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Bodor JN, Patel JD, Wakelee HA, Levy BP, Borghaei H, Pellini B, Costello MR, Dowell JE, Finley G, Huang CH, Neal JW, Nieva JJ, Puri S, Socinski MA, Thomas C, Ross EA, Litwin S, Clapper ML, Treat J. Phase II Randomized Trial of Carboplatin, Pemetrexed, and Bevacizumab With and Without Atezolizumab in Stage IV Nonsquamous Non-Small-Cell Lung Cancer Patients Who Harbor a Sensitizing EGFR Mutation or Have Never Smoked. Clin Lung Cancer 2023; 24:e242-e246. [PMID: 37451930 DOI: 10.1016/j.cllc.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 04/29/2023] [Accepted: 05/08/2023] [Indexed: 07/18/2023]
Abstract
INTRODUCTION Patients with non-small-cell lung cancer (NSCLC) who have never smoked or have tumors with mutations in EGFR generally derive minimal benefit from single-agent PD-1/PD-L1 checkpoint inhibitors. Prior data indicate that adding PD-L1 inhibition to anti-VEGF and cytotoxic chemotherapy may be a promising approach to overcoming immunotherapy resistance in these patients, however prospective validation is needed. This trial in progress (NCT03786692) is evaluating patients with stage IV NSCLC who have never smoked or who have tumors with sensitizing EGFR alterations to determine if a 4-drug combination of atezolizumab, carboplatin, pemetrexed, and bevacizumab can improve outcomes compared to carboplatin, pemetrexed and bevacizumab without atezolizumab. METHODS This is a randomized, phase II, multicenter study evaluating carboplatin, pemetrexed, bevacizumab with and without atezolizumab in 117 patients with stage IV nonsquamous NSCLC. Randomization is 2 to 1 favoring the atezolizumab containing arm. Eligible patients include: 1) those with tumors with sensitizing EGFR alterations in exons 19 or 21 or 2) patients who have never smoked and have wild-type tumors (ie, no EGFR, ALK or ROS1 alterations). Patients are defined as having never smoked if they have smoked less than 100 cigarettes in a lifetime. Patients with EGFR-mutated tumors must have disease progression or intolerance to prior tyrosine kinase inhibitor (TKI) therapy. The primary endpoint is progression-free survival (PFS). Secondary endpoints include overall survival (OS), response rate, duration of response, and time to response. CONCLUSION This phase II trial is accruing patients at U.S. sites through the National Comprehensive Cancer Network (NCCN). The trial opened in August 2019 and accrual is expected to be completed in the Fall of 2024.
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Affiliation(s)
- J Nicholas Bodor
- Department of Hematology/Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Jyoti D Patel
- Hematology Oncology Division, Northwestern University, Chicago, IL
| | - Heather A Wakelee
- Department of Medical Oncology, Stanford Cancer Institute, Stanford, CA
| | - Benjamin P Levy
- Department of Medical Oncology, Johns Hopkins Sidney Kimmel Cancer Center, Washington, DC
| | - Hossein Borghaei
- Department of Hematology/Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Bruna Pellini
- Department of Thoracic Oncology, Moffitt Cancer Center, Tampa, FL
| | - Michael R Costello
- Department of Hematology/Oncology, University of Pennsylvania Abramson Cancer Center at Chester County Hospital, West Chester, PA
| | - Jonathan E Dowell
- Department of Hematology/Oncology, UT Southwestern Harold C. Simmons Comprehensive Cancer Center, Dallas, TX
| | - Gene Finley
- Department of Medical Oncology, Allegheny Health Network, Pittsburgh, PA
| | - Chao H Huang
- Department of Medical Oncology, University of Kansas Medical Center, Kansas City, KS
| | - Joel W Neal
- Department of Medical Oncology, Stanford Cancer Institute, Stanford, CA
| | - Jorge J Nieva
- Department of Medical Oncology, University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA
| | - Sonam Puri
- Division of Oncology, University of Utah Huntsman Cancer Institute, Salt Lake City, UT
| | - Mark A Socinski
- Department of Medical Oncology, AdventHealth Cancer Institute, Orlando, FL
| | | | - Eric A Ross
- Department of Hematology/Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Samuel Litwin
- Department of Hematology/Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Margie L Clapper
- Department of Hematology/Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Joseph Treat
- Department of Hematology/Oncology, Fox Chase Cancer Center, Philadelphia, PA.
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Ghanem P, Murray JC, Marrone KA, Scott SC, Feliciano JL, Lam VK, Hann CL, Ettinger DS, Levy BP, Forde PM, Shah AA, Mecoli C, Brahmer J, Cappelli LC. Improved lung cancer clinical outcomes in patients with autoimmune rheumatic diseases. RMD Open 2023; 9:e003471. [PMID: 37914179 PMCID: PMC10619011 DOI: 10.1136/rmdopen-2023-003471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 10/10/2023] [Indexed: 11/03/2023] Open
Abstract
PURPOSE Concomitant autoimmune rheumatic diseases (ARD) can add morbidity and complicate treatment decisions for patients with lung cancer. We evaluated the tumour characteristics at diagnosis and clinical outcomes in lung cancer patients with or without ARD. METHODS This retrospective cohort study included 10 963 patients with lung cancer, treated at Johns Hopkins. Clinical data including tumour characteristics and outcomes were extracted from the cancer registry. Data on patients' history of 20 ARD were extracted from the electronic medical record. Logistic regression was used to compare tumour characteristics between those with and without ARD; Kaplan-Meier curves and Cox proportional hazards models were performed to compare survival outcomes. RESULTS ARD was present in 3.6% of patients (n=454). The mean age at diagnosis was 69 (SD 10) and 68 (SD 12) in patients with and without ARD (p=0.02). Female sex and smoking history were significantly associated with a history of ARD (OR: 1.75, OR: 1.46, p<0.05). Patients with ARD were more likely to be diagnosed with stage 1 lung cancer (36.8% vs 26.9%, p<0.001) and with smaller tumour size (OR: 0.76, p=0.01), controlling for sex, race and histology. Notably, lung cancer patients with ARD had a significantly prolonged median overall survival (OS) (7.11 years vs 1.7 years, p<0.001), independent of stage. CONCLUSION Patients with ARD and lung cancer had better OS compared with their counterparts, independent of cancer stage and treatments and were less likely to have advanced stage lung cancer at diagnosis. Additional studies are needed to investigate the differential immunological anti-tumour immune activity and genomic variations in patients with and without ARD.
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Affiliation(s)
- Paola Ghanem
- Department of Oncology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joseph C Murray
- Department of Oncology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kristen A Marrone
- Department of Oncology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Susan C Scott
- Department of Oncology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Josephine L Feliciano
- Department of Oncology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Vincent K Lam
- Department of Oncology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Christine L Hann
- Department of Oncology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - David S Ettinger
- Department of Oncology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Benjamin P Levy
- Department of Oncology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Patrick M Forde
- Department of Oncology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ami A Shah
- Division of Rheumatology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Christopher Mecoli
- Division of Rheumatology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Julie Brahmer
- Department of Oncology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Laura C Cappelli
- Division of Rheumatology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Levy BP, Felip E, Reck M, Yang JC, Cappuzzo F, Yoneshima Y, Zhou C, Rawat S, Xie J, Basak P, Xu L, Sands J. TROPION-Lung08: phase III study of datopotamab deruxtecan plus pembrolizumab as first-line therapy for advanced NSCLC. Future Oncol 2023; 19:1461-1472. [PMID: 37249038 DOI: 10.2217/fon-2023-0230] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023] Open
Abstract
Pembrolizumab monotherapy is a standard first-line treatment for PD-L1-high advanced non-small-cell lung cancer (NSCLC) without actionable genomic alterations (AGA). However, few patients experience long-term disease control, highlighting the need for more effective therapies. Datopotamab deruxtecan (Dato-DXd), a novel trophoblast cell-surface antigen 2-directed antibody-drug conjugate, showed encouraging safety and antitumor activity with pembrolizumab in advanced NSCLC. We describe the rationale and design of TROPION-Lung08, a phase III study evaluating safety and efficacy of first-line Dato-DXd plus pembrolizumab versus pembrolizumab monotherapy in patients with advanced/metastatic NSCLC without AGAs and with PD-L1 tumor proportion score ≥50%. Primary end points are progression-free survival and overall survival; secondary end points include objective response rate, duration of response, safety and presence of antidrug antibodies. Clinical trial registration: NCT05215340 (ClinicalTrials.gov).
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Affiliation(s)
- Benjamin P Levy
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Medicine, Washington, DC 20016, USA
| | - Enriqueta Felip
- Vall d'Hebron University Hospital, Vall d'Hebron Institute of Oncology, Barcelona, 08035, Spain
| | - Martin Reck
- Lung Clinic Grosshansdorf, Airway Research Center North (ARCN), Grosshansdorf, 22927, Germany
| | - James Ch Yang
- Department of Oncology, National Taiwan University Hospital, Taipei, 106, Taiwan
| | | | - Yasuto Yoneshima
- Department of Respiratory Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, 812-8582, Japan
| | - Caicun Zhou
- Department of Oncology, Shanghai Pulmonary Hospital & Thoracic Cancer Institute, School of Medicine, Tongji University, Shanghai, 200092, China
| | | | - Jingdong Xie
- Daiichi Sankyo, Inc, Basking Ridge, NJ 07920, USA
| | | | - Lu Xu
- Merck & Co., Inc., Rahway, NJ 07065, USA
- AstraZeneca, Gaithersburg, MD 20878, USA
| | - Jacob Sands
- Dana-Farber Cancer Institute, Boston, MA 02215, USA
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Cheunkarndee T, Ganem P, Marrone KA, Murray JC, Feliciano JL, Hann CL, Scott SC, Ettinger D, Anagnostou V, Forde PM, Brahmer JR, Levy BP, Lam V, Kamson DO. Abstract 4483: Distinct spatial distribution patterns of ALK-inhibitor naïve versus ALK-inhibitor treated ALK-positive NSCLC brain metastases. Cancer Res 2023. [DOI: 10.1158/1538-7445.am2023-4483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Abstract
Abstract
Background: Non-small cell lung cancer (NSCLC) with anaplastic lymphoma kinase rearrangement (ALK+) has a high affinity to form brain metastases (BrM). The cumulative incidence of BrMs in ALK+ lung cancer is over 50%, despite highly effective ALK tyrosine kinase inhibitors (TKIs) with CNS activity. Pharmacokinetic (PK) data from other CNS-active lung cancer TKIs (e.g., osimertinib) have revealed major brain white vs. gray matter drug concentration differences, raising the possibility of a PK-driven effect on BrM formation and response. This study aims to compare the size and distribution of ALK+ NSCLC BrMs at diagnosis in a TKI-naïve and TKI-exposed cohort.
Methods: We retrospectively reviewed brain MRIs from the date of BrM diagnosis for patients with ALK+ NSCLC at Johns Hopkins. Demographic and clinical information were collected by chart review. Each tumor was marked in a standard space brain model in the corresponding anatomic location represented by a sphere of corresponding diameter using 3D Slicer 4.11. FreeSurfer white-gray matter atlases were used to assess BrM distribution. The data for patients who were on TKI vs TKI-naïve at the time of BrM diagnosis were then analyzed separately. T-tests were used to compare the metastatic burden (sum of BrM diameters), mean BrM diameter per patient, number of BM per patient, per individual mean of white matter exclusive (defined as no overlap with gray matter) and deep white matter (≥5mm away from gray matter) BrMs between patient groups.
Results: 429 BrMs were identified in 39 patients, with 25 patients being TKI-naïve at the time of BrM diagnosis while 14 patients were on TKI therapy. TKI-exposed patients had significantly smaller BrM diameters than those in the TKI-naïve group (6.1±3.8 vs 10.2±5.5mm, p=0.02). While metastatic burden was very similar between the groups, the mean number of BrM per patient was numerically higher in the TKI-exposed group (10.6±11.9 vs 6.2±9.5; p=0.22). Notably, patients in the TKI-exposed group also had higher numbers of white matter exclusive (3.5±4.4 vs 1.4±2.0, p=0.05) and deep white matter metastases (3.2±4.3 vs 1.3±2.0, p=0.06) than those who were TKI-naïve.
Conclusion: Our data highlight the differences in BrM characteristics among ALK+ NSCLC exposed to ALK TKI. TKI therapy was associated with similar BrM burden but smaller individual lesions that were more likely to be exclusive to the white matter where drug concentrations might be significantly lower. These findings suggest that suboptimal drug CNS distribution in the white matter may underly brain progression of ALK+ NSCLC despite TKI therapy. Spatial analyses evaluating ALK TKIs of varying CNS penetrance and later disease time points in more granular anatomic regions are ongoing.
Citation Format: Tia Cheunkarndee, Paola Ganem, Kristen A. Marrone, Joseph C. Murray, Josephine L. Feliciano, Christine L. Hann, Susan C. Scott, David Ettinger, Valsamo Anagnostou, Patrick M. Forde, Julie R. Brahmer, Benjamin P. Levy, Vincent Lam, David O. Kamson. Distinct spatial distribution patterns of ALK-inhibitor naïve versus ALK-inhibitor treated ALK-positive NSCLC brain metastases. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 4483.
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Affiliation(s)
| | - Paola Ganem
- 1Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | | | | | - Susan C. Scott
- 1Johns Hopkins University School of Medicine, Baltimore, MD
| | - David Ettinger
- 1Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | | | | | - Vincent Lam
- 1Johns Hopkins University School of Medicine, Baltimore, MD
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Sivapalan L, Murray JC, Canzoniero JV, Landon B, Jackson J, Scott S, Lam V, Levy BP, Sausen M, Anagnostou V. Liquid biopsy approaches to capture tumor evolution and clinical outcomes during cancer immunotherapy. J Immunother Cancer 2023; 11:jitc-2022-005924. [PMID: 36657818 PMCID: PMC9853269 DOI: 10.1136/jitc-2022-005924] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2022] [Indexed: 01/20/2023] Open
Abstract
Circulating cell-free tumor DNA (ctDNA) can serve as a real-time biomarker of tumor burden and provide unique insights into the evolving molecular landscape of cancers under the selective pressure of immunotherapy. Tracking the landscape of genomic alterations detected in ctDNA may reveal the clonal architecture of the metastatic cascade and thus improve our understanding of the molecular wiring of therapeutic responses. While liquid biopsies may provide a rapid and accurate evaluation of tumor burden dynamics during immunotherapy, the complexity of antitumor immune responses is not fully captured through single-feature ctDNA analyses. This underscores a need for integrative studies modeling the tumor and the immune compartment to understand the kinetics of tumor clearance in association with the quality of antitumor immune responses. Clinical applications of ctDNA testing in patients treated with immune checkpoint inhibitors have shown both predictive and prognostic value through the detection of genomic biomarkers, such as tumor mutational burden and microsatellite instability, as well as allowing for real-time monitoring of circulating tumor burden and the assessment of early on-therapy responses. These efforts highlight the emerging role of liquid biopsies in selecting patients for cancer immunotherapy, monitoring therapeutic efficacy, determining the optimal duration of treatment and ultimately guiding treatment selection and sequencing. The clinical translation of liquid biopsies is propelled by the increasing number of ctDNA-directed interventional clinical trials in the immuno-oncology space, signifying a critical step towards implementation of liquid biopsies in precision immuno-oncology.
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Affiliation(s)
- Lavanya Sivapalan
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joseph C Murray
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jenna VanLiere Canzoniero
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Blair Landon
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Susan Scott
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Vincent Lam
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Benjamin P. Levy
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Mark Sausen
- Personal Genome Diagnostics, Baltimore, Maryland, USA
| | - Valsamo Anagnostou
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA,The Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Guo MZ, Murray JC, Ghanem P, Voong KR, Hales RK, Ettinger D, Lam VK, Hann CL, Forde PM, Brahmer JR, Levy BP, Feliciano JL, Marrone KA. Definitive Chemoradiation and Durvalumab Consolidation for Locally Advanced, Unresectable KRAS-mutated Non-Small Cell Lung Cancer. Clin Lung Cancer 2022; 23:620-629. [PMID: 36045016 DOI: 10.1016/j.cllc.2022.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 07/22/2022] [Accepted: 08/03/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND Consolidation durvalumab immunotherapy following definitive chemoradiation (CRT) for unresectable stage III non-small cell lung cancer (NSCLC) improves overall survival. As therapeutic options for patients with KRAS-driven disease evolve, more understanding regarding genomic determinants of response and patterns of progression for durvalumab consolidation is needed to optimize outcomes. METHODS We conducted a single-institutional retrospective analysis of real-world patients with locally advanced, unresectable NSCLC who completed CRT and received durvalumab consolidation. Kaplan-Meier analyses compared progression-free survival (PFS) and overall survival (OS) from start of durvalumab consolidation between patients with KRAS-mutated and non-mutated tumors. Fisher's exact test was used to compare rates of intrathoracic or extrathoracic progression. RESULTS Of 74 response-evaluable patients, 39 had clinical genomic profiling performed. 18 patients had tumors with KRAS mutations, 7 patients had tumors with non-KRAS actionable alterations (EGFR, ALK, ERBB2, BRAF, MET, RET, or ROS1), and 14 patients had tumors without actionable alterations. Median PFS for the overall cohort was 16.1 months. PFS for patients with KRAS-mutated NSCLC was 12.6 months versus 12.7 months for patients with non-actionable tumors (P= 0.77, log-rank). Fisher's exact test revealed a statistically significantly higher rate of extrathoracic progression versus intrathoracic-only progression for patients with KRAS-driven disease compared to patients with non-actionable tumors (P= 0.015). CONCLUSION Patients with KRAS-mutated NSCLC derived similar benefit from durvalumab as patients with non-actionable tumors. A higher rate of extrathoracic progression was also observed among the patients with KRAS-mutated NSCLC compared to patients with non-actionable tumors. This highlights the potential unmet needs for novel systemic therapies and surveillance methods for KRAS-mutated stage III NSCLC.
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Affiliation(s)
- Matthew Z Guo
- Department of Oncology, Johns Hopkins School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD
| | - Joseph C Murray
- Department of Oncology, Johns Hopkins School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD
| | - Paola Ghanem
- Department of Oncology, Johns Hopkins School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD
| | - K Ranh Voong
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD
| | - Russell K Hales
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD
| | - David Ettinger
- Department of Oncology, Johns Hopkins School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD
| | - Vincent K Lam
- Department of Oncology, Johns Hopkins School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD
| | - Christine L Hann
- Department of Oncology, Johns Hopkins School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD
| | - Patrick M Forde
- Department of Oncology, Johns Hopkins School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD
| | - Julie R Brahmer
- Department of Oncology, Johns Hopkins School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD
| | - Benjamin P Levy
- Department of Oncology, Johns Hopkins School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD
| | - Josephine L Feliciano
- Department of Oncology, Johns Hopkins School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD
| | - Kristen A Marrone
- Department of Oncology, Johns Hopkins School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD.
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Scott SC, Shao XM, Niknafs N, Balan A, Pereira G, Marrone KA, Lam VK, Murray JC, Feliciano JL, Levy BP, Ettinger DS, Hann CL, Brahmer JR, Forde PM, Karchin R, Naidoo J, Anagnostou V. Sex-specific differences in immunogenomic features of response to immune checkpoint blockade. Front Oncol 2022; 12:945798. [PMID: 35992816 PMCID: PMC9382103 DOI: 10.3389/fonc.2022.945798] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 07/04/2022] [Indexed: 12/14/2022] Open
Abstract
Introduction The magnitude of response to immune checkpoint inhibitor (ICI) therapy may be sex-dependent, as females have lower response rates and decreased survival after ICI monotherapy. The mechanisms underlying this sex dimorphism in ICI response are unknown, and may be related to sex-driven differences in the immunogenomic landscape of tumors that shape anti-tumor immune responses in the context of therapy. Methods To investigate the association of immunogenic mutations with HLA haplotypes, we leveraged whole exome sequence data and HLA genotypes from 482 non-small cell lung cancer (NSCLC) tumors from The Cancer Genome Atlas (TCGA). To explore sex-specific genomic features linked with ICI response, we analyzed whole exome sequence data from patients with NSCLC treated with ICI. Tumor mutational burden (TMB), HLA class I and II restricted immunogenic missense mutation (IMM) load, and mutational smoking signature were defined for each tumor. IMM load was combined with HLA class I and II haplotypes and correlated with therapeutic response and survival following ICI treatment. We examined rates of durable clinical benefit (DCB) for at least six months from ICI treatment initiation. Findings were validated utilizing whole exome sequence data from an independent cohort of ICI treated NSCLC. Results Analysis of whole exome sequence data from NSCLC tumors of females and males revealed that germline HLA class II diversity (≥9 unique HLA alleles) was associated with higher tumor class II IMM load in females (p=0.01) and not in males (p=0.64). Similarly, in tumors of female patients, somatic HLA class II loss of heterozygosity was associated with increased IMM load (p=0.01) while this association was not observed in tumors in males (p=0.20). In females, TMB (p=0.005), class I IMM load (p=0.005), class II IMM load (p=0.004), and mutational smoking signature (p<0.001) were significantly higher in tumors responding to ICI as compared to non-responding tumors. In contrast, among males, there was no significant association between DCB and any of these features. When IMM was considered in the context of HLA zygosity, high MHC-II restricted IMM load and high HLA class II diversity was significantly associated with overall survival in males (p=0.017). Conclusions Inherent sex-driven differences in immune surveillance affect the immunogenomic determinants of response to ICI and likely mediate the dimorphic outcomes with ICI therapy. Deeper understanding of the selective pressures and mechanisms of immune escape in tumors in males and females can inform patient selection strategies and can be utilized to further hone immunotherapy approaches in cancer.
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Affiliation(s)
- Susan C. Scott
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Xiaoshan M. Shao
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, United States
- Institute for Computational Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Noushin Niknafs
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Archana Balan
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Gavin Pereira
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Kristen A. Marrone
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Vincent K. Lam
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Joseph C. Murray
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Josephine L. Feliciano
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Benjamin P. Levy
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - David S. Ettinger
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Christine L. Hann
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Julie R. Brahmer
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Patrick M. Forde
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Rachel Karchin
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, United States
- Institute for Computational Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Jarushka Naidoo
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Oncology, RCSI University of Medicine and Health Sciences, Dublin, Ireland
- Department of Oncology, Beaumont Hospital, Dublin, Ireland
| | - Valsamo Anagnostou
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- *Correspondence: Valsamo Anagnostou,
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Hwang M, Canzoniero JV, Rosner S, Zhang G, White JR, Belcaid Z, Cherry C, Balan A, Pereira G, Curry A, Niknafs N, Zhang J, Smith KN, Sivapalan L, Chaft JE, Reuss JE, Marrone K, Murray JC, Li QK, Lam V, Levy BP, Hann C, Velculescu VE, Brahmer JR, Forde PM, Seiwert T, Anagnostou V. Peripheral blood immune cell dynamics reflect antitumor immune responses and predict clinical response to immunotherapy. J Immunother Cancer 2022; 10:e004688. [PMID: 35688557 PMCID: PMC9189831 DOI: 10.1136/jitc-2022-004688] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2022] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Despite treatment advancements with immunotherapy, our understanding of response relies on tissue-based, static tumor features such as tumor mutation burden (TMB) and programmed death-ligand 1 (PD-L1) expression. These approaches are limited in capturing the plasticity of tumor-immune system interactions under selective pressure of immune checkpoint blockade and predicting therapeutic response and long-term outcomes. Here, we investigate the relationship between serial assessment of peripheral blood cell counts and tumor burden dynamics in the context of an evolving tumor ecosystem during immune checkpoint blockade. METHODS Using machine learning, we integrated dynamics in peripheral blood immune cell subsets, including neutrophil-lymphocyte ratio (NLR), from 239 patients with metastatic non-small cell lung cancer (NSCLC) and predicted clinical outcome with immune checkpoint blockade. We then sought to interpret NLR dynamics in the context of transcriptomic and T cell repertoire trajectories for 26 patients with early stage NSCLC who received neoadjuvant immune checkpoint blockade. We further determined the relationship between NLR dynamics, pathologic response and circulating tumor DNA (ctDNA) clearance. RESULTS Integrated dynamics of peripheral blood cell counts, predominantly NLR dynamics and changes in eosinophil levels, predicted clinical outcome, outperforming both TMB and PD-L1 expression. As early changes in NLR were a key predictor of response, we linked NLR dynamics with serial RNA sequencing deconvolution and T cell receptor sequencing to investigate differential tumor microenvironment reshaping during therapy for patients with reduction in peripheral NLR. Reductions in NLR were associated with induction of interferon-γ responses driving the expression of antigen presentation and proinflammatory gene sets coupled with reshaping of the intratumoral T cell repertoire. In addition, NLR dynamics reflected tumor regression assessed by pathological responses and complemented ctDNA kinetics in predicting long-term outcome. Elevated peripheral eosinophil levels during immune checkpoint blockade were correlated with therapeutic response in both metastatic and early stage cohorts. CONCLUSIONS Our findings suggest that early dynamics in peripheral blood immune cell subsets reflect changes in the tumor microenvironment and capture antitumor immune responses, ultimately reflecting clinical outcomes with immune checkpoint blockade.
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Affiliation(s)
- Michael Hwang
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jenna Vanliere Canzoniero
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Samuel Rosner
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Guangfan Zhang
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - James R White
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Zineb Belcaid
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christopher Cherry
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Archana Balan
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gavin Pereira
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alexandria Curry
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Noushin Niknafs
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jiajia Zhang
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- The Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kellie N Smith
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- The Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lavanya Sivapalan
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jamie E Chaft
- Thoracic Oncology Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Joshua E Reuss
- Georgetown Lombardi Comprehensive Cancer Center, Washington, DC, USA
| | - Kristen Marrone
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joseph C Murray
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Qing Kay Li
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Vincent Lam
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Benjamin P Levy
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christine Hann
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Victor E Velculescu
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Julie R Brahmer
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- The Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Patrick M Forde
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- The Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tanguy Seiwert
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- The Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Valsamo Anagnostou
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- The Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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9
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Shah PP, Franke JL, Medikonda R, Jackson CM, Srivastava S, Choi J, Forde PM, Brahmer JR, Ettinger DS, Feliciano JL, Levy BP, Marrone KA, Naidoo J, Redmond KJ, Kleinberg LR, Lim M. Mutation status and postresection survival of patients with non-small cell lung cancer brain metastasis: implications of biomarker-driven therapy. J Neurosurg 2021; 136:56-66. [PMID: 34087798 DOI: 10.3171/2020.10.jns201787] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 10/02/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Non-small cell lung cancer (NSCLC) is the most common primary tumor to develop brain metastasis. Prognostic markers are needed to better determine survival after neurosurgical resection of intracranial disease. Given the importance of mutation subtyping in determining systemic therapy and overall prognosis of NSCLC, the authors examined the prognostic value of mutation status for postresection survival of patients with NSCLC brain metastasis. METHODS The authors retrospectively analyzed all cases of NSCLC brain metastasis with available molecular testing data that were resected by a single surgeon at a single academic center from January 2009 to February 2019. Mutation status, demographic characteristics, clinical factors, and treatments were analyzed. Association between predictive variables and overall survival after neurosurgery was determined with Cox regression. RESULTS Of the included patients (n = 84), 40% were male, 76% were smokers, the mean ± SD Karnofsky Performance Status was 85 ± 14, and the mean ± SD age at surgery was 63 ± 11 years. In total, 23%, 26%, and 4% of patients had EGFR, KRAS, and ALK/ROS1 alterations, respectively. On multivariate analysis, survival of patients with EGFR (HR 0.495, p = 0.0672) and KRAS (HR 1.380, p = 0.3617) mutations were not significantly different from survival of patients with wild-type (WT) tumor. However, the subgroup of patients with EGFR mutation who also received tyrosine kinase inhibitor (TKI) therapy had significantly prolonged survival (HR 0.421, p = 0.0471). In addition, postoperative stereotactic radiosurgery (HR 0.409, p = 0.0177) and resected tumor diameter < 3 cm (HR 0.431, p = 0.0146) were also significantly associated with prolonged survival, but Graded Prognostic Assessment score ≤ 1.0 (HR 2.269, p = 0.0364) was significantly associated with shortened survival. CONCLUSIONS Patients with EGFR mutation who receive TKI therapy may have better survival after resection of brain metastasis than patients with WT tumor. These results may inform counseling and decision-making regarding the appropriateness of resection of NSCLC brain metastasis.
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Affiliation(s)
| | | | | | | | | | | | - Patrick M Forde
- 2Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - Julie R Brahmer
- 2Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - David S Ettinger
- 2Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - Josephine L Feliciano
- 2Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - Benjamin P Levy
- 2Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - Kristen A Marrone
- 2Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - Jarushka Naidoo
- 2Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - Kristin J Redmond
- 3Radiation Oncology, Johns Hopkins University School of Medicine; and
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10
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Levy BP, Signorovitch JE, Yang H, Patterson-Lomba O, Xiang CQ, Parisi M. Effectiveness of first-line treatments in metastatic squamous non-small-cell lung cancer. ACTA ACUST UNITED AC 2019; 26:e300-e308. [PMID: 31285672 DOI: 10.3747/co.26.4485] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background Commonly used first-line (1L) chemotherapies for patients with advanced squamous-cell lung cancer (scc) include gemcitabine-platinum (gp), nab-paclitaxel-carboplatin (nabpc), and sb-paclitaxel-carboplatin (sbpc) regimens. However, no head-to-head trials have compared those treatments. In the present study, we compared the efficacy of 1L gp, nabpc, and sbpc in patients with scc and in patients with scc who subsequently received second-line (2L) immunotherapy. Methods Medical records of patients who initiated the 1L treatments of interest between June 2014 and October 2015 were reviewed by 132 participating physicians. Kaplan-Meier curves were used to evaluate overall survival (os), progression-free survival (pfs), and treatment discontinuation (td), and then Cox proportional hazards regression was used to compare the results between the cohorts. Results Medical records of 458 patients with scc receiving gp (n = 139), nabpc (n = 159), or sbpc (n = 160) as 1L therapy were reviewed. Median os was longer with nabpc (23.9 months) than with gp (16.9 months; adjusted hazard ratio vs. nabpc: 1.55; p < 0.05) and with sbpc (18.3 months; adjusted hazard ratio: 1.42; p = 0.10). No differences were observed in pfs (median pfs: 8.8, 8.0, and 7.6 months for gp, nabpc, and sbpc respectively; log-rank p = 0.76) or in td (median td: 5.5, 5.7, and 4.6 months respectively; p = 0.65). For patients who subsequently received 2L immunotherapy, no differences in os were observed (median os: 27.3, 25.0, and 23.0 months respectively; p = 0.59). Conclusions In a nationwide sample of scc patients, longer median os was associated with 1L nabpc than with gp and sbpc. Median os for all 1L agents considered was similar in the subgroup of patients who sequenced to a 2L immunotherapy.
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Affiliation(s)
- B P Levy
- Johns Hopkins Sidney Kimmel Cancer Center at Sibley Memorial Hospital, Washington, DC
| | | | - H Yang
- Analysis Group, Inc., Boston, MA
| | | | | | - M Parisi
- Celgene Corporation, Summit, NJ, U.S.A
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11
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Parikh AB, Marrone KA, Becker DJ, Brahmer JR, Ettinger DS, Levy BP. A pooled analysis of two phase II trials evaluating metformin plus platinum-based chemotherapy in advanced non-small cell lung cancer. Cancer Treat Res Commun 2019; 20:100150. [PMID: 31102920 DOI: 10.1016/j.ctarc.2019.100150] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 05/08/2019] [Accepted: 05/09/2019] [Indexed: 06/09/2023]
Abstract
BACKGROUND Despite a wealth of preclinical and observational data, prospective data regarding the use of metformin in lung cancer is extremely limited. METHODS We pooled individualized data from two prospective trials evaluating metformin plus platinum-based chemotherapy, with or without bevacizumab, in non-diabetic patients with untreated advanced NSCLC. In addition to reporting on clinical efficacy and safety endpoints, we also explored metformin's activity in key molecular cohorts. RESULTS 33 patients were included in the pooled analysis, of whom 70% were current or previous smokers. 82% had standard tissue molecular testing results available. KRAS, EGFR, and LKB1 mutation prevalence was 48%, 26%, and 8.3%, respectively. Composite median PFS was 6 months for all patients (95% CI: [1.36, 7.96]), 7.2 months for KRAS mutants (95% CI: [1.18, 9.21]), and 6.6 months for EGFR mutants (95% CI: [1.18, 15.29]). Composite median OS was 14.8 months for all patients (95% CI: [8.25, 19.99]), 17.5 months for KRAS mutants (95% CI: [8.86, 26.96]), and 13.3 months for EGFR mutants (95% CI: [2.60, 25.86]). Lymphopenia was the most common grade 3 AE (12%), followed by leukopenia, nausea, vomiting, and hypertension (9% each). There were 2 grade 4 AEs, neutropenia (21%) and sepsis (3%), and 1 grade 5 AE (colonic perforation) attributed to bevacizumab. CONCLUSION Our results confirm the previously shown efficacy and tolerability of metformin in combination with chemotherapy and highlight encouraging activity in key molecular cohorts. Future efforts should build on this work by prospectively studying metformin in these molecular subgroups.
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Affiliation(s)
- Anish B Parikh
- Tisch Cancer Institute, Division of Hematology/Oncology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1079, New York, NY, USA.
| | - Kristen A Marrone
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA
| | - Daniel J Becker
- Manhattan Veterans Association Hospital, NYU Langone Perlmutter Cancer Center, New York, NY, USA
| | - Julie R Brahmer
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA
| | - David S Ettinger
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA
| | - Benjamin P Levy
- Johns Hopkins Sidney Kimmel Cancer Center at Sibley Memorial Hospital, Washington, DC, USA
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12
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Levy BP, Giaccone G, Besse B, Felip E, Garassino MC, Domine Gomez M, Garrido P, Piperdi B, Ponce-Aix S, Menezes D, MacBeth KJ, Risueño A, Slepetis R, Wu X, Fandi A, Paz-Ares L. Randomised phase 2 study of pembrolizumab plus CC-486 versus pembrolizumab plus placebo in patients with previously treated advanced non-small cell lung cancer. Eur J Cancer 2019; 108:120-128. [PMID: 30654297 DOI: 10.1016/j.ejca.2018.11.028] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 11/15/2018] [Accepted: 11/23/2018] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Preclinical and early clinical studies suggest that combining epigenetic agents with checkpoint inhibitors can potentially improve outcomes in patients with previously treated advanced non-small cell lung cancer (NSCLC). This phase 2 trial examined second-line pembrolizumab + CC-486 (oral azacitidine) in patients with advanced NSCLC. METHODS Patients with one prior line of platinum-containing therapy were randomised in a ratio of 1:1 to CC-486 or placebo, on days 1-14, in combination with pembrolizumab on day 1 of a 21-day cycle. The primary end-point was progression-free survival (PFS). Key secondary end-points included overall survival (OS), overall response rate (ORR) and safety. RESULTS Among 100 patients randomised (pembrolizumab + CC-486: 51; pembrolizumab + placebo: 49), most were male (57.0%), were white (87.0%) and had Eastern Cooperative Oncology Group performance status 1 (68.0%). No significant difference in PFS was observed between the pembrolizumab + CC-486 and pembrolizumab + placebo arms (median, 2.9 and 4.0 months, respectively; hazard ratio [HR], 1.374; 90% confidence interval [CI], 0.926-2.038; P = 0.1789). Median OS was 11.9 months versus not estimable (HR, 1.375; 90% CI, 0.830-2.276; P = 0.2968); ORR was 20% versus 14%. Median treatment duration was shorter (15.0 versus 24.1 weeks), and the number of cycles was lower (5.0 versus 7.0) with pembrolizumab + CC-486 versus pembrolizumab + placebo. No new safety signals for CC-486 or pembrolizumab were detected. Treatment-emergent adverse events were more common in the pembrolizumab + CC-486 arm, particularly gastrointestinal, potentially impacting treatment feasibility. CONCLUSIONS No improvement in PFS was observed with pembrolizumab + CC-486 versus pembrolizumab + placebo. Decreased treatment exposure due to adverse events may have impacted efficacy with pembrolizumab + CC-486.
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MESH Headings
- Adenocarcinoma of Lung/drug therapy
- Adenocarcinoma of Lung/pathology
- Adult
- Aged
- Aged, 80 and over
- Antibodies, Monoclonal, Humanized/administration & dosage
- Antibodies, Monoclonal, Humanized/therapeutic use
- Antineoplastic Agents, Immunological/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Azacitidine/administration & dosage
- Carcinoma, Non-Small-Cell Lung/drug therapy
- Carcinoma, Non-Small-Cell Lung/pathology
- Carcinoma, Squamous Cell/drug therapy
- Carcinoma, Squamous Cell/pathology
- Female
- Humans
- Lung Neoplasms/drug therapy
- Lung Neoplasms/pathology
- Male
- Middle Aged
- Progression-Free Survival
- Survival Rate
- Treatment Outcome
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Affiliation(s)
- Benjamin P Levy
- Johns Hopkins Sidney Kimmel Cancer Center, Washington, DC, USA.
| | - Giuseppe Giaccone
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, USA
| | - Benjamin Besse
- Department of Cancer Medicine, Gustave Roussy, Villejuif and Paris-Sud University, Orsay, France
| | | | | | - Manuel Domine Gomez
- Instituto de Investigacion Sanitaria-Fundación Jimenez Diaz (IIS- FJD), Madrid, Spain
| | - Pilar Garrido
- IRYCIS, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | | | - Santiago Ponce-Aix
- Hospital Universitario 12 de Octubre, Universidad Complutense, CNIO and CiberOnc, Madrid, Spain
| | | | | | - Alberto Risueño
- Celgene Institute for Translational Research Europe, Seville, Spain
| | | | | | | | - Luis Paz-Ares
- Hospital Universitario 12 de Octubre, Universidad Complutense, CNIO and CiberOnc, Madrid, Spain.
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13
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Ahluwalia MS, Becker K, Levy BP. Epidermal Growth Factor Receptor Tyrosine Kinase Inhibitors for Central Nervous System Metastases from Non-Small Cell Lung Cancer. Oncologist 2018; 23:1199-1209. [PMID: 29650684 DOI: 10.1634/theoncologist.2017-0572] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 02/22/2018] [Indexed: 12/14/2022] Open
Abstract
Central nervous system (CNS) metastases are a common complication in patients with epidermal growth factor receptor (EGFR)-mutated non-small cell lung cancer (NSCLC), resulting in a poor prognosis and limited treatment options. Treatment of CNS metastases requires a multidisciplinary approach, and the optimal treatment options and sequence of therapies are yet to be established. Many systemic therapies have poor efficacy in the CNS due to the challenges of crossing the blood-brain barrier (BBB), creating a major unmet need for the development of agents with good BBB-penetrating biopharmaceutical properties. Although the CNS penetration of first- and second-generation EGFR tyrosine kinase inhibitors (TKIs) is generally low, EGFR-TKI treatment has been shown to delay time to CNS progression in patients with CNS metastases from EGFR-mutated disease. However, a major challenge with EGFR-TKI treatment for patients with NSCLC is the development of acquired resistance, which occurs in most patients treated with a first-line EGFR-TKI. Novel EGFR-TKIs, such as osimertinib, have been specifically designed to address the challenges of acquired resistance and poor BBB permeability and have demonstrated efficacy in the CNS. A rational, iterative drug development process to design agents that could penetrate the BBB could prevent morbidity and mortality associated with CNS disease progression. To ensure a consistent approach to evaluating CNS efficacy, special consideration also needs to be given to clinical trial endpoints. IMPLICATIONS FOR PRACTICE Historically, treatment options for patients who develop central nervous system (CNS) metastases have been limited and associated with poor outcomes. The development of epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) has improved outcomes for patients with EGFR-mutated disease, and emerging data have demonstrated the ability of these drugs to cross the blood-brain barrier and elicit significant intracranial responses. Recent studies have indicated a role for next-generation EGFR-TKIs, such as osimertinib, in the treatment of CNS metastases. In the context of an evolving treatment paradigm, treatment should be individualized to the patient and requires a multidisciplinary approach.
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Affiliation(s)
| | - Kevin Becker
- Maimonides Medical Center, Brooklyn, New York, USA
| | - Benjamin P Levy
- Johns Hopkins University School of Medicine, Washington DC, USA
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14
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Parikh AB, Kozuch P, Rohs N, Becker DJ, Levy BP. Metformin as a repurposed therapy in advanced non-small cell lung cancer (NSCLC): results of a phase II trial. Invest New Drugs 2017; 35:813-819. [DOI: 10.1007/s10637-017-0511-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Accepted: 09/14/2017] [Indexed: 11/24/2022]
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15
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Becker DJ, Lin D, Lee S, Levy BP, Makarov DV, Gold HT, Sherman S. Exploration of the ASCO and ESMO Value Frameworks for Antineoplastic Drugs. J Oncol Pract 2017; 13:e653-e665. [DOI: 10.1200/jop.2016.020339] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose: In 2015, both ASCO and the European Society for Medical Oncology (ESMO) proposed frameworks to quantify the benefit of antineoplastic drugs in the face of rising costs. We applied these frameworks to drugs approved by the US Food and Drug Administration over the past 12 years and examined relationships between costs and benefits. Methods: We searched FDA.gov for drugs that received initial approval for solid tumors from 2004 to 2015 and calculated the ASCO Net Health Benefit version 2016 (NHB16) and 2015 (NHB15) and the ESMO Magnitude of Clinical Benefit Scale scores for each drug. We calculated descriptive statistics and explored correlations and associations among benefit scores, cost, and independent variables. Results: We identified 55 drug approvals supported by phase II (18.2%) and III (81.8%) trials, with primary outcomes of overall survival (36.4%), progression-free survival (43.6%), or response rate (20.0%). No significant association was found between NHB16 and year of approval ( P = .81), organ system ( P = .20), or trial comparator arm ( P = .17), but trials with progression-free survival outcomes were associated with higher scores ( P = .007). Both NHB15 and Magnitude of Clinical Benefit Scale scores were approximately normally distributed, but only a moderate correlation existed between them ( r = 0.40, P = .006). No correlation between benefit score and cost (NHB16, r = 0.19; ESMO, r = −0.07) was found. Before 2010, two (15.3%) of 13 approved drugs exceeded $500/NHB point × month compared with 10 (25.0%) of 40 drugs subsequently approved. Conclusion: Our analysis of the ASCO and ESMO value frameworks illuminates the heterogeneous benefit of new medications and highlights challenges in constructing a unified concept of drug value. Drug benefit does not correlate with cost, and the number of high cost/benefit outliers has increased.
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Affiliation(s)
- Daniel J. Becker
- New York University School of Medicine; Veterans Affairs–New York Harbor Healthcare System; and Icahn School of Medicine at Mount Sinai, New York, NY
| | - Daniel Lin
- New York University School of Medicine; Veterans Affairs–New York Harbor Healthcare System; and Icahn School of Medicine at Mount Sinai, New York, NY
| | - Steve Lee
- New York University School of Medicine; Veterans Affairs–New York Harbor Healthcare System; and Icahn School of Medicine at Mount Sinai, New York, NY
| | - Benjamin P. Levy
- New York University School of Medicine; Veterans Affairs–New York Harbor Healthcare System; and Icahn School of Medicine at Mount Sinai, New York, NY
| | - Danil V. Makarov
- New York University School of Medicine; Veterans Affairs–New York Harbor Healthcare System; and Icahn School of Medicine at Mount Sinai, New York, NY
| | - Heather T. Gold
- New York University School of Medicine; Veterans Affairs–New York Harbor Healthcare System; and Icahn School of Medicine at Mount Sinai, New York, NY
| | - Scott Sherman
- New York University School of Medicine; Veterans Affairs–New York Harbor Healthcare System; and Icahn School of Medicine at Mount Sinai, New York, NY
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16
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Becker DJ, Wisnivesky JP, Grossbard ML, Chachoua A, Camidge DR, Levy BP. Survival of Asian Females With Advanced Lung Cancer in the Era of Tyrosine Kinase Inhibitor Therapy. Clin Lung Cancer 2016; 18:e35-e40. [PMID: 28029530 DOI: 10.1016/j.cllc.2016.08.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 07/06/2016] [Accepted: 08/23/2016] [Indexed: 12/09/2022]
Abstract
INTRODUCTION We examined the effect of access to epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (TKI) therapy on survival for Asian female (AF) EGFR mutation-enriched patients with advanced lung adenocarcinoma. MATERIALS AND METHODS We used the Surveillance Epidemiology and End Results database to study patients with stage IV lung adenocarcinoma diagnosed from 1998 to 2012. We compared survival (lung cancer-specific survival [LCSS] and overall survival) between AFs and non-Asian males (NAMs), an EGFR mutation-enriched and EGFR mutation-unenriched population, respectively, with a diagnosis in the pre-EGFR TKI (1998-2004) and EGFR TKI (2005-2012) eras. We used Cox proportional hazards models to examine the interaction of access to TKI treatment and EGFR enrichment status. RESULTS Among 3029 AF and 35,352 NAM patients, we found that LCSS was best for AFs with a diagnosis in the TKI era (median, 14 months), followed by AFs with a diagnosis in the pre-TKI era (median, 8 months), NAMs with a diagnosis in the TKI era (median, 5 months), and NAMs with a diagnosis in the pre-TKI era (median, 4 months; log-rank P < .0001). In a multivariable model, the effect of a diagnosis in the TKI era on survival was greater for AFs than for NAMs (LCSS, P = .0020; overall survival, P = .0007). A lung cancer diagnosis in the TKI era was associated with an overall mortality decrease of 26% for AFs (hazard ratio, 0.740; 95% confidence interval, 0.682-0.80) and 15.9% for NAMs (hazard ratio, 0.841; 95% confidence interval, 0.822-0.860). CONCLUSIONS We found increased survival for lung adenocarcinoma diagnoses made after widespread access to EGFR TKIs, with the greatest increase among AF patients enriched for EGFR mutations. The present analysis eliminated the effect of crossover, which has complicated assessments of the survival advantage in EGFR TKI randomized trials.
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Affiliation(s)
- Daniel J Becker
- Section of Hematology Oncology, Veterans Affairs-New York Harbor Healthcare System, Manhattan Campus, New York, NY; Department of Medicine, New York University School of Medicine, New York, NY.
| | - Juan P Wisnivesky
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Michael L Grossbard
- Department of Medicine, New York University School of Medicine, New York, NY
| | - Abraham Chachoua
- Department of Medicine, New York University School of Medicine, New York, NY
| | - D Ross Camidge
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Benjamin P Levy
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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Levy BP, Rao P, Becker DJ, Becker K. Attacking a Moving Target: Understanding Resistance and Managing Progression in EGFR-Positive Lung Cancer Patients Treated With Tyrosine Kinase Inhibitors. Oncology (Williston Park) 2016; 30:601-612. [PMID: 27432364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Multiple randomized studies have demonstrated improved response rates, progression-free survival, and quality of life for treatment-naive, advanced-stage adenocarcinoma patients harboring sensitizing EGFR mutations when they are treated with tyrosine kinase inhibitor therapy, as compared with chemotherapy. Despite improved outcomes with these agents, the majority of patients will eventually develop resistance and subsequent clinical progression. Recently, there has been a firmer understanding of the molecular mechanisms of the resistance that develops as a consequence of treatment, most notably the identification of a second-site EGFR mutation, T790M. While this understanding can inform subsequent treatment decisions, disease progression can be heterogeneous, and there are several competing therapeutic options. Treatment decisions must consider this clinical heterogeneity, factoring in the pace of disease growth, lung cancer-related symptoms, and the potential presence of T790M mutations. Herein, we review the available literature addressing these competing strategies and attempt to clarify best treatment practices, including the emerging role of T790M-directed therapies.
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Levy BP, Chioda MD, Herndon D, Longshore JW, Mohamed M, Ou SHI, Reynolds C, Singh J, Wistuba II, Bunn PA, Hirsch FR. Molecular Testing for Treatment of Metastatic Non-Small Cell Lung Cancer: How to Implement Evidence-Based Recommendations. Oncologist 2015; 20:1175-81. [PMID: 26330460 DOI: 10.1634/theoncologist.2015-0114] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 07/02/2015] [Indexed: 12/28/2022] Open
Abstract
The recent discovery of relevant biomarkers has reshaped our approach to therapy selection for patients with non-small cell lung cancer. The unprecedented outcomes demonstrated with tyrosine kinase inhibitors in molecularly defined cohorts of patients has underscored the importance of genetic profiling in this disease. Despite published guidelines on biomarker testing, successful tumor genotyping faces significant hurdles at both academic and community-based practices. Oncologists are now faced with interpreting large-scale genomic data from multiple tumor types, possibly making it difficult to stay current with practice standards in lung cancer. In addition, physicians' lack of time, resources, and face-to-face opportunities can interfere with the multidisciplinary approach that is essential to delivery of care. Finally, several challenges exist in optimizing the amount and quality of tissue for molecular testing. Recognizing the importance of biomarker testing, a series of advisory boards were recently convened to address these hurdles and clarify best practices. We reviewed these challenges and established recommendations to help optimize tissue acquisition, processing, and testing within the framework of a multidisciplinary approach.
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Affiliation(s)
- Benjamin P Levy
- Mount Sinai Health Systems, New York, New York, USA; Pfizer Oncology, New York, New York, USA; Cone Health Cancer Center, Greensboro, North Carolina, USA; Carolinas Pathology Group, Carolinas HealthCare System, Charlotte, North Carolina, USA; Chao Family Comprehensive Cancer Center, University of California at Irvine School of Medicine, Orange, California, USA; US Oncology Research, Ocala, Florida, USA; Carolinas HealthCare System, Charlotte, North Carolina, USA; The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; University of Colorado Cancer Center, Aurora, Colorado, USA
| | - Marc D Chioda
- Mount Sinai Health Systems, New York, New York, USA; Pfizer Oncology, New York, New York, USA; Cone Health Cancer Center, Greensboro, North Carolina, USA; Carolinas Pathology Group, Carolinas HealthCare System, Charlotte, North Carolina, USA; Chao Family Comprehensive Cancer Center, University of California at Irvine School of Medicine, Orange, California, USA; US Oncology Research, Ocala, Florida, USA; Carolinas HealthCare System, Charlotte, North Carolina, USA; The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; University of Colorado Cancer Center, Aurora, Colorado, USA
| | - Dana Herndon
- Mount Sinai Health Systems, New York, New York, USA; Pfizer Oncology, New York, New York, USA; Cone Health Cancer Center, Greensboro, North Carolina, USA; Carolinas Pathology Group, Carolinas HealthCare System, Charlotte, North Carolina, USA; Chao Family Comprehensive Cancer Center, University of California at Irvine School of Medicine, Orange, California, USA; US Oncology Research, Ocala, Florida, USA; Carolinas HealthCare System, Charlotte, North Carolina, USA; The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; University of Colorado Cancer Center, Aurora, Colorado, USA
| | - John W Longshore
- Mount Sinai Health Systems, New York, New York, USA; Pfizer Oncology, New York, New York, USA; Cone Health Cancer Center, Greensboro, North Carolina, USA; Carolinas Pathology Group, Carolinas HealthCare System, Charlotte, North Carolina, USA; Chao Family Comprehensive Cancer Center, University of California at Irvine School of Medicine, Orange, California, USA; US Oncology Research, Ocala, Florida, USA; Carolinas HealthCare System, Charlotte, North Carolina, USA; The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; University of Colorado Cancer Center, Aurora, Colorado, USA
| | - Mohamed Mohamed
- Mount Sinai Health Systems, New York, New York, USA; Pfizer Oncology, New York, New York, USA; Cone Health Cancer Center, Greensboro, North Carolina, USA; Carolinas Pathology Group, Carolinas HealthCare System, Charlotte, North Carolina, USA; Chao Family Comprehensive Cancer Center, University of California at Irvine School of Medicine, Orange, California, USA; US Oncology Research, Ocala, Florida, USA; Carolinas HealthCare System, Charlotte, North Carolina, USA; The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; University of Colorado Cancer Center, Aurora, Colorado, USA
| | - Sai-Hong Ignatius Ou
- Mount Sinai Health Systems, New York, New York, USA; Pfizer Oncology, New York, New York, USA; Cone Health Cancer Center, Greensboro, North Carolina, USA; Carolinas Pathology Group, Carolinas HealthCare System, Charlotte, North Carolina, USA; Chao Family Comprehensive Cancer Center, University of California at Irvine School of Medicine, Orange, California, USA; US Oncology Research, Ocala, Florida, USA; Carolinas HealthCare System, Charlotte, North Carolina, USA; The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; University of Colorado Cancer Center, Aurora, Colorado, USA
| | - Craig Reynolds
- Mount Sinai Health Systems, New York, New York, USA; Pfizer Oncology, New York, New York, USA; Cone Health Cancer Center, Greensboro, North Carolina, USA; Carolinas Pathology Group, Carolinas HealthCare System, Charlotte, North Carolina, USA; Chao Family Comprehensive Cancer Center, University of California at Irvine School of Medicine, Orange, California, USA; US Oncology Research, Ocala, Florida, USA; Carolinas HealthCare System, Charlotte, North Carolina, USA; The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; University of Colorado Cancer Center, Aurora, Colorado, USA
| | - Jaspal Singh
- Mount Sinai Health Systems, New York, New York, USA; Pfizer Oncology, New York, New York, USA; Cone Health Cancer Center, Greensboro, North Carolina, USA; Carolinas Pathology Group, Carolinas HealthCare System, Charlotte, North Carolina, USA; Chao Family Comprehensive Cancer Center, University of California at Irvine School of Medicine, Orange, California, USA; US Oncology Research, Ocala, Florida, USA; Carolinas HealthCare System, Charlotte, North Carolina, USA; The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; University of Colorado Cancer Center, Aurora, Colorado, USA
| | - Ignacio I Wistuba
- Mount Sinai Health Systems, New York, New York, USA; Pfizer Oncology, New York, New York, USA; Cone Health Cancer Center, Greensboro, North Carolina, USA; Carolinas Pathology Group, Carolinas HealthCare System, Charlotte, North Carolina, USA; Chao Family Comprehensive Cancer Center, University of California at Irvine School of Medicine, Orange, California, USA; US Oncology Research, Ocala, Florida, USA; Carolinas HealthCare System, Charlotte, North Carolina, USA; The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; University of Colorado Cancer Center, Aurora, Colorado, USA
| | - Paul A Bunn
- Mount Sinai Health Systems, New York, New York, USA; Pfizer Oncology, New York, New York, USA; Cone Health Cancer Center, Greensboro, North Carolina, USA; Carolinas Pathology Group, Carolinas HealthCare System, Charlotte, North Carolina, USA; Chao Family Comprehensive Cancer Center, University of California at Irvine School of Medicine, Orange, California, USA; US Oncology Research, Ocala, Florida, USA; Carolinas HealthCare System, Charlotte, North Carolina, USA; The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; University of Colorado Cancer Center, Aurora, Colorado, USA
| | - Fred R Hirsch
- Mount Sinai Health Systems, New York, New York, USA; Pfizer Oncology, New York, New York, USA; Cone Health Cancer Center, Greensboro, North Carolina, USA; Carolinas Pathology Group, Carolinas HealthCare System, Charlotte, North Carolina, USA; Chao Family Comprehensive Cancer Center, University of California at Irvine School of Medicine, Orange, California, USA; US Oncology Research, Ocala, Florida, USA; Carolinas HealthCare System, Charlotte, North Carolina, USA; The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; University of Colorado Cancer Center, Aurora, Colorado, USA
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Lehmann CU, Longhurst CA, Hersh W, Mohan V, Levy BP, Embi PJ, Finnell JT, Turner AM, Martin R, Williamson J, Munger B. Clinical Informatics Fellowship Programs: In Search of a Viable Financial Model: An open letter to the Centers for Medicare and Medicaid Services. Appl Clin Inform 2015; 6:267-70. [PMID: 26171074 DOI: 10.4338/aci-2015-03-ie-0030] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 03/28/2015] [Indexed: 11/23/2022] Open
Abstract
In the US, the new subspecialty of Clinical Informatics focuses on systems-level improvements in care delivery through the use of health information technology (HIT), data analytics, clinical decision support, data visualization and related tools. Clinical informatics is one of the first subspecialties in medicine open to physicians trained in any primary specialty. Clinical Informatics benefits patients and payers such as Medicare and Medicaid through its potential to reduce errors, increase safety, reduce costs, and improve care coordination and efficiency. Even though Clinical Informatics benefits patients and payers, because GME funding from the Centers for Medicare and Medicaid Services (CMS) has not grown at the same rate as training programs, the majority of the cost of training new Clinical Informaticians is currently paid by academic health science centers, which is unsustainable. To maintain the value of HIT investments by the government and health care organizations, we must train sufficient leaders in Clinical Informatics. In the best interest of patients, payers, and the US society, it is therefore critical to find viable financial models for Clinical Informatics fellowship programs. To support the development of adequate training programs in Clinical Informatics, we request that the Centers for Medicare and Medicaid Services (CMS) issue clarifying guidance that would allow accredited ACGME institutions to bill for clinical services delivered by fellows at the fellowship program site within their primary specialty.
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Affiliation(s)
- C U Lehmann
- Departments of Pediatrics and Biomedical Informatics, Vanderbilt University , Nashville, TN
| | - C A Longhurst
- Departments of Pediatrics and Medicine, Stanford University , Palo Alto, CA
| | - W Hersh
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University , Portland, OR
| | - V Mohan
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University , Portland, OR
| | - B P Levy
- Departments of Pathology and Biomedical and Health Information Sciences, University of Illinois at Chicago , Chicago, IL
| | - P J Embi
- Departments of Biomedical Informatics and Internal Medicine, The Ohio State University , Columbus, OH
| | - J T Finnell
- Department of Emergency Medicine and Regenstrief Institute, Indiana University , Indianapolis, IN
| | - A M Turner
- Departments of Biomedical Informatics and Medical Education, University of Washington , Seattle, WA
| | - R Martin
- American Medical Informatics Association , Bethesda, MD
| | - J Williamson
- American Medical Informatics Association , Bethesda, MD
| | - B Munger
- Executive Director (Ret.), American Board of Emergency Medicine
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Rizvi NA, Mazières J, Planchard D, Stinchcombe TE, Dy GK, Antonia SJ, Horn L, Lena H, Minenza E, Mennecier B, Otterson GA, Campos LT, Gandara DR, Levy BP, Nair SG, Zalcman G, Wolf J, Souquet PJ, Baldini E, Cappuzzo F, Chouaid C, Dowlati A, Sanborn R, Lopez-Chavez A, Grohe C, Huber RM, Harbison CT, Baudelet C, Lestini BJ, Ramalingam SS. Activity and safety of nivolumab, an anti-PD-1 immune checkpoint inhibitor, for patients with advanced, refractory squamous non-small-cell lung cancer (CheckMate 063): a phase 2, single-arm trial. Lancet Oncol 2015; 16:257-65. [PMID: 25704439 DOI: 10.1016/s1470-2045(15)70054-9] [Citation(s) in RCA: 1115] [Impact Index Per Article: 123.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Patients with squamous non-small-cell lung cancer that is refractory to multiple treatments have poor outcomes. We assessed the activity of nivolumab, a fully human IgG4 PD-1 immune checkpoint inhibitor antibody, for patients with advanced, refractory, squamous non-small-cell lung cancer. METHODS We did this phase 2, single-arm trial at 27 sites (academic, hospital, and private cancer centres) in France, Germany, Italy, and USA. Patients who had received two or more previous treatments received intravenous nivolumab (3 mg/kg) every 2 weeks until progression or unacceptable toxic effects. The primary endpoint was the proportion of patients with a confirmed objective response as assessed by an independent radiology review committee. We included all treated patients in the analyses. This study is registered with ClinicalTrials.gov, number NCT01721759. FINDINGS Between Nov 16, 2012, and July 22, 2013, we enrolled and treated 117 patients. 17 (14·5%, 95% CI 8·7-22·2) of 117 patients had an objective response as assessed by an independent radiology review committee. Median time to response was 3·3 months (IQR 2·2-4·8), and median duration of response was not reached (95% CI 8·31-not applicable); 13 (77%) of 17 of responses were ongoing at the time of analysis. 30 (26%) of 117 patients had stable disease (median duration 6·0 months, 95% CI 4·7-10·9). 20 (17%) of 117 patients reported grade 3-4 treatment-related adverse events, including: fatigue (five [4%] of 117 patients), pneumonitis (four [3%]), and diarrhoea (three [3%]). There were two treatment-associated deaths caused by pneumonia and ischaemic stroke that occurred in patients with multiple comorbidities in the setting of progressive disease. INTERPRETATION Nivolumab has clinically meaningful activity and a manageable safety profile in previously treated patients with advanced, refractory, squamous non-small cell lung cancer. These data support the assessment of nivolumab in randomised, controlled, phase 3 studies of first-line and second-line treatment. FUNDING Bristol-Myers Squibb.
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Affiliation(s)
- Naiyer A Rizvi
- Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
| | - Julien Mazières
- Hôpital Larrey, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | | | | | - Grace K Dy
- Roswell Park Cancer Institute, Buffalo, NY, USA
| | | | - Leora Horn
- Vanderbilt-Ingram Cancer Center, Nashville, TN, USA
| | - Hervé Lena
- Centre Hospitalier Universitaire de Rennes, Rennes, France
| | | | | | | | | | - David R Gandara
- University of California Davis Cancer Center, Sacramento, CA, USA
| | - Benjamin P Levy
- Mount Sinai Beth Israel Comprehensive Cancer Center, New York, NY, USA
| | | | | | | | | | | | | | | | | | | | - Ariel Lopez-Chavez
- University of Miami, Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | | | - Rudolf M Huber
- Klinikum der Universitaet Muenchen-Innenstadt, German Center for Lung Research, Munich, Germany
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Levy BP, Becker DJ. The time for low-dose computed tomography screening is now: a medical oncologist perspective. Oncology (Williston Park) 2014; 28:964-966. [PMID: 25381211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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Saxena A, Nagasaka M, Li Z, Becker DJ, Levy BP. Double trouble: a case of concurrent de novo T790M and L858R EGFR mutations in treatment-naive advanced non-small-cell lung cancer. Oncology (Williston Park) 2014; 28:526-534. [PMID: 25134330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Becker DJ, Talwar S, Levy BP, Thorn M, Roitman J, Blum RH, Harrison LB, Grossbard ML. Impact of oncology drug shortages on patient therapy: unplanned treatment changes. J Oncol Pract 2013; 9:e122-8. [PMID: 23942928 DOI: 10.1200/jop.2012.000799] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Cancer drug shortages have increased considerably over the past 5 years, but quantitative analyses of the scope and effects are limited. We assessed the effects of drug shortages on outpatient medication use in a single New York City university hospital. METHODS We examined pharmacy records for drug shortages, as defined by the American Society of Health-System Pharmacists. We assessed outpatient records for all patients with cancer treated with infusional antineoplastic medications from April 2010 to September 2010 and April 2011 to September 2011. RESULTS Twelve medications were in shortage in 2010 and 22 in 2011. Drugs in shortage were used for 170 patients (50.8%) in 2010 and 241 patients (63.6%) in 2011 (P < .001). Of 235 patients treated in August-September 2011, there were 23(9.8%) documented therapy changes due to shortages, compared with zero changes in August-September 2010 (P < .001). Among patients treated in August-September 2010, 24 (11.4%) received paclitaxel and 19 (9.0%) received docetaxel. Among patients treated in August-September 2011, 11 (4.7%) received paclitaxel and 38 (16.2%) received docetaxel, a 69% decrease for paclitaxel and 80% increase for docetaxel from 1 year prior (P = .009, and P = .024, respectively). The estimated cost of a single treatment with paclitaxel for one patient with body-surface area 1.75 was $47.59 versus $858.39 for docetaxel, a 1,704% increase. Surveyed physicians frequently reported lower level evidence (30.4%) and increased risk of toxicity (34.8%) with alternative therapy in drug shortage cases. CONCLUSION Oncology drug shortages affected the majority of patients in our center and increased at an alarming rate. Drug shortages have substantial economic costs and mandate treatment changes that may affect efficacy and toxicity.
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Affiliation(s)
- Daniel J Becker
- Continuum Cancer Center; Columbia University College of Physicians and Surgeons; and Albert Einstein College of Medicine, New York, NY
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Darshan MS, Loftus MS, Thadani-Mulero M, Levy BP, Escuin D, Zhou XK, Gjyrezi A, Chanel-Vos C, Shen R, Tagawa ST, Bander NH, Nanus DM, Giannakakou P. Taxane-induced blockade to nuclear accumulation of the androgen receptor predicts clinical responses in metastatic prostate cancer. Cancer Res 2011; 71:6019-29. [PMID: 21799031 DOI: 10.1158/0008-5472.can-11-1417] [Citation(s) in RCA: 361] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Prostate cancer progression requires active androgen receptor (AR) signaling which occurs following translocation of AR from the cytoplasm to the nucleus. Chemotherapy with taxanes improves survival in patients with castrate resistant prostate cancer (CRPC). Taxanes induce microtubule stabilization, mitotic arrest, and apoptotic cell death, but recent data suggest that taxanes can also affect AR signaling. Here, we report that taxanes inhibit ligand-induced AR nuclear translocation and downstream transcriptional activation of AR target genes such as prostate-specific antigen. AR nuclear translocation was not inhibited in cells with acquired β-tubulin mutations that prevent taxane-induced microtubule stabilization, confirming a role for microtubules in AR trafficking. Upon ligand activation, AR associated with the minus-end-microtubule motor dynein, thereby trafficking on microtubules to translocate to the nucleus. Analysis of circulating tumor cells (CTC) isolated from the peripheral blood of CRPC patients receiving taxane chemotherapy revealed a significant correlation between AR cytoplasmic sequestration and clinical response to therapy. These results indicate that taxanes act in CRPC patients at least in part by inhibiting AR nuclear transport and signaling. Further, they suggest that monitoring AR subcellular localization in the CTCs of CRPC patients might predict clinical responses to taxane chemotherapy.
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Affiliation(s)
- Medha S Darshan
- Department of Medicine, Division of Hematology and Medical Oncology, Weill Cornell Medical College of Cornell University, New York, New York 10065-4896, USA
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Levy BP, Drilon A, Makarian L, Patel AA, Grossbard ML. Systemic approaches for multifocal bronchioloalveolar carcinoma: is there an appropriate target? Oncology (Williston Park) 2010; 24:888-900. [PMID: 21138169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Bronchioloalveolar carcinoma (BAC) is a subset of pulmonary adenocarcinoma characterized by distinct and unique pathological, molecular, radiographic, and clinical features. While the incidence of pure BAC is rare, comprising only 1% to 4% of non-small-cell lung cancer (NSCLC), mixed subtypes (including BAC with focal invasion and adenocarcinoma with BAC features) represent as much as 20% of adenocarcinomas--and that figure may be increasing. Despite the longstanding recognition of this entity, there is no established treatment paradigm for patients with multifocal BAC, resulting in competing approaches and treatment controversies. Current options for multifocal BAC include both surgery and systemic therapies. Unfortunately, prospective data on systemic approaches are limited by study design and small patient numbers; there are only seven phase II studies involving four therapies. This article evaluates key characteristics of BAC, including the current understanding of histopathology and tumor biology. In addition, it comprehensively reviews the systemic phase II studies in an attempt to clarify the therapeutic challenges in this disease. It also includes the first proposed treatment paradigm that integrates both EGFR mutational status and the sub-histologies, mucinous and nonmucinous BAC.
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Affiliation(s)
- Benjamin P Levy
- Albert Einstein College of Medicine, New York, New York, USA.
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Levy BP. Certification of death. Tenn Med 2000; 93:462-3. [PMID: 11117075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Affiliation(s)
- B P Levy
- Tennessee Department of Health, Nashville, Tennessee, USA
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Levy BP. Reporting deaths to the medical examiner. Tenn Med 2000; 93:298-9. [PMID: 10943148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Affiliation(s)
- B P Levy
- Tennessee Department of Health, Nashville, USA
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Levy BP. Tennessee's medical examiner system. Tenn Med 2000; 93:174. [PMID: 10821073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Affiliation(s)
- B P Levy
- Tennessee Department of Health, Nashville, USA
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Monica RA, Levy BP. The management of a periodontal patient. Ont Dent 1973; 50:24-6. [PMID: 4515358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Monica RA, Levy BP. The management of a periodontal patient. J Wis State Dent Soc 1972; 48:209-17. [PMID: 4505524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Reeve CM, Levy BP. Gingival cysts: a review of the literature and a report of four cases. Periodontics 1968; 6:115-7. [PMID: 5240494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Levy BP, Reeve CM. Use of an intra-oral bandage. Periodontics 1968; 6:87. [PMID: 5239221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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