Assessment of Doxorubicin and Pembrolizumab in Patients With Advanced Anthracycline-Naive Sarcoma: A Phase 1/2 Nonrandomized Clinical Trial

Question

Is the combination of doxorubicin and pembrolizumab an effective and feasible regimen for patients with advanced sarcoma?

Findings

In this nonrandomized phase 1/2 clinical trial of 37 patients with advanced sarcoma, the combination of doxorubicin and pembrolizumab was well tolerated. The objective response rate was 13% for phase 2 patients and 19% overall, with median progression-free survival of 8.1 months and median overall survival of 27.6 months.

Meaning

Doxorubicin in combination with pembrolizumab is a promising combination worthy of further study, especially in certain sarcoma subtypes, including undifferentiated pleomorphic sarcoma and dedifferentiated liposarcoma.

Importance

Anthracycline-based therapy is standard first-line treatment for most patients with advanced and metastatic sarcomas. Although multiple trials have attempted to show improved outcomes in patients with soft-tissue sarcoma over doxorubicin monotherapy, each has fallen short of demonstrating improved outcomes.

Objective

To evaluate the safety and efficacy of doxorubicin in combination with pembrolizumab in patients with advanced, anthracycline-naive sarcomas.

Design, Setting, and Participants

This nonrandomized clinical trial used a 2-stage phase 2 design and was performed at a single, academic sarcoma specialty center. Patients were adults with good performance status and end-organ function. Patients with all sarcoma subtypes were allowed to enroll with the exception of osteosarcoma, Ewing sarcoma, and alveolar and embryonal rhabdomyosarcoma.

Interventions

Two dose levels of doxorubicin (45 and 75 mg/m²) were tested for safety in combination with pembrolizumab.

Main Outcomes and Measures

Objective response rate (ORR) was the primary end point. Overall survival (OS) and progression-free survival (PFS) were secondary end points. Correlative studies included immunohistochemistry, gene expression, and serum cytokines.

Results

A total of 37 patients (22 men; 15 women) were treated in the combined phase 1/2 trial. The median (range) patient age was 58.4 (25-80) years. The most common histologic subtype was leiomyosarcoma (11 patients). Doxorubicin plus pembrolizumab was well tolerated without significant unexpected toxic effects. The ORR was 13% for phase 2 patients and 19% overall. Median PFS was 8.1 (95% CI, 7.6-10.8) months. Median OS was 27.6 (95% CI, 18.7-not reached) months at the time of this analysis. Two of 3 patients with undifferentiated pleomorphic sarcoma and 2 of 4 patients with dedifferentiated liposarcoma had durable partial responses. Tumor-infiltrating lymphocytes were present in 21% of evaluable tumors and associated with inferior PFS (log-rank P = .03). No dose-limiting toxic effects were observed.

Conclusions and Relevance

In this nonrandomized clinical trial, doxorubicin plus pembrolizumab was well tolerated. Although the primary end point for ORR was not reached, the PFS and OS observed compared favorably with prior published studies. Further studies are warranted, especially those focusing on undifferentiated pleomorphic sarcoma and dedifferentiated liposarcoma.

Trial Registration

ClinicalTrials.gov Identifier: NCT02888665

A phase I/II study of pembrolizumab (Pem) and doxorubicin (Dox) in treating patients with metastatic/unresectable sarcoma

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Background: Patients with advanced soft tissue sarcomas (STS) treated with single agent Dox have a median progression-free survival (PFS) of 4.6 months (mo) and response rate (RR) of 14%. Dox sensitizes tumors to Pem through calreticulin release and killing of immunosuppressive cells. Thus we hypothesize that combining Dox + Pem will improve patient outcomes. Methods: A phase I/II trial (NCT02888665) evaluating Dox+Pem was designed for Dox naïve STS and select bone sarcomas with a 1° endpoints of safety (CTCAE v4.03) and response rate (RR) by RECIST 1.1. Patients received one “priming” dose of Pem (200mg IV) prior to starting Dox+Pem Q3wks. Dox+Pem was continued for up to 6 cycles, followed by Pem monotherapy for up to 2 years or progression. The phase I portion used a 3+3 design with 2 Dox doses (45 & 75 mg/m2), followed by a Simon 2-stage expansion. A retrospective study of patients treated at our center on non-ifosfamide containing Dox trials (DoxT) was performed in order to compare our observed PFS with a comparable historic population. Results: Treatment was well tolerated; detailed safety data will be presented. No additional cardiac risk was observed. No DLTs were observed during phase I and 75mg/m2 was selected as the phase 2 Dox dose. The study met criteria for expansion to the 2nd stage. Though the planned enrollment was 41, the study closed after 37 as it was clear that the RR (22% , including phase I patients) would not meet the phase 2 RR target of 29%. However, 59% of patients had stable disease (disease control rate = 81%) with tumor regression in a majority of patients. The median PFS on Dox + Pem was 8.1 mo (95% CI: 6.3, 10.8). Patients treated with Dox + Pem had a significantly longer median PFS compared to the DoxT cohort (4.1 mo, 95%CI 3.0 – 6.6, p < 0.001). Conclusions: Dox+Pem is well-tolerated. While this study failed to meet its 1° RR endpoint, a highly significant improvement in PFS was observed compared with historical controls. This is consistent with findings in other cancers, such as head & neck, where improved clinical outcomes were observed without significant increase in RR by RECIST. A randomized trial of Dox +/- Pem should be carefully considered in light of recent negative trials in STS. Clinical trial information: NCT02888665.

Prevalence of symptom clusters among sarcoma patients in active treatment

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Background: Cancer patients (pt) frequently experience symptoms from cancer or its treatment. Two or three co-occurring, uncontrolled symptoms (symptom clusters, SC), can worsen cancer pt morbidity and mortality. Although SC have been characterized in other cancer pts, little research has been conducted in sarcoma pts. Methods: SC were studied via retrospective chart review of adult sarcoma pts receiving treatment between 09/2018-01/2019 in a dedicated sarcoma clinic. Pts completed a 33-item, modified Patient Reported Outcomes-Common Terminology Criteria for Adverse Events (mPRO-CTCAE)-based review of systems (hereafter “form”) for ongoing clinical care with presence of individual symptoms defined as ≥“occasionally.” Demographic, disease and treatment specific data was collected; descriptive data (%’s) are presented. Results: Pts (n = 153 completing 321 forms) were median 57 years (range 20-81), 48% male, 68% white, with lower extremity (29%) or abdomen (46%) sarcoma with 67% receiving IV chemo (33% oral chemo), with the majority at full dose (77%). Most had leiomyosarcoma 18%, liposarcoma 14%, GIST 12%, or NOS 24% with 59% metastatic disease. Five SC triads occurring in > 25% of pts who fully completed one form were identified (see Table). Eighty-one pts completed 2 or more forms (mean 26.7 days from first to second form [std dev 17.7, range 2-77]) with 50-67% of evaluable pts having ongoing SC triads. Conclusions: Symptom clusters are common among sarcoma patients on active treatment. Future research should address optimal management of these clusters. Additional data, including severity/interference of symptoms, longitudinal changes and predictors of SC, will be presented.[Table: see text]

Monitoring and enforcing cultural competence in Medicaid managed behavioral health care

In recent years cultural competence has expanded beyond language provisions to include understanding and factoring into services provision the cultural perspectives clients may have that are different from the majority culture. The federal government requires state Medicaid programs to offer culturally competent services, but little is known about how states implement such mandates and monitor and enforce them. We reviewed the origins and implications of cultural competence mandates and conducted a brief case study of 5 states to learn about the implementation of cultural competence provisions in behavioral managed care contracts. We found that states and managed behavioral health organizations (MBHOs) vary in their definitions and implementation of standards to ensure mental health care access for vulnerable populations. Although states had a variety of oversight mechanisms, varying contractual requirements ranging from optional to required, vague contract language, no existing standardized indicators or definitions, and scant data on the cultural characteristics of the populations enrolled in Medicaid managed care hamper monitoring and enforcement of cultural competence by states. Implications for MBHOs, states, and the federal government, as well as services researchers, follow.

EPSDT in the Commonwealth of Pennsylvania, 1967-1991: a case study of a federally-sponsored, state-administered program

Understanding the state-level processes that can shape the operations of health and welfare programs is of particular importance today. This article describes the process by which the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program was implemented in the Commonwealth of Pennsylvania. The case study highlights the factors that facilitated and hindered the transformation of this federal policy into a local program. Implications for children's health programming are identified.

Immunization among African American children: implications for social work

Although childhood immunizations have proved to be one of the most effective means of preventing and controlling the spread of infectious and communicable diseases, thousands of preschool children, particularly children from urban African American poor families, are not being immunized. This article discusses the critical problem of low rates of immunization for this population and identifies ways social workers can play an active role in ensuring that more children are immunized. Immunization of preschool children is a function of the interrelationship among health-seeking behavior of parents, financial and nonfinancial barriers to health care, and provider practices that inhibit appropriate immunization. Improving access to existing public programs, facilitating community organization efforts, assisting communities through self-help and mutual-aid initiatives, and supporting national efforts can improve immunization status among poor children.

A programmatic approach to improving the health of poor children

There is a consensus among policy makers, physicians, child health advocates, and the general public on the need for federal action to improve the health care delivery system for poor children. What should be done, how it will be done, and who will be responsible remains a controversy. This article addresses the problems and potential of the Early and Periodic Screening Diagnosis and Treatment (EPSDT) Program within the context of Medicaid, and proposes a programmatic strategy to make EPSDT more effective.