecting real-world care at more than 280 US community and academic cancer clinics (approximately 800 sites of care). Patients included those with advanced NSCLC without other identifiable variations diagnosed in the period after the US Food and Drug Administration's initial first-line approval of ICIs for patients with high PD-L1 expression (≥50%).

EXPOSURE

First-line ICI treatment.

MAIN OUTCOMES AND MEASURES

Patterns of PD-L1 testing and first-line ICI treatment among all patients and patients stratified by tumor histologic type (squamous vs nonsquamous).

RESULTS

A total of 45 631 patients (mean [SD] age, 68.4 [9.6] years; 21 614 [47.4%] female) with advanced NSCLC were included in the study. PD-L1 testing increased from 468 (7.2%) in 2015 to 4202 (73.2%) in 2018. Within a subset of 7785 patients receiving first-line treatment in the period after first-line approval of pembrolizumab, those who received PD-L1 testing had a greater odds of receiving an ICI (odds ratio, 2.11; 95% CI, 1.89-2.36). Among patients with high PD-L1 expression (≥50%), 1541 (83.5%) received first-line ICI treatment; 776 patients (40.3%) with low PD-L1 expression (1%-49%) and 348 (32.3%) with negative PD-L1 expression (0%) also received ICIs. In addition, 755 untested patients (32.8%) were treated with a first-line ICI. The proportion of patients who received ICIs without PD-L1 testing increased during the study period (59 [17%] in quarter 4 of 2016 to 141 [53.8%] in quarter 4 of 2018).

CONCLUSIONS AND RELEVANCE

In this study, use of first-line ICI treatment increased among patients with advanced NSCLC with negative, low, or untested PD-L1 expression status in 2016 through 2018. These findings suggest that national practice was rapidly responsive to new clinical evidence rather than adhering to regulatory guidance in place at the time.

Effectiveness of PD-1/PD-L1 inhibitors in the treatment of lung cancer: Brightness and challenge

Immune checkpoint inhibitors (ICIs), especially inhibitors of the PD-1/PD-L1 axis, have significantly affected the outcomes of patients with lung cancer. Nivolumab and pembrolizumab have been approved as PD-1 blocking antibodies, whereas atezolizumab, avelumab, and durvalumab are approved as PD-L1 blocking antibodies by the United States Food and Drug Administration. However, which patient may benefit the most and how to identify patients at risk of primary or acquired resistance has not been completely defined. Meanwhile, close attention has been paid to the ongoing international and domestic clinical trials in Chinese patients with lung cancer. This review aimed to provide deep insight into the effectiveness of PD-1/PD-L1 inhibitors in patients with lung cancer, including the current settings for varied disease status, the predictive biomarkers, the resistance to ICIs, and the ongoing clinical trials in Chinese patients.

Comparative efficacy and safety of first-line treatments for advanced non-small cell lung cancer with immune checkpoint inhibitors: A systematic review and meta-analysis

Background

Non‐small cell lung cancer (NSCLC) is the predominant type of lung cancer, and most clinically curable patients are diagnosed with locally advanced disease. Although the efficacy of standard platinum‐based chemotherapy doublets is relatively limited. The effect of immune checkpoint inhibitors (ICIs) remains controversial, and its role in the first‐line treatment of advanced NSCLC is obscure. Thus, we carried out a systematic review and meta‐analysis to compare the efficacy and safety of ICIs for advanced NSCLC.

Methods

The PubMed, Cochrane Central Register Trial, and American Society of Clinical Oncology databases were searched from inception to 30 April 2018. We searched for randomized controlled trials comparing single‐agent programmed cell death protein 1/programmed death‐ligand 1 inhibitors (nivolumab, pembrolizumab, or atezolizumab) or cytotoxic T‐lymphocyte‐associated antigen 4 inhibitor (ipilimumab) with chemotherapy in NSCLC patients. Progression‐free survival, overall survival, objective response rate, and adverse events were pooled for meta‐analysis by Review Manager (RevMan version 5.3) software.

Results

After exclusion of ineligible studies, 12 eligible randomized controlled trials were included. Data showed that ICIs significantly improved progression‐free survival (HR 0.66, 95% CI 0.57–0.77, P < 0.00001), overall survival (HR 0.77, 95% CI 0.64–0.91, P = 0.003), and but not objective response rate (RR 1.97, 95% CI 1.25–3.13, P = 0.004) in all unselected NSCLC populations. However, they failed to increase the OS of programmed death‐ligand 1 = 1–49% subgroup (HR 0.78, 95% CI 0.51–1.19, P = 0.25) and PFS of programmed death‐ligand 1<1% subgroup (HR 0.85; 95%CI 0.70 to 1.03, P=0.09) in ICIs+chemotherapy over chemotherapy. Meanwhile, OS of programmed death‐ligand =1‐49% subgroup (HR 0.92; 95%CI 0.77 to 1.10, P=0.36) and PFS of programmed death‐ligand 1≥50% subgroup (HR 0.76; 95%CI 0.52 to 1.11, P=0.15) showed no significant differences in ICIs over chemotherapy. Furthermore, fewer adverse events were observed in the ICIs groups than control groups.

Conclusion

ICIs are overall better tolerated than chemotherapy. Our results provide further evidence supporting the favorable risk/benefit ratio for ICIs.

Retrospect and Prospect for Lung Cancer in China: Clinical Advances of Immune Checkpoint Inhibitors

Lung cancer is the most commonly diagnosed cancer and the leading cause of cancer-related deaths in China. The recent emergence of immunotherapy treatment options, such as the use of programmed cell death protein 1 (PD-1)/programmed death-ligand 1 (PD-L1) checkpoint inhibitors, has also led to a paradigm shift in the treatment of non-small cell lung cancer, and has provided promising directions for the treatment of small cell lung cancer. This review provides a summary of the developmental process of immunotherapy, especially immune checkpoint inhibitors in lung cancer, ongoing international and domestic clinical trials in this field, and the challenges and considerations related to the use of immunotherapy in Chinese patients with lung cancer, with the aim of providing detailed information for future immunotherapy-related clinical trials in China. Research regarding immune checkpoint inhibitors in China is several years behind similar research in several developed countries. However, although PD-1/PD-L1 inhibitor-related clinical trials remain in their early stages in China, increased efforts by Chinese clinicians, researchers, and government staff have been directed toward trying to introduce novel drugs into the clinical setting. Because of the specific characteristics of Chinese patients with lung cancer (such as high epidermal growth factor receptor mutation rates, later disease stages, and different toxicity profiles), large-scale clinical trials targeting the Chinese population or Chinese participation in multinational trials should be promoted. IMPLICATIONS FOR PRACTICE: As the leading cause of cancer-related morbidity and mortality, lung cancer is a major public health problem in China. Immunotherapy based on programmed cell death protein 1/programmed death-ligand 1 checkpoint inhibitors may result in new treatment directions and a paradigm shift for Chinese patients with lung cancer. Although checkpoint inhibitor-related clinical trials remain in their early stages in China, increased efforts by Chinese clinicians, researchers, and government staff have been directed toward trying to introduce novel drugs into the clinical setting by encouraging the development of large-scale clinical trials targeting the Chinese population and promoting Chinese patients with lung cancer to participate in international trials.

Immune-checkpoint inhibitor plus chemotherapy versus conventional chemotherapy for first-line treatment in advanced non-small cell lung carcinoma: a systematic review and meta-analysis

BACKGROUND

Immune-checkpoint inhibitors plus chemotherapy are emerging as effective first-line treatment in advanced non-small-cell lung carcinoma (NSCLC), but little is known about the magnitude of benefits and potential clinical predictors.

METHODS

We performed a meta-analysis of randomized trials that compared PD-1/PD-L1 inhibitor plus chemotherapy with chemotherapy in first line of treatment for advanced NSCLC. The outcomes included progression-free survival (PFS), overall survival (OS), objective response rate (ORR) and treatment-related adverse events (AEs). A fixed-effect or random-effects model was adopted depending on between-study heterogeneity.

RESULTS

Six trials involving 3144 patients were included. PD-1/PD-L1 inhibitor plus chemotherapy was significantly associated with improvement of PFS (hazards ratio [HR], 0.62; 95% CI 0.57-0.67; P < .001), OS (HR, 0.68; 95% CI 0.53-0.87; P = .002) and ORR (relative ratio [RR], 1.56; 95% CI 1.29-1.89; P < .001), irrespective of PD-L1 expression level. The significant predictor(s) for treatment benefit with combination therapy versus chemotherapy alone were PD-L1 expression level for PFS (P < .001); types of checkpoint inhibitor for ORR (P < .001); histology (P = .025), age (P = .038), gender (P < .001), and types of checkpoint inhibitor (P < .001) for OS. In safety analyses, PD-1/PD-L1 inhibitor plus chemotherapy had significantly higher incidence of adverse events (AEs) of grade 3 or higher (RR, 1.14; P = .007), AEs leading to treatment discontinuation (RR, 1.29; P = .022), serious AEs (RR 1.70; P = .006), immune mediated AEs of any grade (RR, 2.37; P < .001), and immune mediated AEs of grade 3 or higher (RR, 3.71; P < .001).

CONCLUSIONS

PD-1/PD-L1 inhibitor plus chemotherapy, compared with chemotherapy, is associated with significantly improved PFS, ORR, and OS in first-line therapy in NSCLC, at the expense of increased treatment-related AEs.

New strategies in immunotherapy for lung cancer: beyond PD-1/PD-L1

Immunotherapy has significantly altered the treatment landscape for many cancers, including non-small cell lung cancer (NSCLC). Currently approved immuno-oncology agents for lung cancer are aimed at the reversal of immune checkpoints, programmed death protein-1 (PD-1) and programmed death ligand-1 (PD-L1). Although responses to checkpoint inhibitors are encouraging, and in some cases durable, these successes are not universal among all treated patients. In order to optimize our treatment approach utilizing immunotherapy, we must better understand the interaction between cancer and the immune system and evasion mechanisms. In this review, we will provide an overview of the immune system and cancer, and review novel therapies that promote tumor antigen release for immune system detection, activate the effector T-cell response, and reverse inhibitory antitumor signals.