Biomarkers of systemic inflammation predict survival with first-line immune checkpoint inhibitors in non-small-cell lung cancer

INTRODUCTION

Pembrolizumab is an established first-line option for patients with advanced non-small-cell lung cancer (NSCLC) expressing programmed death-ligand 1 ≥50%. Durable responses are seen in a subset of patients; however, many derive little clinical benefit. Biomarkers of the systemic inflammatory response predict survival in NSCLC. We evaluated their prognostic significance in patients receiving first-line pembrolizumab for advanced NSCLC.

METHODS

Patients treated with first-line pembrolizumab for advanced NSCLC with programmed death-ligand 1 expression ≥50% at two regional Scottish cancer centres were identified. Pretreatment inflammatory biomarkers (white cell count, neutrophil count, neutrophil/lymphocyte ratio, platelet/lymphocyte ratio, albumin, prognostic nutritional index) were recorded. The relationship between these and progression-free survival (PFS) and overall survival (OS) were examined.

RESULTS

Data were available for 219 patients. On multivariate analysis, albumin and neutrophil count were independently associated with PFS (P < 0.001, P = 0.002, respectively) and OS (both P < 0.001). A simple score combining these biomarkers was explored. The Scottish Inflammatory Prognostic Score (SIPS) assigned 1 point each for albumin <35 g/l and neutrophil count >7.5 × 10⁹/l to give a three-tier categorical score. SIPS predicted PFS [hazard ratio 2.06, 95% confidence interval (CI) 1.68-2.52 (P < 0.001)] and OS [hazard ratio 2.33, 95% CI 1.86-2.92 (P < 0.001)]. It stratified PFS from 2.5 (SIPS2), to 8.7 (SIPS1) to 17.9 months (SIPS0) (P < 0.001) and OS from 5.1 (SIPS2), to 12.4 (SIPS1) to 28.7 months (SIPS0) (P < 0.001). The relative risk of death before 6 months was 2.96 (95% CI 1.98-4.42) in patients with SIPS2 compared with those with SIPS0-1 (P < 0.001).

CONCLUSIONS

SIPS, a simple score combining albumin and neutrophil count, predicts survival in patients with NSCLC receiving first-line pembrolizumab. Unlike many proposed prognostic scores, SIPS uses only routinely collected pretreatment test results and provides a categorical score. It stratifies survival across clinically meaningful time periods that may assist clinicians and patients with treatment decisions. We advocate validation of the prognostic utility of SIPS in this and other immune checkpoint inhibitor treatment settings.

A biobank analysis of prognostic biomarkers of the systemic inflammatory response in patients presenting with malignancy of undefined primary origin

BACKGROUND

Survival prediction in patients presenting with malignancy of undefined primary origin (MUO) is challenging, with a lack of validated prognostic tools. Biomarkers of the systemic inflammatory response independently predict survival in other cancer types, but their role in MUO is unclear. The aim of this study was to assess biomarkers of the systemic inflammatory response in patients presenting with MUO.

PATIENTS AND METHODS

A biobank of 1049 patients presenting with MUO referred to a regional oncology service in Scotland was analysed. Key inflammatory biomarkers (white cell count, neutrophil count and C-reactive protein combined with albumin [to give the modified Glasgow Prognostic Score {mGPS}]) were examined. The relationship between these and survival was examined using Kaplan-Meier and Cox regression methods.

RESULTS

Data were available for 1049 patients. Median survival was 4.3 months (interquartile range: 1.7-16.0 months). On multivariate analysis mGPS was independently associated with survival and stratified survival from 13.6 months (mGPS: 0) to 2.3 months (mGPS: 2) (p < 0.001). The mGPS was predictive of survival on multivariate analysis in patients found to have a non-cancer diagnosis (p = 0.034), an identified primary cancer (0.002), cancer of unknown primary (CUP) (p = 0.011), those for whom biopsy was not done (MUO) (p = 0.036), those found to have an identified primary cancer (0.002) and even those found to have a non-cancer diagnosis (p = 0.034) after further detailed investigations. In patients with CUP mGPS predicted survival regardless of the recognised clinicopathological prognostic subgroup (p < 0.001).

CONCLUSIONS

The results of the present study demonstrate that biomarkers of the systemic inflammatory response are reliable prognostic factors in patients presenting with MUO. These simple, objective, routine clinical tests may inform clinical management.

Pain management in patients with malignant mesothelioma: challenges and solutions

Malignant pleural mesothelioma (MPM) is an aggressive cancer with a considerable symptom burden and poor prognosis. Focus on maintaining patients’ quality of life and pain control is therefore paramount. Pain management in MPM is complex due to its multifactorial etiology resulting from direct tumor infiltration of the surrounding soft tissue, bone, and encasement of the intercostal nerves. A variety of treatment modalities, including pharmacological and non-pharmacological options, are often required to achieve adequate pain control in this challenging disease. This review article examines the current challenges and solutions available for pain management in MPM.

SYSTEMS-2: A randomised phase II study of radiotherapy dose escalation for pain control in malignant pleural mesothelioma

SYSTEMS-2 is a randomised study of radiotherapy dose escalation for pain control in 112 patients with malignant pleural mesothelioma (MPM). Standard palliative (20 Gy/5#) or dose escalated treatment (36 Gy/6#) will be delivered using advanced radiotherapy techniques and pain responses will be compared at week 5. Data will guide optimal palliative radiotherapy in MPM.

Characteristics of the case mix, organisation and delivery in cancer palliative care: a challenge for good-quality research

OBJECTIVES

Palliative care (PC) services and patients differ across countries. Data on PC delivery paired with medical and self-reported data are seldom reported. Aims were to describe (1) PC organisation and services in participating centres and (2) characteristics of patients in PC programmes.

METHODS

This was an international prospective multicentre study with a single web-based survey on PC organisation, services and academics and patients' self-reported symptoms collected at baseline and monthly thereafter, with concurrent registrations of medical data by healthcare providers. Participants were patients ≥18 enrolled in a PC programme.

RESULTS

30 centres in 12 countries participated; 24 hospitals, 4 hospices, 1 nursing home, 1 home-care service. 22 centres (73%) had PC in-house teams and inpatient and outpatient services. 20 centres (67%) had integral chemotherapy/radiotherapy services, and most (28/30) had access to general medical or oncology inpatient units. Physicians or nurses were present 24 hours/7 days in 50% and 60% of centres, respectively. 50 centres (50%) had professorships, and 12 centres (40%) had full-time/part-time research staff. Data were available on 1698 patients: 50% females; median age 66 (range 21-97); median Karnofsky score 70 (10-100); 1409 patients (83%) had metastatic/disseminated disease; tiredness and pain in the past 24 hours were most prominent. During follow-up, 1060 patients (62%) died; 450 (44%) <3 months from inclusion and 701 (68%) within 6 months. ANOVA and χ² tests showed that hospice/nursing home patients were significantly older, had poorer performance status and had shorter survival compared with hospital-patients (p<.0.001).

CONCLUSIONS

There is a wide variation in PC services and patients across Europe. Detailed characterisation is the first step in improving PC services and research.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Identifier: NCT01362816.

Epidermal growth factor receptor-inhibition (EGFR-I) in the treatment of neuropathic pain

BACKGROUND

Neurobiological work has demonstrated that expression of mitogen-activated protein kinases (MAPK) is upregulated on neurones and glial cells after nerve damage. Furthermore, the epidermal growth factor receptor (EGFR) has been identified as having a key role in this process and subsequent interruption of this using EGFR-Inhibitors (EGFR-I), may improve neuropathic pain. The aim of this report was to explore if EGFR-I attenuated neuropathic pain in humans.

METHODS

A selection of patients with neuropathic pain were treated off-label with one of four EGFR-Is, approved for the treatment of cancer. All patients had chronic and severe neuropathic pain (as defined by diagnostic criteria). Pain intensity, interference with function, and adverse events were prospectively registered.

RESULTS

Twenty patients were treated. Eighteen patients experienced clinically significant pain relief after treatment with EGFR-I. Median observed pain reduction for all patients was 8.5 (IQR=5-9.5) points on a 0-10 numeric rating scale. Neuropathic pain spike duration and frequency also improved. Pain relief was most often achieved within 24 h and was more rapid in cases of i.v. than oral administration. All four EGFR-I that were tested were of equal efficacy. The duration of pain relief was consistent with the individual drugs' half-lives. No cases of drug-tolerance were observed. Side-effects were predominantly skin reactions. One grade 3 adverse event was registered. Median follow-up for responders was 7 months (Range 1-37).

CONCLUSIONS

EGFR-I improves neuropathic pain and this is in keeping with basic science work. Controlled clinical trials are now eagerly awaited to assess this further.

Does chemotherapy improve health-related quality of life in advanced pancreatic cancer? A systematic review

Chemotherapy is increasingly being used in advanced pancreatic cancer, but side-effects are common. The aim of this systematic review was to assess whether chemotherapy improves health-related quality of life (HRQoL), pain or cachexia. Thirty studies were reviewed. Four of 23 studies evaluating HRQoL, 7 of 24 studies evaluating pain and 0 of 8 studies evaluating cachexia found differences between treatment arms. Change in HRQoL from baseline was evaluated in 14 studies: five studies reported an improvement in at least one treatment arm; three a worsening and the remaining stable scores. Change in pain intensity from baseline was evaluated in eight studies, and improvement was observed in seven. Of the four studies reporting improved survival, three reported improved HRQoL or pain. In conclusion, chemotherapy can stabilize HRQoL and improve pain control. Effects on cachexia are hard to elucidate. Improved survival does not come at the expense of HRQoL or pain control.

Radiotherapy for the treatment of pain in malignant pleural mesothelioma: a systematic review

Radiotherapy is commonly used to treat pain in malignant pleural mesothelioma (MPM). The purpose of this systematic review is to examine the evidence for this practice. Medline (1946-2013), Embase (1974-2013) and Central (The Cochrane Library Issue 9, 2012) databases were searched. Eligible studies met the following criteria: MPM (histological or radiological diagnosis), radiotherapy given with the intent of improving pain, response rates to radiotherapy reported, dose and fractionation reported and the relationship between radiotherapy and pain response explored. All studies had independent review and were graded according to evidence level. Eight studies met the eligibility criteria. Two studies were prospective single arm phase II studies while the remainder were retrospective case series. All were graded as either Level 2 or Level 3 evidence. Due to marked heterogeneity among studies, quantitative synthesis of results was not possible. No high quality evidence currently exists to support radiotherapy in treating pain in MPM. Studies focusing on clear pain endpoints and improving target delineation are needed. Such studies should also use modern radiotherapy techniques and concentrate on dose escalation.

Assessing salivary cortisol in studies of child development

In a series of studies, we evaluated the susceptibility of radioimmunoassays (RIA) for saliva cortisol to interference effects caused by oral stimulants used to facilitate saliva collection in studies with children. When added directly to saliva samples, oral stimulants (drink mix crystals) artificially inflated estimated cortisol concentrations. The magnitude of the interference effect was concentration-dependent and more pronounced for some stimulants and RIA procedures than for others. Analysis of samples collected using oral stimulants from child and adult participants confirmed stimulant interference as an extraneous source of variability in measured saliva cortisol. Associations between serum and saliva cortisol and between saliva cortisol and "behavioral" variables were attenuated by stimulant interference. A survey of six large child studies estimated interference effects, indexed by low sample pH, to be present in 14.7% of the 1,148 total saliva samples, or 2%-54% (M = 22%) of samples within each study. Recommendations to minimize the impact of stimulant interference in studies involving salivary cortisol in the context of child health and development are outlined.

Daycare tonsillectomy and/or adenoidectomy at the British Columbia Children's Hospital

The fact that tonsillectomy (T), or tonsillectomy with adenoidectomy (T & A) or adenoidectomy (A) can be performed safely in selected children on a daycare or outpatient basis is well proven. This article illustrates the approach that the British Columbia Children's Hospital (B.C.C.H.) took to confirm that the procedures were safe locally. A pilot project was started in June of 1984 to perform daycare adenoidectomies only, using two full-time pediatric otolaryngologists. When this proved successful, other otolaryngologists were encouraged to use the program. In June of 1988, a second pilot project was started for daycare tonsillectomies (or tonsillectomy and adenoidectomy). Criteria were established for patient selection, preparation, anesthesia, post-anesthetic recovery (PAR), Daycare Unit (DCU) nursing, and discharge. Follow-up information was obtained. Daycare tonsillectomy with or without adenoidectomy and daycare adenoidectomy are now routine procedures at B.C.C.H.