Abstract CT188: IMmotion151: updated overall survival (OS) and exploratory analysis of the association of gene expression and clinical outcomes with atezolizumab plus bevacizumab vs sunitinib in patients with locally advanced or metastatic renal cell carcinoma (mRCC)

Background: In IMmotion151 (NCT02420821), atezo (anti-PD-L1) + bev (anti-VEGF) improved PFS vs sun as 1L treatment in patients (pts) with mRCC (Rini, Lancet 2019). Gene expression analyses of baseline tumor tissue revealed 7 distinct transcriptomic clusters associated with objective response rate and PFS (Motzer, Cancer Cell 2020). Final OS, safety and association of transcriptome subsets with OS are presented.

Methods: Treatment-naive pts across prognostic risk groups were randomized 1:1 to receive atezo 1200 mg IV + bev 15 mg/kg IV q3w or sun 50 mg PO QD 4 wk on/2 wk off. Co-primary endpoints were PFS by investigator per RECIST 1.1 in PD-L1+ (≥ 1% IC) pts and OS in ITT pts. Secondary endpoints included OS in PD-L1+ pts and safety. Exploratory endpoints included biomarker analyses.

Results: In the final analysis (minimum follow-up 40 mo) with a 55% (504/915) OS event rate, atezo + bev did not show an OS benefit vs sun (Table). Treatment-related AEs (TRAEs) were observed in 92% (415/451) and 96% (430/446) of ITT pts in the atezo + bev and sun arms, and Grade 3-4 TRAEs were observed in 46% (205/451) and 56% (250/446), respectively. In exploratory biomarker analyses, sun showed an improved OS trend in tumors characterized by an angiogenic transcription profile, and atezo + bev showed improved OS trend in tumors characterized by T-effector/proliferative, proliferative or small nucleolar RNA transcription profiles (Table). When the latter 3 groups were combined, atezo + bev resulted in better OS than sun (HR, 0.70; 95% CI: 0.50, 0.98).

Conclusions: Overall, in this final analysis, no OS improvement with atezo + bev vs sun was seen. The safety of atezo + bev was consistent with the known safety profile of each component. Biomarker studies generated hypotheses for which pt subgroups are most likely to benefit from combined anti-VEGF + anti-PD-L1 therapy.

PopulationCluster transcription profileHR (95% CI)P valueMedian OS (atezo + bev)Median OS (sun)ITT (n=915)NA0.91 (0.76, 1.08)a0.27b36.135.3PD-L1+ (n=362)NA0.85 (0.64, 1.13)a0.2638.731.6Cluster 1 (n=98)Angiogenic/stromal0.94 (0.52, 1.72)_NR48.2Cluster 2 (n=245)Angiogenic1.32 (0.91, 1.91)_46.2NRCluster 3 (n=156)Complement/Ω-oxidative0.99 (0.64, 1.54)_35.036.6Cluster 4 (n=116)T-effector/proliferative0.66 (0.41, 1.06)_38.723.3Cluster 5 (n=74)Proliferative0.66 (0.39, 1.12)_21.715.5Cluster 6 (n=106)Stromal/proliferative0.90 (0.57, 1.40)_15.912.7Cluster 7 (n=28)snoRNANC_NR42.1Gene expression clusters 4 (T-effector/proliferative) + 5 (proliferative) + 7 (snoRNA) (n=218)_0.70 (0.50, 0.98)_35.421.2aPts were stratified by MSKCC Risk Score (good vs intermediate vs poor), liver metastases (yes vs no) and PD-L1 IHC status (< 1% vs ≥ 1% PD-L1 expression on IC; SP142 IHC assay).bThe pre-specified α boundary was 0.0203.atezo, atezolizumab; bev, bevacizumab; HR, hazard ratio; IC, tumor-infiltrating immune cells; IHC, immunohistochemistry; ITT, intention to treat; MSKCC, Memorial Sloan Kettering Cancer Center; NA, not applicable; NC, not calculated; NR, not reported; OS, overall survival; PD-L1, programmed death-ligand 1; PFS, progression free survival; snoRNA, small nucleolar RNA; sun, sunitinib.

Citation Format: Brian I. Rini, Michael B. Atkins, Bernard Escudier, Thomas Powles, David F. McDermott, Boris Y. Alekseev, Jae-Lyun Lee, Daniil Stroyakovskiy, Cristina Suarez Rodriguez, Ugo De Giorgi, Frede Donskov, Begoña Mellado, Romain Banchereau, Habib Hamidi, Omara Khan, Veronica Craine, Mahrukh Huseni, Nick Flinn, Sarita Dubey, Robert Motzer. IMmotion151: updated overall survival (OS) and exploratory analysis of the association of gene expression and clinical outcomes with atezolizumab plus bevacizumab vs sunitinib in patients with locally advanced or metastatic renal cell carcinoma (mRCC) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr CT188.

Efficacy outcomes of nivolumab + cabozantinib versus pembrolizumab + axitinib in patients with advanced renal cell carcinoma (aRCC): Matching-adjusted indirect comparison (MAIC)

4578

Background: Nivolumab in combination with cabozantinib (N+C) has demonstrated significantly improved progression-free survival (PFS), objective response rate (ORR), and overall survival (OS), compared with sunitinib as a first-line (1L) treatment for aRCC in the phase 3 CheckMate (CM) 9ER trial. As there are no head-to-head trials comparing N+C with pembrolizumab in combination with axitinib (P+A), this study compared the efficacy of N+C with P+A as 1L treatment in aRCC. Methods: An MAIC was conducted using individual patient data on N+C (N = 323) from the CM 9ER trial (median follow-up: 23.5 months) and published data on P+A (N = 432) from the KEYNOTE (KN)-426 trialof P+A (median follow-up: 30.6 months). Individual patients within the CM 9ER trial population were reweighted to match the key patient characteristics published in KN-426 trial, including age, gender, previous nephrectomy, International Metastatic RCC Database Consortium risk score, and sites of metastasis. After weighting, hazards ratios (HR) of PFS, duration of response (DoR), and OS comparing N+C vs. P+A were estimated using weighted Cox proportional hazards models, and ORR was compared using a weighted Wald test. All comparisons were conducted using the corresponding sunitinib arms as an anchor. Results: After weighting, patient characteristics in the CM 9ER trial were comparable to those in the KN-426 trial. In the weighted population, N+C had a median PFS of 19.3 months (95% CI: 15.2, 22.4) compared to a median PFS of 15.7 months (95% CI: 13.7, 20.6) for P+A. Using sunitinib as an anchor arm, N+C was associated with a 30% reduction in risk of progression or death compared to P+A, (HR: 0.70, 95% CI: 0.53, 0.93; P = 0.015; table). In addition, N+C was associated with numerically, although not statistically, higher improvement in ORR vs sunitinib (difference: 8.4%, 95% CI: -1.7%, 18.4%; P = 0.105) and improved DoR (HR: 0.79; 95% CI: 0.47, 1.31; P = 0.359). Similar OS outcomes were observed for N+C and P+A (HR: 0.99; 95% CI: 0.67, 1.44; P = 0.940). Conclusions: After adjusting for cross-trial differences, N+C had a more favorable efficacy profile compared to P+A, including statistically significant PFS benefits, numerically improved ORR and DoR, and similar OS.[Table: see text]

Clinical activity of durvalumab and savolitinib in MET-driven, metastatic papillary renal cancer

4511

Background: Savolitinib is a potent and selective MET inhibitor with activity in MET-driven papillary renal cancer (PRC). Durvalumab is a PD-L1 inhibitor which has been tested in combination with savolitinib in metastatic PRC with response rates of 29% (12/41). Here we describe the efficacy of this combination in MET-driven metastatic PRC. Methods: This single arm phase I/II trial explored durvalumab (1500mg Q4W) and savolitinib (600mg OD) together in metastatic PRC, with a 4wk savolitinib run in. Biomarker analysis results were compared with responses to treatment as planned in the protocol. The analysis presented here focuses on those patients with MET DNA alterations (central analysis:chromosome 7 gain/MET or HGF amplification/MET kinase domain mutations). Confirmed response rate (RR) (RECIST v1.1), progression-free survival (PFS), tolerability (CTCAE v4.03) and overall survival (OS) were analysed. Results: 42 patients were enrolled in the metastatic papillary cohort, of which 41 patients received treatment. The median follow up was 26.8 months. The confirmed RR was 29% (12/41) and median PFS was 4.9 months (95% CI 2.5-10.0). 14/41 (34%) of these patients had MET-driven disease. 71% (10/14) of MET-driven patients had not previously received systemic therapy and 7% (1/14) were PD-L1 positive. IMDC good, intermediate, and poor risk disease occurred in 36% (5/14), 57% (8/14), and 7% (1/14) of MET-driven patients respectively. Confirmed RR in MET-driven patients was 57% (8/14) with duration of response at 9.4 months (95% CI 3.9-Not reached [NR]). Median PFS and OS in MET-driven patients were 10.5 months (95% CI 2.9-15.7) and 27.4 months (95% CI 7.3-NR) respectively. No new safety signals were seen. Conclusions: The combination of savolitinib and durvalumab has clinical activity in MET-driven PRC. A randomised phase III study is planned based upon these data. Clinical trial information: NCT02819596.

Randomized phase Ib study to evaluate safety, pharmacokinetics and therapeutic activity of simlukafusp α in combination with atezolizumab ± bevacizumab in patients with unresectable advanced/ metastatic renal cell carcinoma (RCC) (NCT03063762)

4556

Background: Simlukafusp α ([SIM], FAP-IL2v) is a novel IL-2v immunocytokine engineered to preferentially activate effector CD8 T and NK cells, but not regulatory T cells (Tregs), due to abolished binding to Interleukin-2 receptor α (IL-2Rα) and retained affinity to IL-2Rβγ. High affinity binding of SIM to fibroblast activation protein (FAP), expressed on cancer-associated fibroblasts, mediates its accumulation in malignant lesions. Methods: The Dose-Escalation (DE) consisted of: Arm A: SIM 5-25 mg weekly for 4 weeks, and every 2 weeks (Q2W) thereafter in combination with atezolizumab [ATZ] 840mg Q2W; and Arm B: same as Arm A + bevacizumab [BEV] 10 mg/kg Q2W. Patients (pts) not previously treated were evaluated in the Extension Part: Arm C (n=3): SIM + ATZ every 3 weeks (Q3W); or Arm D (n=25): SIM + ATZ + BEV (“triplet”) Q3W. Primary objectives were: finding the recommended dose of SIM and assessment of objective response rate (ORR) by RECIST v1.1. Results: We enrolled 69 pts with unresectable advanced/ metastatic clear-cell and/or sarcomatoid RCC. Median age of patients was 57 years (range: 35-78). The recommended dose for extension of SIM was 10 mg. Median treatment duration in days in each arm were: A: 106 (range: 1-877); B: 324 (8-940); C: 659 (71-768); D: 437 (1-682). Twenty-five pts are evaluable for therapeutic activity in Arm A [ORR: 24% (6 PR; 90% CI 12.95, 40.12)]; 15 in Arm B [46.7% (1 CR, 6PR; 90% CI 27.67, 66.68)]; 3 in Arm C [33.3% (1PR; 90% CI 7.83, 74.65)]; and 23 in Arm D [47.8% (2 CR, 9 PR; 90% CI 35.74, 68.15)]. Twelve patients are ongoing on study treatment. Treatment related grade 3 and 4 adverse events (AE) occurred respectively in 69.7% and 9.1% patients. The most common serious AEs were pyrexia (10.6 %) and infusion-related reactions (9.1%). 65.2% Of the patients reported at least one AE of elevations in liver transaminases/GGT/ alkaline phosphatase/bilirubin. Drug-related AEs led to dose modification/interruption in 37.9 % of the pts, and treatment discontinuation in 3% of the patients. SIM led to preferential expansion and activation of NK and CD8 T cells (but not Tregs) in peripheral blood and augmented tumor infiltration and tumor inflammation. Intriguingly responses were observed not only in pts with PD-L1 positive or inflamed tumors, but also in pts with PD-L1 negative tumors (n=13) or poorly infiltrated tumors classified as immune deserts (n=2). Conclusions: The combination of SIM with ATZ ± BEV was feasible with an acceptable safety profile. Clinical activity was more favorable for the triplet among the study Arms, but comparable to the ATZ + BEV combination in the IMmotion151 (Rini B, et al 2019). Observed pharmacodynamic findings were consistent with the expected effects. Clinical trial information: NCT03063762.

CONTACT-03: Randomized, open-label phase III study of atezolizumab plus cabozantinib versus cabozantinib monotherapy following progression on/after immune checkpoint inhibitor (ICI) treatment in patients with advanced/metastatic renal cell carcinoma

TPS370

Background: Combining anti-angiogenic drugs with immune checkpoint inhibitors (ICI) after progression on ICIs presents a promising therapeutic approach in renal cell carcinoma (RCC). Atezolizumab (anti-PD-L1 mAb) has shown activity in combination with anti-angiogenic therapy after prior progression with ICI. Cabozantinib (VEGFR-TAM-TKI), a standard of care therapy in RCC, promotes an immune-permissive environment and may enhance atezolizumab activity. In phase Ib COSMIC-021, cabozantinib + atezolizumab safety and efficacy was favorable in clear-cell(cc) RCC and non(n)-ccRCC (Pal et al [702O] and McGregor et al [709P], ESMO 2020). The phase III CONTACT-03 study is further evaluating cabozantinib + atezolizumab vs cabozantinib in second-line/third-line RCC after prior ICC therapy. Methods: CONTACT-03 (NCT04338269) is a phase III, open-label, randomized, multicenter study that will enroll ≈500 patients across more than 150 sites globally. The trial opened in July 2020 and is actively recruiting adult patients with RCC. Key inclusion criteria include histologically confirmed locally advanced or metastatic ccRCC or nccRCC (papillary or unclassified); radiographic disease progression during or following first-line/second-line ICI treatment; measurable disease (RECIST 1.1); KPS score ≥70%; and availability of an archival tumor specimen and fresh biopsy (if clinically feasible). Patients must have adequate hematological and end organ function. Prior ICI therapy must be a PD-1/PD-L1 inhibitor (mono- or combination therapy) and must be in the immediate preceding line of therapy. Key exclusion criteria include prior treatment with cabozantinib or a mTOR inhibitor. Patients with symptomatic, untreated, or actively progressing CNS metastases or significant other intercurrent illness are not eligible. Stratification factors are IMDC risk group (0 vs 1-2 vs ≥3); line of most recent prior ICI therapy (first vs second); and histology (dominant cc without sarcomatoid vs dominant non-cc [papillary or unclassified] without sarcomatoid vs any sarcomatoid component [cc or ncc]). Patients will be randomized 1:1 to receive atezolizumab (1200 mg/IV/q3w) plus cabozantinib (60 mg/oral/qd) or cabozantinib alone (60 mg/oral/qd) until unacceptable toxicity or loss of clinical benefit. Patients will not be allowed to crossover from the control arm to the experimental arm. Multiple primary endpoints are independent review facility (IRF)-assessed PFS and OS. Additional endpoints include investigator-assessed PFS, IRF- and investigator-assessed ORR and DOR; HRQOL, biomarkers and safety. Radiographic efficacy will be assessed per RECIST 1.1. Clinical trial information: NCT04338269 .

INMUNOSUN-SOGUG trial: A prospective phase II study to assess the efficacy and safety of sunitinib as second-line (2L) treatment in patients (pts) with metastatic renal cell cancer (RCC) who received immunotherapy-based combination upfront

5060

Background: Immunotherapy (IO)-based combinations have replaced tyrosine kinase inhibitors (TKI) as standard upfront treatment of metastatic RCC pts. Selection of 2L treatment after progression to novel combinations in 1st-line (1L) is mostly based on retrospective series or subgroups analysis of randomized trials. We aim to evaluate the activity and safety of sunitinib in advanced RCC after progression on an IO-based 1L approach. Methods: This is a prospective, non-randomized, open-label and multicenter phase II study. Pts with ECOG 0-2 and locally advanced or metastatic RCC after treatment in 1L with a prior PD-1 and/or PD-L1 and/or CTLA-4 inhibitor were included. Sunitinib was administered at 50 mg/day on a 4/2 schedule until disease progression. Primary endpoint was overall response rate (ORR) by RECIST v 1.1 criteria. Results: Twenty pts were enrolled in the study. Median age was 66 yo, 70% had intermediate prognosis by Heng's scale, and 88% ECOG 1. 45% of pts received atezolizumab, 30% pembrolizumab, 20% nivolumab and 15% ipilimumab-based regimens as 1L. ORR to 1L treatment was 45%. Median time from end of 1L to sunitinib onset date was 1.1 months (0.3-22.1). Two (10%) pts had partial response with sunitinib and 11 (55%) stable disease for a total disease control rate of 65%. With a median follow-up of 8.8 months, median PFS was 6.8 months (0.0-13.9) and median OS 13.6 months (10.5-16.6). Median duration of treatment was 4 months (0.9-16-2). Most common treatment-related adverse events, all grades, were asthenia (55%), dysgeusia (35%), diarrhea (30%), hypertension (30%), mucosal inflammation (25%), palmar-plantar erythrodysesthesia (25%), anemia (20%), neutropenia (20%) and nausea (15%); grade 3 were asthenia (15%), hypertension (10%) and neutropenia (10%). Conclusions: To our knowledge, the INMUNOSUN trial is the first study to evaluate prospectively the activity of a single agent TKI in a pure 2L setting of metastatic RCC pts treated with an IO-based approach upfront. ORR and PFS with sunitinib seem lower than expected when used as a 1L. Consistency in toxicity profile was observed. Clinical trial information: NCT03066427 .

Cabozantinib in combination with atezolizumab in urothelial carcinoma previously treated with platinum-containing chemotherapy: Results from cohort 2 of the COSMIC-021 study

5013

Background: Cabozantinib (C), an inhibitor of MET, AXL, and VEGFR, has been shown to promote an immune-permissive environment and has shown promising clinical activity in combination with immune checkpoint inhibitors (ICIs) in solid tumors including renal cell carcinoma and urothelial carcinoma (UC). ICI monotherapy is approved for patients (pts) with locally advanced or metastatic UC with disease progression after platinum-containing chemotherapy. COSMIC-021, a multi-center phase 1b study, is evaluating the combination of C with atezolizumab (A) in various solid tumors (NCT03170960). We report results from Cohort 2 in UC pts with prior platinum-containing chemotherapy. Methods: Eligible pts had ECOG PS 0-1 and had progressed on or after a platinum-containing chemotherapy (including pts with disease recurrences < 12 months after the end of perioperative chemotherapy). Pts received C 40 mg PO QD and A 1200 mg IV Q3W. CT/MRI scans were performed Q6W for first year and Q12W thereafter. The primary endpoint is objective response rate (ORR) per RECIST v1.1 by investigator. Other endpoints include safety, duration of response (DOR), PFS, and OS. Results: As of Dec 20, 2019, 30 pts with advanced UC were enrolled with a median follow-up of 16.5 mo (range 12, 21). Median age was 66 yrs (range 44, 84), 73% were male, and 60% had ECOG PS 1. Primary tumor sites were bladder (80%), renal pelvis (10%), and ureter (10%); the most frequent metastatic sites included lung (40%) and liver (27%). Fourteen pts (47%) had received ≥2 prior systemic anticancer therapies. The most common treatment-related AEs (TRAEs) of any grade were asthenia (37%), diarrhea (27%), decreased appetite (23%), increased transaminases (23%), and mucosal inflammation (20%). Grade 3/4 TRAEs occurred in 57% of pts, with no grade 5 TRAEs. Confirmed ORR per RECIST v1.1 was 27% (8 of 30 pts), including 2 pts with CR. DCR (CR+PR+SD) was 64%. Median DOR was not reached, with the longest DOR ongoing at 14.3+ mos. Median PFS was 5.4 mo (range 0.0+, 17.3+). Conclusions: C in combination with A demonstrated encouraging clinical activity in pts with advanced UC with an acceptable safety profile. Additional cohorts of pts with advanced UC are being explored in the study. Clinical trial information: NCT03170960 .

The role of previous radical local treatment (RLT) on the outcome of immune checkpoint inhibitors (ICI) in patients (pts) with metastatic urothelial carcinoma (mUC)

496

Background: There is a growing interest in local treatment for metastatic solid tumors. Recently, retrospective studies have reported the potential benefit of RLT to primary bladder cancer in pts with metastatic disease. We tested the impact of previous RLT in pts with mUC treated with ICI. Methods: Data from pts with mUC treated with ICI collected between May 2013 and May 2019 using a multi-institutional database was evaluated. Stratification was made according to previous RLT with ICI versus no RLT with ICI. We defined RLT as radical surgery (RS) or ≥50 Gy of radiotherapy (RT) delivered to the bladder. The X2 test was used to determine differences in rates. Overall survival (OS) between previous RLT plus ICI (group A) versus no RLT plus ICI (group B) generated using Kaplan-Meier method was compared by log-rank test. OS was calculated from the date of initiation of ICI to the date of death. Analyses were performed using SPSS v21. Results: A total of 115 pts with mUC were treated with ICI, 62 (53.9%) previously were treated with RS, 7(6.1%) RT and 46 (40%) no received RLT. ICI prescribed were atezolizumab (55.7%), pembrolizumab (16.5%), durvalumab (11.3%), durvalumab/tremelimumab (7.8%), nivolumab (5.2%) and avelumab (3.5%). The disease control rate (CR [6.9%] +PR [9.6%] +SD [14.1%]) was higher for pts with previous RLT compared to those pts who did not receive RLT (CR [3.2%] + PR [5.8%] + SD [6.4%](P=0.325). Median OS was 11.23 mo (95% CI; 6.02-16.44) and 7.95 mo (95%IC; 5.15-10.75) for group A and group B, respectively (P=0.481). Conclusions: This multicenter cohort suggests that previous RLT might play an impact for control disease in pts with mUC treated with ICI. Although this is hypothesis generating, the true value of this approach remains to be demonstrated in prospective studies.

Effect of concurrent proton pump inhibitors (PPI) use in patients (pts) treated with immune checkpoint inhibitors (ICI) for metastatic urothelial carcinoma (mUC)

500

Background: PPI are widely used in pts with cancer. PPI are associated with anti-inflammatory properties and direct effects on neutrophils and monocytes that might prevent inflammation. We investigate the role of PPI on outcomes of pt receiving ICI in mUC. Methods: Medical records from pts with mUC treated with ICI from May 2013 to May 2019 using a multi-institutional database was evaluated. Use of PPI was defined: 30 days prior, during the treatment and 30 days after the last dose of ICI. ORR were assessed according to RECIST v1.1. The X2 test was used to determine differences in rates. PFS and OS were estimated using Kaplan-Method and long rank test was used to assess differences between groups. All analyses were performed using SPSS v21. Results: Overall, 115 pts received therapy with ICI. Of these pts, 20 were not included due to the absence of information about PPI. Thus, 95 pts were included for the analysis. 50 (52.6%) pts received PPI. Median age was 68 years, 79 pts (83.2%) were male, 78 pts (82.1%) had ECOG PS 0-1, 20 pts (21.1%) had liver metastasis and 36 pts (37.9%) received ICI treatment as frontline therapy. ICI prescribed were atezolizumab (58.9%), pembrolizumab (17.9%), durvalumab (12.6%), nivolumab (6.3%) and durvalumab/tremelimumab (4.2%). Pts with no PPIs use had higher ORR (CR [8.9%] +PR [14.4%]) compared to those pt who use PPIs (CR [4.4%] + PR [8.9%]) (P=0.197). Median PFS was 10.05 mo (95% CI: 3.86-16.27) for non PPI users and 3.87 mo (95% CI:1.84-5.91) for PPI users (P=0.04). Median OS was 19.71 mo (95% IC:8.93-30.49) for non PPI users and 7.9 mo (4.4-11.45) for PPI users (P=0.072). Conclusions: We have observed shorter PFS and trend toward lower OS and ORR for PPI users. The real impact of PPI should be confirmed in prospective studies.

Retrospective study to identify clinical factors related to a high benefit of axitinib in mRCC: Results from AXILONG Spanish real-world study

650

Background: AXILONG is a Pfizer observational multi-institutional retrospective study, evaluating clinical factors which could be related with a higher benefit of axitinib in pretreated mRCC patients in two pre-specified subgroups with extreme response to axitinib. Methods: Medical records from 157 patients treated in 40 Spanish hospitals with axitinib under clinical practice were retrospectively reviewed and included in the study. Of note, patients had to had an extreme response with axitinib, which means being a long responder (LR) to axitinib, defined as those patients who achieved a median Progression Free Survival (mPFS) of 9 months or longer, or refractory patients (RP) those who achieved a Progression Disease (PD) as best response. Results: In this analysis, we describe the results of a subgroup of patients who received axitinib in second-line after sunitinib, which represents the 68,2% (n=107) of the patients included in the whole study. The 55,1% (n=59) of this subgroup were LR and the 44,9% (n=48) were RP. In this sub-group of patients, the mPFS in LR was 18,7 months (95%CI; 12,9-24,4) and the overall response rate (ORR) was 43,9% (3,5% CR). Median overall survival (mOS) since the start of axitinib was 28,2 months for both sub-groups included, being 44,8 months in the LR patients and 7,3 months in the RP (95% CI, 12.79–34.65; p <0,001). In this population the 1st line mPSF was 27,2 months in LR and 10,9 months in RP (95%CI; 12,97-20,15; p ≤0,001). Conclusions: Despite the limitations of the AXILONG study there were a subgroup of patients who can be considered long responders o axitinib in whom we can obtain a high benefit in terms of efficacy, when treating with the sequence sunitinib-axitinib. Clinical trial information: NCT03538717 .[Table: see text]

Overall survival results for durvalumab and savolitinib in metastatic papillary renal cancer

619

Background: There is a strong rationale for investigating MET and PD-L1 inhibition in metastatic papillary renal cancer (PRC). We previously reported response rates (RR) and progression free survival (PFS) for savolitinib (MET inhibitor) and durvalumab (PD-L1 inhibitor) together. Here we report overall survival (OS) data available 12 months after the last patient was enrolled. Methods: This single arm phase I/II trial explores durvalumab (1500mg Q4W) and savolitinib (600mg OD) together in PRC, with a 4wk savolitinib run in. Treatment naïve or previously treated patients with metastatic PRC were included. Confirmed RR (RECIST v1.1), PFS, tolerability (CTCAE v4.03) and overall survival (OS) were analysed. MET and PD-L1 biomarkers were explored (NCT02819596). Results: 42 patients were enrolled with 41 receiving at least one dose of study treatment. Safety and efficacy analyses were performed on these 41 patients. The median follow up was 14.3 months. IMDC good, intermediate and poor risk disease occurred in 29%, 63%, and 7% of patients respectively. Overall confirmed RR was 27% while median PFS was 4.9 months (95% CI: 2.5 – 12.0 months). Median OS was 12.3 months (95% CI: 5.8 – 21.3 months). Confirmed RR and median OS in the previously untreated cohort (N=27) were 33% and 12.3 months (95% CI: 4.7 – not reached (NR) months) respectively. Treatment related Grade 3/4 toxicity occurred in 34% of patients. No new safety signals were seen. PD-L1 and MET expression were not associated with higher RR (25% and 40% respectively) or longer OS. Conclusions: The combination of savolitinib and durvalumab has clinical activity in PRC and outcomes were not enhanced in biomarker positive cancers. Clinical trial information: NCT02819596.

Patient-reported outcomes (PROs) in IMmotion150: Atezolizumab (atezo) alone or with bevacizumab (bev) versus sunitinib (sun) in first-line metastatic renal cell carcinoma (mRCC)

4515

Background: The phase 2 IMmotion150 study showed improved PFS with atezo + bev vs sun in patients (pts) whose tumors were PD-L1+ and corroborated the activity of atezo monotherapy in previously untreated mRCC. This study offers an opportunity to evaluate PROs with immunotherapy and VEGF-directed therapy alone and in combination. Methods: Pts randomized to atezo 1200 mg IV q3w alone or with bev 15 mg/kg IV q3w, or sun 50 mg po qd for 4 wk on/2 wk off completed the MD Anderson Symptom Inventory (MDASI) and Brief Fatigue Inventory (BFI) q3w of each 6-wk cycle until progression (RECIST 1.1). Time to deterioration (TTD; first ≥ 2-point score increase over baseline [BL]) and change from BL (effect size [ES] ≥ 0.2 suggests a clinically important difference vs sun) in MDASI symptom severity and interference and BFI fatigue severity and interference scores are reported for all-comers. Results: Completion rates were > 90% at BL and ≥ 80% at most visits across arms. BL PRO scores indicating mild symptoms and interference were similar across arms. Delayed TTD of symptom severity and interference with daily life was seen with atezo vs sun and atezo + bev vs sun and was longest with atezo alone (Table). Pts reported milder symptoms and less interference during the first 6 cycles with atezo vs sun: ES mean (range) was 0.36 (0.07-0.68) for core symptom severity and 0.36 (0.04-0.83) for symptom interference. The 5 worst pt-reported symptoms during tx (dry mouth, fatigue, rash, drowsiness, lack of appetite) were all in the sun arm; all 16 symptoms measured were milder with atezo vs sun. Conclusions: PROs suggest that atezo alone or with bev maintained daily function with minimal symptom interference vs sun. Clinical activity, safety and PRO data for atezo support its investigation in adjuvant tx of high-risk RCC pts (IMmotion010; NCT03024996). Clinical trial information: NCT01984242. [Table: see text]

Impact of immune-related adverse events on survival in patients with metastastic urothelial carcinoma treated with immune-checkpoint inhibitors

4531

Background: Immune-checkpoints inhibitors (ICIs) represents the standard of care for platinum-pretreated advanced urothelial cancer patients (pts). By enhancing T-cell activation, a unique spectrum of inflammatory side effects has emerged, also known as immune-related adverse events (irAEs). Data regarding the association between irAEs and pts outcomes are conflicting. Here we conducted a retrospective analysis to investigate the association between irAEs profile and disease outcome in metastastic urothelial carcinoma (mUC) pts. Methods: Medical records from pts with mUC included in clinical trials between July 2013 and June 2018 and treated with ICIs were reviewed. Pts previously treated with platinum-based chemotherapy or cisplatin ineligible pts who had not been previously treated with chemotherapy were included. Clinical responses were assessed as complete response (CR), partial response (PR), stable disease (SD), and progressive disease (PD) according to RECIST v1.1. Adverse events were graded based CTCAE v4.03. Overall survival (OS) was calculated from the date of initiation of ICI to the date of death. X2 test was used to determine differences in rates. OS was estimated using Kaplan-Method and long rank test was used to assess differences between groups. All analyses were performed using SPSS v21. Results: From a total of 52 pts, 44 (84.6%) were treated with ICI monotherapy and 8 (15.3%) in combination (anti-CTLA4 or targeted therapy). Median age was 65 years, 42 pts (80.8%) were male, 44 patients (84.6%) had ECOG PS 0-1, 14 pts (26.9%) had liver metastasis. Overall irAEs were observed in 30 pts (57.7%) and 10 pts (19.2%) developed grade 3/4 irAES. Most common grade 3/4 irAEs were diarrhea (6.6%), rash (6.6%) and hepatitis (6.6%). Disease control rate (CR [26%]+PR[33%]+SD[20%]) was higher for patients with irAEs compared to those patients who did not developed irAEs (CR [13.6%]+PR[0%]+SD[22.7%], this difference was statically significant (P = 0.002). Median OS was 11.23 mo (CI 95%, 3.76-18.70) for the overall cohort, while median OS was 21.91 mo for those patients with irAEs compared to 6.47 mo in patients who did not developed irAEs (P = 0.004). Conclusions: In this analysis we found that the development of irAEs was a strong predictor of improved OS in mUC patients treated with ICI.

Active surveillance in metastatic renal-cell carcinoma: a prospective, phase 2 trial

BACKGROUND

A subset of patients with metastatic renal-cell carcinoma show indolent growth of metastases. Because of the toxicity and non-curative nature of systemic therapy, some of these patients could benefit from initial active surveillance. We aimed to characterise the time to initiation of systemic therapy in patients with metastatic renal-cell carcinoma under active surveillance.

METHODS

In this prospective phase 2 trial, we enrolled patients with treatment-naive, asymptomatic, metastatic renal-cell carcinoma from five hospitals in the USA, Spain, and the UK. Patients were radiographically assessed at baseline, every 3 months for year 1, every 4 months for year 2, then every 6 months thereafter. Patients continued on observation until initiation of systemic therapy for metastatic renal-cell carcinoma; a decision that was made at the discretion of the treating physician and patient. The primary endpoint of the study was time to initiation of systemic therapy in the per-protocol population. The follow-up of patients is ongoing.

FINDINGS

Between Aug 21, 2008, and June 7, 2013, we enrolled 52 patients. Median follow-up of patients in the study was 38·1 months (IQR 29·4-48·9). In the 48 patients included in analysis, median time on surveillance from registration on study until initiation of systemic therapy was 14·9 months (95% CI 10·6-25·0). Multivariate analysis showed that higher numbers of International Metastatic Database Consortium (IMDC) adverse risk factors (p=0·0403) and higher numbers of metastatic disease sites (p=0·0414) were associated with a shorter surveillance period. 22 (46%) patients died during the study period, all from metastatic renal-cell carcinoma.

INTERPRETATION

A subset of patients with metastatic renal-cell carcinoma can safely undergo surveillance before starting systemic therapy. Additional investigation is required to further define the benefits and risks of this approach.

FUNDING

None.

Pain measurement in the elderly: a review

Measurement of pain in the elderly is an issue that has received limited attention. The purpose of this review was to analyze and synthesize research findings from 1975 to 1999 that are related to pain measurement in the elderly. Based on best-evidence synthesis criteria, the review led to the selection of 15 studies. These studies used a descriptive and quantitative analytic approach and were not based on a theoretical framework. Comparison of selected pain measurement tools was incorporated in 40% of the included studies. Substantial gaps in knowledge were identified; namely, these included determining the reliability and validity of selected tools for the institutionalized or community-dwelling elder; modifying instruments to overcome barriers such as communication issues, cultural diversity, or cognitive dysfunction; and expanding the scope of pain measurement to other dimensions of the pain experience.

Studies of resistance to chloroquine, quinine, amodiaquine and mefloquine among Philippine strains of Plasmodium falciparum

One hundred cases of slide-confirmed Plasmodium falciparum malaria admitted to the San Lazaro Hospital, Manila, Philippines were screened for in vitro resistance to chloroquine, quinine, amodiaquine and mefloquine using the microtechnique. 59 of the 100 primary parasite isolates produced schizonts, whereas the remaining 41 isolates did not. 51 of the 59 isolates tested were resistant in vitro to chloroquine and eight were sensitive. In contrast, three of the primary isolates were resistant to quinine, three showed resistance to amodiaquine and four were mefloquine-resistant. 43 of the strains judged chloroquine-resistant in vitro were fully in vitro sensitive to amodiaquine, quinine and mefloquine. One chloroquine-resistant isolate was also resistant to quinine alone. Three isolates that were resistant to chloroquine were also resistant to amodiaquine. An additional three were cross-resistant to chloroquine and mefloquine. A single isolate was found to be resistant to chloroquine, quinine and mefloquine and another was cross-resistant to chloroquine, quinine and amodiaquine. All strains demonstrating in vitro resistance to amodiaquine, quinine or mefloquine also showed in vitro resistance to chloroquine. The parasites in 22 patients showed in vivo resistance to chloroquine therapy. 86% were of the R1 type, 9% were R2 and 5% R3. All 22 patients demonstrating in vivo resistance to chloroquine showed in vitro resistance.

Chloroquine resistant Plasmodium falciparum: effect of rabbit serum and incubation time on the in vitro (microtechnique) prediction of in vivo resistance

A study of chloroquine resistance of 54 isolates of Plasmodium falciparum is reported. Sixty-four percent of the isolates tested produced schizonts in vitro (micro-technique), whereas the remaining 36 percent did not. The accuracy of the in vitro test to predict in vivo resistance was increased when the primary parasite isolates were cultured in the presence of rabbit serum and when the cultures were allowed to incubate for more than 48 hours. Thirteen isolates of P. falciparum that showed in vitro resistance were confirmed in vivo resistant. Eleven of these cases were identified as R-I and two as R-II. Only one case of in vivo resistance (R-II) was observed among the 19 isolates that failed to produce schizonts in vitro.

Chloroquine and quinine resistant Plasmodium falciparum on the island of Mindoro, Philippines, 1982

A field study was conducted on the island of Mindoro, Republic of the Philippines in which over 800 persons were screened for malaria and approximately 8% were found positive. The in vitro microtechnique was used to test for sensitivity to chloroquine, amodiaquine, mefloquine and quinine in 20 slide-confirmed P. falciparum cases. Sixteen of these cases were also followed for in vivo chloroquine sensitivity. Four cases showed in vitro resistance to chloroquine; 2 also showed resistance to quinine. All showed in vitro sensitivity to mefloquine and amodiaquine. The results of in vivo test were consistent with either a sensitive (S) or R-1, resistant response to chloroquine. Taken together, the in vitro and in vivo chloroquine tests indicate 4 cases of chloroquine resistance at the R1 level.