Effect of immunotherapy-infusion time of day on survival of patients with advanced cancers: a study-level meta-analysis

BACKGROUND

Immune checkpoint inhibitors (ICIs) have become the standard of care for numerous malignancies. Emerging evidence suggests that the time of day (ToD) of ICI administration could impact the outcomes of patients with cancer. The consistency of ToD effects on ICI efficacy awaits initial evaluation.

MATERIALS AND METHODS

This meta-analysis integrates progression-free survival (PFS) and overall survival (OS) data from studies with a defined 'cut-off' ToD. Hazard ratios (HRs) [95% confidence interval (CI)] of an earlier progression or death according to 'early' or 'late' ToD of ICIs were collected from each report and pooled.

RESULTS

Thirteen studies involved 1663 patients (Eastern Cooperative Oncology Group performance status 0-1, 83%; males/females, 67%/33%) with non-small-cell lung cancer (47%), renal cell carcinoma (24%), melanoma (20%), urothelial cancer (5%), or esophageal carcinoma (4%). Most patients received anti-programmed cell death protein 1 or anti-programmed death-ligand 1 (98%), and a small proportion also received anti-cytotoxic T-lymphocyte-associated protein 4 (anti-CTLA-4) (18%). ToD cut-offs were 13:00 or 14:00 (i.e. ICI median infusion time), for six studies, and 16:00 or 16:30 (i.e. reported threshold for weaker vaccination responses) for seven studies. Pooled analyses revealed that the early ToD groups had longer OS (HR 0.50, 95% CI 0.42-0.58; P < 0.00001) and PFS (HR 0.51, 95% CI 0.42-0.61; P < 0.00001) compared with the late ToD groups.

CONCLUSIONS

Patients with selected metastatic cancers seemed to largely benefit from early ToD ICI infusions, which is consistent with circadian mechanisms in immune-cell functions and trafficking. Prospective randomized trials are needed to establish recommendations for optimal circadian timing of ICI-based cancer therapies.

Sex moderates circadian chemotherapy effects on survival of patients with metastatic colorectal cancer: a meta-analysis

BACKGROUND

Molecular circadian clocks can modify cancer chemotherapy effects, with a possible moderation according to sex differences. We investigated whether sex determine the optimal delivery schedule of chemotherapy for metastatic colorectal cancer.

PATIENTS AND METHODS

A meta-analysis was performed using individual data from three international Phase III trials comparing 5-fluorouracil, leucovorin and oxaliplatin administered in chronomodulated (chronoFLO) or conventional (CONV) infusions. The data from 345 females and 497 males were updated at 9 years. The main end point was survival.

RESULTS

Overall survival was improved in males on chronoFLO when compared with CONV (P = 0.009), with respective median values of 20.8 (95% CL, 18.7 to 22.9) and 17.5 months (16.1 to 18.8). Conversely, median survival was 16.6 months (13.9 to 19.3) on chronoFLO and 18.4 months (16.6 to 20.2) on CONV in females (P = 0.012). The sex versus schedule interaction was a strong predictive factor of optimal treatment schedule, with a hazard ratio of 1.59 (1.30 to 1.75) for overall survival (P = 0.002) in multivariate analysis.

CONCLUSIONS

Males lived significantly longer on chronomodulated chemotherapy rather than on conventional chemotherapy. The current chronoFLO schedule deserves prospective assessment as a safe and more effective first-line treatment option than conventional delivery for male patients.

Relevance of sex and PER2 SNPs for predicting irinotecan tolerability in cancer patients

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Background: Advances in understanding the mechanisms underlying diseases and drug responses are creating increasing opportunities to offer safer and more effective treatments to individual patients (pts). Biomarkers are needed for predicting likelihood of therapeutic safety and efficacy in each individual pt. Down-regulation of core clock gene PER2 in tumors predicted for poor survival in pts with metastatic colorectal cancer (Jacobelli. J Clin Oncol. 26: 2008 May 20 suppl; abstr 11032).

Methods: A clinical data base and tissue bank involving primary tumor (T) and healthy adjacent colon mucosa (C) from 139 pts treated with circadian-shaped or standard infusion of (A)-single-agent irinotecan (63 pts) or (B) in combination with oxaliplatin and 5FU (76 pts) for previously-treated metastatic colorectal cancer was established and tissues were collected. Clinical relevance of constitutive or acquired single nucleotide polymorphisms (SNPs) for 5 metabolism (ABCB1, ABCB2, CES2, TOP1, UGT1A1) and for two PER2 SNP's (A4572G and C3968T).

Results: No acquired mutation in the genes analysed was found (100% T and C concordance). The incidence of grade 3-4 toxic event of any kind was significantly lower in women as compared to men in A population(39% vs 76%, p=0.007) and in A+B population (p=0.05), independently from other factors (p=0.02) this difference is lost if you consider only B population where oxaliplatin is added (p=0.5). No SNP in metabolism genes predicted for toxicity in this cohort. Conversely, SNPs in core clock gene PER2 (1 pt with A4572G and 4 pts C3968T) were significantly associated with higher incidence of G3-4 toxicity (100% in polymorphic pts. vs 17.2% in wild type pts, p=0.01).

Conclusions: Irinotecan tolerability is sex dependent and woman has significative low incidence of toxic effects. We demonstrated for the first time an association between constitutive SNPs in a core clock gene and toxicity, further supporting the relevance of the circadian timing system in chemotherapy tolerability. Moreover, our findings are in good agreement with data in mice, supporting the hypothesis that sex determines two chronotoxicity classes in patients with metastatic colorectal cancer.

No significant financial relationships to disclose.

Chemotherapy-induced neutropenia association with survival in metastatic colorectal cancer (MCC): Schedule dependency

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Background: Circadian clocks control cellular proliferation and drug metabolism over 24 h. However, circadian chronomodulated chemotherapy with 5-fluorouracil, leucovorin and oxaliplatin (chronoFLO4) offered no survival benefit as compared to the non-time stipulated FOLFOX2 in an international randomized trial involving patients (pts) with previously untreated MCC (EORTC05963). We hypothesized that treatment near maximum tolerated dose could disrupt circadian clocks thus impairing the efficacy of chronoFLO4 but not of FOLFOX2.

Methods: Pts with available data (N=556) were categorized into three subgroups according to the worst grade of neutropenia experienced during treatment. Distinct multivariate models were constructed for each treatment schedule.

Results: Neutropenia (all grades) occurred in 39% of the pts on chronoFLO4 as compared to 67% of those on FOLFOX2 (p< 0.0001), with G3-4 being encountered in 7% and 25%, respectively (p< 0.0001). In both schedules, neutropenia was more frequent and more severe in women than in men (p<0.04).The occurrence (but not the severity) of neutropenia was significantly associated with improved objective response rate, progression-free and overall survival in pts on FOLFOX2 (p< 0.0001), confirming previous results by others. In pts on chronoFLO4, the occurrence of neutropenia was not associated with any efficacy advantage (p=0.36), and worst survival was observed in pts developing severe neutropenia.

Conclusions: Neutropenia was more frequent and severe in women than in men, and on FOLFOX2 than on chronoFLO4. Neutropenia was positively correlated with survival in pts on FOLFOX2 supporting intra-patient dose escalation to achieve toxicity for conventional chemotherapy. No survival prolongation was found in pts with neutropenia on chronoFLO4. Thus, reaching maximum tolerated dose was unnecessary to achieve optimal effectiveness of circadian-timed therapy, and should even be avoided.

[Table: see text]

No significant financial relationships to disclose.

Altered circadian rhythm in rest and activity (CircAct): Independent prognostic value for survival in patients (pts) with metastatic colorectal cancer (MCC)

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Background: Altered CircAct accelerated tumor growth in experimental models (JNCI 2002, 2005; Cancer Res 2004). CircAct was found to be related to survival in two studies (St) in MCC pts (St 1, Clin Cancer Res 2000; St 2, ASCO 2005 #3553). The current study attempted to provide an independent prognostic stratification criteria for survival according to baseline CircAct as a first step toward the development of a comprehensive prognostic model based on circadian physiology. Methods: CircAct was continuously and non- invasively assessed over 72h with a wrist accelerometer (Ambulatory Monitoring, USA), before chemotherapy in two independent datasets of 169 MCC pts (60% pretreated) at Paul Brousse Hospital (St 1) and 130 chemo-naïve MCC pts registered in the international EORTC 05963 trial (St 2). Activity distribution during rest and wakefulness was objectively quantified by I<O (50=no rhythm; 100=marked rhythm). Kaplan-Meier survival curves with logrank tests and Cox regression models were used for analyses. Results: In both St, pts with I<O = 92 (21% in St 1 and 22% in St 2) displayed a significantly poorer survival as compared to those pts with I<O > 92 (Table). The hazard ratios (HR) were 0.37 [95%CI: 0.25 to 0.55] (p<0.0001) in St 1 and 0.56 [0.36 to 0.87] (p=0.01) in St 2. The prognostic value of altered CircAct persisted after adjusting for PS (HR=0.46 [0.30 to 0.69], p=0.0002 in St 1; HR=0.61 [0.38 to 0.97], p=0.04 in St 2). Conclusions: The independent stratification of MCC pts for survival according to baseline altered CircAct occurred using a threshold value of 92 for I<O in both separate datasets. Subsequent studies will involve additional biomarkers of circadian physiology (cortisol, melatonin, clock genes) in order to further improve this prognostic stratification as a step toward tailored treatment of MCC pts.

[Table: see text]

No significant financial relationships to disclose.

Expression of neurotrophins and their receptors in pigment cell lesions of the skin

The neurotrophins (NTs) are a group of growth factors involved in the development of the nervous system and presumed to play a role in neural crest-derived tumours. The expression of three NTs (NGF, BDNF, and NT-3) and their receptors (NTRs; i.e. low-affinity pan-NT receptor p75, Trk-B, and Trk-C) was studied in frozen sections of benign and malignant cutaneous pigment cell lesions, using immunohistochemistry. In order to understand the possible role of these growth factors and their receptors in the progression of primary cutaneous malignant melanomas (PCMMs), their distribution in the radial (RGP) and vertical (VGP) growth phases was particularly studied. While most of the common acquired naevi were unreactive, Spitz and blue naevi showed scattered immunoreactive cells, especially for the p75 NTR. Dysplastic naevi, but not common naevi, expressed NT-3 in their junctional component. PCMM and melanoma metastases often showed a diffuse pattern of immunostaining. NT-3 was significantly more frequently expressed in the RGP of PCMMs than in the junctional component of benign naevi, whereas more extensive immunoreactivity for NGF was found in the VGP of PCMMs, compared with the RGP; metastases more frequently expressed NGF, BDNF, and Trk-B than PCMMs. Interestingly, neurotropic melanoma expressed all NTs/NTRs except Trk-B. These immuunohistochemical data confirm suggestions from previous in vitro studies that autocrine loops of certain NTs and their respective receptors may be involved in melanoma progression; in addition, NT-3 may be involved in the junctional growth of dysplastic naevi. The precise role of these growth factors in melanoma, however, will await further functional studies.