Real-world treatment patterns and outcomes among individuals receiving first-line pembrolizumab therapy for recurrent/metastatic head and neck squamous cell carcinoma

Pembrolizumab with Carboplatin and Paclitaxel Versus Alternative Systemic Treatments Recommended for the First-Line Treatment of Recurrent/Metastatic Head and Neck Cancer: An Indirect Treatment Comparison

INTRODUCTION

Based on the results of KEYNOTE-048 (NCT02358031), first-line standard-of-care treatment for patients with recurrent or metastatic head and neck squamous cell carcinoma (R/M HNSCC) includes pembrolizumab alone or with platinum and fluorouracil (5-FU). Results from the single-arm KEYNOTE-B10 (NCT04489888) showed promising antitumor activity and a manageable safety profile offering an alternative pembrolizumab and chemotherapy regimen (KN-B10), with paclitaxel replacing 5-FU. With KEYNOTE-B10 being a non-comparative trial, this study aims to estimate the comparative efficacy of KN-B10 versus alternative first-line systemic treatments for R/M HNSCC via an indirect treatment comparison analysis.

METHODS

A systematic literature review (October 2023) identified six connected randomized controlled trials with similar eligibility criteria to KEYNOTE-B10. Interventions included cetuximab + platinum + 5-FU (EXTREME), cetuximab + cisplatin + docetaxel (TPEx), pembrolizumab + platinum + 5-FU (KN-048), platinum + 5-FU, cisplatin + paclitaxel, cisplatin, 5-FU, and methotrexate. To connect KEYNOTE-B10 to the network, individual patient-level data were weighted to match the population characteristics of the most similar trial in the network (KEYNOTE-048). The comparative efficacy of KN-B10 versus other interventions was estimated via fixed-effect Bayesian network meta-analyses. Due to violations of the proportional-hazards assumption, fractional polynomials were used to model overall survival (OS) and progression-free survival (PFS).

RESULTS

For objective response, KN-B10 was comparable to EXTREME and TPEx and more efficacious than all other identified treatments (range of odds ratios [ORs]: 1.69-11.75), including KN-048 (OR: 1.69; 95% credible interval: 1.01-2.81). For OS and PFS, KN-B10 was comparable to EXTREME (with improvements in OS after month 12), TPEx, and KN-048. KN-B10 improved OS versus platinum + 5-FU (range of time-varying hazard ratios: 0.60-0.18; months 9-60), cisplatin + paclitaxel (0.53-0.24; 9-36), cisplatin (0.59-0.32; 6-24), 5-FU (0.58-0.20; 6-36), and methotrexate (0.61-0.07; 6-60). KN-B10 improved PFS versus platinum + 5-FU (0.60-0.31; 3-36).

CONCLUSION

The improved or comparable efficacy of KN-B10 versus alternative first-line interventions in terms of relevant clinical outcomes, as shown in this study, supports its recommendations for the treatment of R/M HNSCC.

The Burden of Recurrent Head and Neck Squamous Cell Carcinoma Across the United Kingdom: Results From a National Snapshot Study

BACKGROUND

To investigate the management of recurrent head and neck squamous cell carcinoma (rHNSCC) and describe survival outcomes.

METHODS

Post hoc subgroup analysis of a retrospective national observational cohort was conducted. All patients with rHNSCC who received a definitive treatment decision between September 1, 2021 and November 30, 2021 were included. Survival analysis was stratified according to subsite, primary versus recurrent disease, and surgical versus nonsurgical treatment.

RESULTS

Data from 202 rHNSCC patients were derived from a cohort of 1488 patients submitted by 50 UK centers. Median age was 66 years (IQR 58-74), and 142 (70.3%) were male. The most common recurrence subsites were oropharynx (20.5%), oral cavity (19.5%), larynx (16.4%), and hypopharynx (14.9%). Ninety-three (48.4%) were managed curatively. Surgery was the most common treatment for laryngeal (59.4%), oral cavity (60.5%), hypopharyngeal (44.8%), and oropharyngeal (37.5%) cancers. Two-year overall (OS), disease-free (DFS), disease-specific (DSS), and local recurrence free survival (LRFS) were 41.1%, 39.1%, 42.2%, and 39.3%, respectively. rHNSCC treated with surgery had improved OS (p = 0.0005), DFS (p = 0.012), DSS (p = 0.0003), and LRFS (p = 0.007), over nonsurgical treatments. Compared to primary cancers, rHNSCC presents with more advanced T stage (p < 0.001) and distant metastasis (p < 0.001), receives less curative treatment (p < 0.001), and has worse survival outcomes (all p < 0.001). On multivariate analysis, salvage surgery, radiotherapy, and p16 status were independent prognostic factors of all survival outcomes.

CONCLUSIONS

Recurrent HNSCC is associated with high rates of incurable disease and worse survival than primary cancers. Surgery remains the most common curative treatment in rHNSCC, however future studies are necessary to improve patient selection and optimize outcomes following salvage treatment.

PD-L1 testing patterns in recurrent/metastatic head and neck squamous cell carcinoma (R/M HNSCC) in the U.S

BACKGROUND

Pembrolizumab with/without platinum + 5-FU is approved for the first-line (1L) treatment of R/M HNSCC, and its monotherapy use requires PD-L1 Combined Positive Score (CPS) ≥ 1. We aimed to understand PD-L1 testing patterns and associations with patient characteristics and treatment choice in R/M HNSCC.

METHODS

Adults with R/M HNSCC initiating 1L systemic therapy were included from a U.S. nationwide database primarily compromised of community practices (07/01/2019-12/31/2023). PD-L1 testing patterns, treatment sequence, and time gaps related to testing and treatment initiation were summarized. Logistic regression was used to test associations between patient characteristics and PD-L1 testing patterns, and between CPS scores and 1L pembrolizumab monotherapy use.

RESULTS

Of 2,207 patients, 32.7 % received PD-L1 testing before 1L therapy initiation, 17.4 % after 1L therapy initiation, and 50.0 % were never tested. Most patients (55.9 %) who tested positive before 1L therapy received pembrolizumab monotherapy while those who tested negative received pembrolizumab + platinum + 5-FU most commonly (31.6 %). Among patients untested before 1L therapy, the most common 1L treatment was pembrolizumab monotherapy (24.3 %). Patients with an ECOG ≥ 2 had higher odds of being tested before 1L therapy (OR: 1.42, p < 0.01). CPS scores were associated with higher odds of receiving 1L pembrolizumab monotherapy (OR: 4.11 and 4.96 for CPS 1-19 and ≥ 20, respectively; both p < 0.0001).

CONCLUSIONS

This study revealed low utilization of PD-L1 testing to guide treatment choice and impactful gaps between specimen collection, the receipt of results, and 1L therapy initiation. There is a need to improve clinician awareness of the importance of PD-L1 testing and an opportunity for updated guidelines on testing.

Real-World Evidence on the Effectiveness of Pembrolizumab in Patients With Recurrent/Metastatic/Unresectable Head and Neck Squamous Cell Cancer: A Systematic Review and Meta-Analysis

The aim of the review was to systematically review real-world data on the effectiveness and safety of pembrolizumab in recurrent/metastatic/unresectable head and neck squamous cell cancer (HNSCC) patients. Two independent reviewers retrieved the studies separately and simultaneously. PubMed, Embase, Scopus, Web of Science, and Cochrane Central were searched for prospective and retrospective studies on recurrent/metastatic/unresectable HNSCC patients treated with either pembrolizumab monotherapy or pembrolizumab combination therapy published till November 2024. Studies published in the English language and available as full-text articles were included while studies with patients treated with additional chemotherapeutic agents that do not include chemotherapy with fluorouracil, platinum, cetuximab, or radiotherapy were excluded. Outcomes were overall response rate, progression-free survival, overall survival, and adverse events. Forest plots were generated using RevMan software version 5.4 (2020; The Cochrane Collaboration, London, United Kingdom). The ROBINS-I (Risk Of Bias In Non-randomised Studies - of Interventions) tool was used for the assessment of the potential risk of bias and the quality of evidence was synthesized using GRADEpro (Evidence Prime Inc., Hamilton, Canada). We identified 5884 records, removed 2784 duplicate records, and screened 3100 studies. A total of 2931 records were excluded based on title/abstract. Of the remaining 169 articles, nine studies satisfied eligibility criteria and were included for final review. Pooled data suggested that 1006 patients were administered with pembrolizumab monotherapy while 448 patients received pembrolizumab combination therapy. Monotherapy improved the overall response rate compared to combination therapy. No significant difference in progression-free survival and overall survival was found between the two groups. Adverse events were reported less in pembrolizumab monotherapy compared to pembrolizumab combination therapy. The studies were assessed at high risk of bias and graded at low to very low quality of evidence. The study showed some beneficial effects of pembrolizumab monotherapy in recurrent/metastatic/unresectable HNSCC patients in real-world scenarios. However, more studies are required to generate robust evidence.

Neoadjuvant chemoimmunotherapy for laryngeal preservation in locally advanced hypopharyngeal cancer

OBJECTIVES

To retrospectively investigate the pathological response rate, laryngeal preservation surgery (LPS) rate and progression free survival (PFS) of neoadjuvant chemoimmunotherapy in the treatment of locally advanced hypopharyngeal cancer (LAHPC).

MATERIALS AND METHODS

In this study, LAHPC patients, who were first diagnosed and underwent surgery at the First Affiliated Hospital of Naval Medical University between January 2021 and January 2024, preoperatively administered PD-1 inhibitor and TP induction regimen (albumin-bound paclitaxel 260 mg/m2 and cisplatin 80 mg/m2). The primary endpoint was major pathological response (MPR), with ORR rate, LPS rate and PFS as the secondary endpoints. Then, the correlation between MPR and overall response rate (ORR) was further validated.

RESULTS

A total of 46 patients satisfied the inclusion criteria, with the median follow-up period of 10.5 months. After neoadjuvant chemoimmunotherapy, the ORR was observed to be 71.9 %, and the LPS rate reached 80.4 % (76.5 % in stage IV patients). The pathological response indicated a favorable response, with the MPR ratio at 52.2 % and pathological complete response (pCR) ratio at 32.6 %. The imaging score highly correlated with pathological response (Kappa = 0.058, P<0.001), while the MPR and ORR shared a strong positive linear relationship (r = 0.753, P<0.001). The 1-year and 2-year PFS rates were 97.1 % and 93.8 % for all patients, with stage IV patients having a 1-year PFS of 92.2 %. Patients who achieved MPR demonstrated a significant prognostic advantage (P=0.008), with no recurrence instances or mortality reported. Grade 3 adverse events were observed in 8.7 % of the cohort. The most common Grade 1-2 adverse events were alopecia, reactive telangiosis and loss of appetite, and no delayed surgery occurred.

CONCLUSION

Neoadjuvant therapy of PD-1 inhibitor combined with TP effectively improved the MPR and LPS rates of LAHPC patients, especially in those at clinical stage IV.

Real-world use of first-line pembrolizumab + platinum + taxane combination regimens in recurrent / metastatic head and neck squamous cell carcinoma

Introduction

The programmed death-1 (PD-1) immune checkpoint inhibitor pembrolizumab is currently approved in the US for the first-line (1L) treatment of recurrent or metastatic head and neck squamous cell carcinoma (R/M HNSCC), either alone or in combination with platinum and 5-fluorouracil (5-FU). However, the toxicity of 5-FU has motivated the study of alternate combinations that replace 5-FU with a taxane. The objective of the current study was to describe the baseline characteristics, treatment patterns and sequences, and real-world outcomes of individuals receiving pembrolizumab + platinum + taxane as 1L treatment for R/M HNSCC in the US.

Methods

This was a retrospective study of US adults ≥18 years of age receiving pembrolizumab + platinum + taxane as 1L treatment for R/M HNSCC, using electronic health record data from a nationwide de-identified database. Real-world overall survival (rwOS), time on treatment (rwToT), and time to next treatment (rwTTNT) outcomes were assessed using Kaplan-Meier analysis.

Results

The study population comprised 83 individuals (80.7% male) with a median age of 64 years. The most common tumor site was the oropharynx (48.2%); 70.0% of these tumors were HPV-positive. A total of 71.1% of the study population had an Eastern Cooperative Oncology Group performance status of 0-1 at index date, 71.8% had a combined positive score for programmed death ligand-1 (PD-L1) expression of ≥1, and 30.8% had a score of ≥20. The median (95% CI) rwOS was 14.9 (8.8-23.3) months, rwToT was 5.3 (4.0-8.2) months, and rwTTNT was 8.7 (6.8-12.3) months. Among the 24 individuals who received a subsequent therapy, the most common second-line therapies were cetuximab-based (n = 9) or pembrolizumab-containing (n = 8) regimens.

Conclusions

The rwOS and other real-world outcomes observed for this study population further support pembrolizumab + platinum + taxane combination therapy as a potential 1L treatment option for R/M HNSCC.

Ultra-high combined positive score and high serum albumin are favorable prognostic biomarkers for immune checkpoint inhibitors in head and neck squamous cell carcinoma

BACKGROUND

Biomarkers that predict response to immune checkpoint inhibitor (ICI) in recurrent metastatic squamous cell carcinoma of the head and neck (RMHNSCC) are not well known.

METHODS

We prospectively measured the combined positive score (CPS) and administered ICI to patients with RMHNSCC.

RESULTS

Of 51 patients, 23 patients had a CPS <20 and 12 patients (23.5%) had a CPS ≥90. CPS showed a negative correlation with serum albumin. Survival analysis showed a 2-year survival rate of 24.1%. In multivariate analysis, CPS ≥90 (HR 0.3026, p = 0.02614) and albumin >3.5 (HR 0.3463, p = 0.01354) were the significant factors and plus chemotherapy (HR 0.4648, p = 0.07632) was not significant. Seven patients (14%) with CPS ≥90 and albumin >3.5 showed a 2-year survival rate of 66. 7%.

CONCLUSIONS

CPS ≥90 and albumin >3.5 cases are a subgroup of RMHNSCC that respond extremely well to ICI.