Impact of Race on Outcomes of Advanced Stage Non-Small Cell Lung Cancer Patients Receiving Immunotherapy

BACKGROUND

The impact of race in advanced stage non-small cell lung cancer (NSCLC) patients treated with immune checkpoint inhibitors (ICIs) is conflicting. Our study sought to examine racial disparities in time to treatment initiation (TTI), overall survival (OS), and progression-free survival (PFS) using a population that was almost equally black and white.

METHODS

This was a retrospective cohort study of stage IV NSCLC patients > 18 years receiving immunotherapy at our center between 2014 and 2021. Kaplan-Meier curves and the multivariate Cox proportional hazards model determined the predictors of OS and PFS. Analyses were undertaken using IBM PSAW (SPSS v.28).

RESULTS

Out of 194 patients who met the inclusion criteria, 42.3% were black (n = 82). In the multivariate analysis, there was no difference in PFS (HR: 0.96; 95% CI: 0.66,1.40; p = 0.846) or OS (HR: 0.99; 95% CI: 0.66, 1.48; p = 0.966). No difference in treatment selection was observed between white and black patients (p = 0.363), nor was there a difference observed in median time to overall treatment initiation (p = 0.201).

CONCLUSIONS

No difference was observed in OS and PFS in black and white patients. Black patients' reception of timelier immunotherapy was an unanticipated finding. Future studies are necessary to better understand how race impacts patient outcomes.

Peripheral blood t cell responses to immunotherapy related adverse events in metastatic non-small cell lung cancer

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Background: There has been prospective and retrospective evidence for the onset of immunotherapy (IO) related adverse events (irAE) and efficacy of anti programmed death (PD1) and Programmed death Ligand 1(PD L1) antibodies. The incidence of irAE in these studies ranged anywhere from 30-44%. There have been attempts in the past to cluster irAEs into distinct subtypes by T cell profiling before and after immunotherapy. Identifying the trend of CD4/CD8 changes during irAE may aid in finding ways to mitigate the severe toxicities, so the benefits of immunotherapy can be extended to far more number of patients. Methods: We have collected blood samples from 20 patients of Non Small Cell Lung Cancer patients (NSCLC) before each cycle of immunotherapy with informed consent. We have measured the different inflammatory markers such as IL6, IL10 using ELISA and isolated cellular components such as CD4, CD8 T cells along with others using magnetic bead technique, from these samples in our research laboratory at East Carolina University. We have also collected clinical information including the adverse events with their (Common Terminology Criteria for Adverse events) CTCAE 5.0 grading, different cell counts and C- reactive Protein (CRP). Results: In the cohort of 20 patients, 9 experienced irAE, out of which 6 had grade 2, including thyroiditis, pneumonitis, dermatitis, cytokine release syndrome (CRS), 1 had grade 3 pneumonitis, 1 had grade 4 pneumonitis and 1 had grade 1 CRS. When we looked at the CD4/CD8 ratio before each cycle, the one prior to the incidence of the irAE had at least 30-40% drop in the ratio consistently although there were minor fluctuations in the ratio at other times in both directions. Conclusions: Although most irAEs can be treated and reversed with steroids and other immunosuppressive agents, prolonged immunosuppression can lead to reduced efficacy of IO and development of undue opportunistic infections. Experience with IO has shown that earlier initiation of immunosuppression shortens the required treatment. However, given the challenge in the subtility of the earlier presentation, therapies are frequently delayed. Hence, biomarker to identify the early manifestations is of critical importance for early intervention. Studies suggest there is clonal expansion of CD8 T cells preceding grade 2-3 irAEs. Studies also indicate that increased T cells in the tumor is indicative of response to immunotherapy. Our observation suggests that increased CD8 in proportion to CD4 in the peripheral blood precedes the onset of irAE. It is unclear as to how this leads to increased toxicity when the immunotherapy treatment works by affecting T cell function. One possible explanation is that the T cell response in the tumor tissue is beneficial, however, T cell response in the peripheral blood may indicate response against self antigens leading to toxicities in the form of irAE.

Correlation of clinical outcomes with programmed death ligand-1 expression on liquid biopsy

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Background: Programmed death ligand-1 (PD-L1) expression is predictive of immunotherapy benefit. However, tissue PD-L1 protein immunohistochemical testing can be fraught with tissue acquisition and heterogeneity limitations. PD-L1 expression by RNA sequencing can be performed by both tissue and plasma with tissue PD-L1 protein correlations. What has not been well characterized is the correlation of plasma cell free circulating tumor RNA (cfRNA) PD-L1 and clinical outcomes with immunotherapy. Plasma cfRNA PD-L1 expression was evaluated and correlated with immunotherapy benefit in advanced non-small cell lung cancers (NSCLC). Methods: Patients with advanced NSCLC undergoing plasma next-generation sequencing including plasma cfRNA.PD-L1 testing in a Clinical Laboratory Improvement Amendments (CLIA) and College of American pathologists (CAP) accredited laboratory were retrospectively identified and evaluated at a single institution. Plasma PD-L1 positive patients underwent a de-identified chart abstraction to identify those patients with advanced NSCLC treated with front line immunotherapy regimens and those who received cytotoxic chemotherapy alone. Results: Sixteen patients with plasma PD-L1 expression treated with front-line immunotherapy regimens including single-agent immune checkpoint inhibitors, and combinatorial chemo-immune or chemo-immune-bevacizumab regimens were assessed for overall survival (OS). Eleven patients with plasma PD-L1 expression who received chemotherapy were used as a non-immunotherapy OS comparison. Median OS for the immunotherapy treated patients was thirteen months with a thirty percent three year landmark OS versus four months median OS and a ten percent three-year landmark OS for those treated with chemotherapy alone. Comparative log-rank test p-value 0.0091 and a hazard ratio of 0.36 (95%-CI 0.13-0.99). Conclusions: Plasma cfRNA PD-L1 expression is predictive of a statistically significant survival benefit from immunotherapy treatment compared to chemotherapy in the first line treatment of advanced NSCLC. The three year landmark OS of thirty percent parallels tissue PD-L1 directed immunotherapy-based treatment outcomes. The clinical utility of plasma cfRNA PD-L1 to overcome tissue acquisition and PD-L1 protein heterogeneity limitations and to study the dynamic nature of PD-L1 expression with non-immune cancer treatments and potential immunotherapy response monitoring are undergoing ongoing research.

Plasma cell free PD-L1 RNA expression correlated with tissue PD-L1 immunohistochemical staining and tumor mutation burden in non-small cell lung cancer

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Background: Programmed death ligand-1 (PD-L1) protein expression by immunohistochemical staining (IHC) correlates with response to immune checkpoint inhibitor (ICI) therapies in non-small cell lung cancer (NSCLC). Tumor mutational burden (TMB) is another immune biomarker of ICI response in NSCLC. Clinical studies indicate tissue PD-L1 protein expression and TMB are independent yet complementary. Both are limited by tissue acquisition and potential heterogeneity. Plasma cell free PD-L1 RNA (cfRNA) levels and tissue protein PD-L1 expression and TMB was analyzed and correlated in patients with advanced NSCLC. Methods: Patients with advanced NSCLC underwent complementary plasma and tissue next generation sequencing (NGS) with immune biomarkers prior to treatment. Plasma PD-L1 cfRNA was assessed by the Circulogene proprietary direct-on-specimen enrichment technology NGS platform. Correlating tissue testing was performed by the Caris Molecular Intelligence platform with the anti-PD-L1 22C3 IHC antibody and TMB measuring the total number of non-synonymous somatic mutations per megabase. Results: 107 patients with advanced NSCLC were evaluated with simultaneous plasma and tissue NGS testing. 17% (95% confidence interval [CI] 10-24%) patients plasma PD-L1 positive. 48.5% (CI 38-57%) tissue IHC PD-L1 positive. 7 of 18 plasma PD-L1 positive patients were tissue PD-L1 negative. 48% (CI 39-58%) total patients TMB ≥ 10 mutations per megabase (TMB high). Correlating TMB high in 72% (CI 50-94%) of plasma PD-L1 positive and 56% (CI 42-69%) of tissue PD-L1 positive patients. TMB high in 49% (CI 37-59%) plasma PD-L1 negative and 50% (CI 35-65%) tissue PD-L1 negative patients. Conclusions: Although less frequent than tissue PD-L1 protein expression, plasma PD-L1 cfRNA expression correlated with a higher association of tissue TMB high findings than tissue PD-L1 positive patients. There was not any TMB high difference between plasma PD-L1 negative and tissue PD-L1 negative patients. Over one-third of plasma PD-L1 positive patients were tissue PD-L1 negative. Clinical correlation with immune checkpoint inhibitor therapies is ongoing.

The real-world incidence of immunotherapy-related thyroid dysfunction: A retrospective analysis of a single center's experience over five years

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Background: Immunotherapy related thyroid abnormalities are well described. Any grade abnormality has been reported in 6-18% of patients. The clinical relevance of thyroid abnormalities in a real-world setting is still unclear. In this retrospective study, we analyzed immunotherapy type with time to thyroid dysfunction, grade of thyroid dysfunction, and number that ultimately required treatment. Methods: We retrospectively collected data for patients who received immunotherapy from April 2015 to August 2019. We recorded the type of immunotherapy, any abnormal TSH and grade of abnormality using the immune checkpoint inhibitor related adverse events Common Terminology Criteria for Adverse Events (IRAE-CTCAE), number of days from start of treatment to first noted abnormal TSH, and number requiring treatment with levothyroxine. At our large academic center, we analyze thyroid function prior to starting immunotherapy and at every treatment. Results: Of our 374 patients, 159 had some grade of thyroid dysfunction after receiving immunotherapy. Of the 159 patients with thyroid dysfunction, 23 had atezolizumab, (A), 81 had nivolumab (N), and 55 had pembrolizumab (P). Within these sub-groups, the majority of the adverse events were grade one, 74% in the A group, 57% in the N group, and 76% in the P group. Of these, zero were treated with levothyroxine. Grade two toxicities were seen in 22% in the A group, 31% in the N group, and 22% in the P group. Of these, a total of eight patient required treatment with levothyroxine. Average days to abnormal TSH was 97 in the A group, 94 in the N group, and 130 in the P group. Conclusions: In our population, 42.5% of patients had some grade of thyroid dysfunction which is higher than the previously reported values, however, the majority of abnormalities were grade one and self-resolved. This may indicate that transient changes in TSH are much more common than previously noted but not necessarily clinically relevant.

The use of liquid and tissue biopsy genomic testing in lung cancer: A single-institution experience

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Background: Liquid biopsy is an evolving minimally invasive technique to detect cell-free DNA (cfDNA) and cfRNA mutations by next generation sequencing (NGS) in plasma. In our Thoracic Oncology Program, we compared plasma liquid biopsy and tissue-based NGS assay results. Methods: Circulogene Theranostics Personalized Gene Profile (CGP), a 50-gene plasma NGS panel with proprietary direct-on-specimen enrichment technology, and tissue Caris Molecular Intelligence (CMI) NGS cfDNA and cfRNA including microsatellite instability (MSI)/microsatellite stability (MSS) and total mutational burden (TMB) results were retrospectively compiled and compared upon diagnosis. Results: 106 non-surgical lung cancer patients (median age 65 years, range 27-88; 66 men, 40 women) underwent CGP testing. 49 patients had sufficient tissue for comparative CMI. MSI detected in 20.4% (10/49) by CGP; no tissue MSI was found by CMI (0/44). 3 out of 4 (75%) MSI detected by CGP had high TMB ≥ 10 mut/Mb by CMI. 75% MSS patients by CGP had low TMB (12/16). Comparative plasma versus tissue mutations findings: TP53 mutations 60.3% (64/106) CGP and 69.3% (34/49) CMI. CGP TP53 mutated patients, high TMB 70.5 % (20/34) by CMI; EGFR mutations 13.2% (14/106) CGP and 14.2% (7/49) CMI; KRAS mutations 2.8 % (3/106) by CGP versus 28.5% (19/49); one ROS1 by CGP missed by CMI and one ALK by CGP insufficient tissue CMI. A higher frequency of BRAF 16.9% (18/106), PIK3CA 28.3% (30/106), PTEN 22.6% (24/106), and MET 7.5% (8/106) alterations was identified by plasma/CGP than comparative tissue/CMI 6.1% (3/49), 2% (1/49), 6.1% (3/49), and 0% (0/49) respectively. Conclusions: Our findings indicate that Circulogene liquid biopsy NGS detected common mutations, including actionable variants in lung cancer, providing expanded and complementary tumor molecular biology and therapeutic information to tissue NGS.

Abstract P1-15-04: Outcome of small (≤1 cm), node-negative breast cancer

Background: Screening mammogram has resulted in increased diagnosis of very small breast cancers, especially less than 1 cm node negative. These small tumors have excellent prognosis with cancer-specific survival rates as high as 90% to 95%. This study evaluates outcome in different subtypes of very early breast cancer in a national population database.

Method: Patients with stage I breast cancer, tumor ≤ 1cm with negative nodes (T1aN0 (<0.5cm), T1bN0 (≥ 0.5cm to ≤ 1cm) diagnosed between 2006 and 2011 were identified in the SEER database. We excluded patients with missing biomarker information. Treatment outcome and prognostic factors for disease-specific survival (DSS) and overall survival (OS) were evaluated.

Results: We identified 70,543 cases and included 54,796 patients with stage T1aN0M0 and T1bN0M0 in the final analysis. The mean age was 62.09 yrs. (CI 95% 62.2-61.99), 84% are white, 7% black and 7% others.89% had ER positive tumor, 11% ER negative and 3% had Her 2 positive tumors.71% of patients had T1b (≤ 1cm). The 5-year disease specific survival (DSS) and overall survival (OS) for patients with stage T1aN0, T1bN0 was 98.7% and 93.7%, respectively. Estrogen receptor (ER) positive tumors were associated with improved 5-yr DSS 99% vs. 96% in ER negative (p<0.0001) and OS in ER positive 94% vs. 92%( p<0.0001). Among white patients 5-yr DSS was 98.8% and OS was 93.7% while 5yr-DSS was 94%, OS 91.5% among black vs. 5-yr DSS 99% and OS 96.3% in others (Asian or Pacific Islanders, AI), (p<0.0001). Tumor subtype was not associated with significant difference in outcome but T1a tumor was associated with OS 94.5% vs. 93.4% with T1b tumors (p<0.0001) On cox model analysis factors which correlated with prolonged DSS and OS are race (p<0.0001), older age (p<0.0001), ER positivity (p<0.0001) and tumor less than 5mm (p=0.0006).

Conclusions: Very early breast cancer is associated with excellent outcome but has some heterogeneity. Nonwhite/Non Black race was associated with better survival compared to white and black patients. ER positive tumors, and older age were also associated with better outcome. This data while reassuring also brings into question the overtreatment of this disease subset. One of the limitations of this dataset is lack of details of systemic therapy administered. Conventional prognostic factors are not sufficient to risk stratify very early breast cancer and molecular profiling may help identify patients who will need adjuvant treatment.

Citation Format: Muzaffar M, Namireddy P, Naqash R, Wong J, Vohra N. Outcome of small (≤1 cm), node-negative breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-15-04.

Equality during end-of-life cancer care: Trends in aggressiveness of cancer care at the end of life

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Background: Aggressive cancer care at the end of life (EOL) can impact quality of life and have major economic burden. The purpose of this study was to portray the aggressiveness of EOL cancer care, and its relation to race, gender and social factors in Eastern North Carolina with high rural and minority population. Methods: This is a retrospective analysis of 401 stage 4 solid tumor patients who died between 2011 and 2014. Aggressiveness of care was calculated by a composite score adopted from Earle et al. Scores range from 0 to 7 with higher scores indicating more aggressive EOL care. 1 point was given to each indicator of aggressiveness in the last 30 days of life: ED visits ≥2,hospital admissions ≥2,any ICU admission,hospitalized days ≥14,new chemotherapy, hospice care ≤ 3 days, and any chemotherapy in the last 14 days. Results: Among the 401 patients, 217 (54%) were white and 178 (44%) were black. The mean composite score of aggressiveness (CSA) for whites was 1.18 and for blacks it was 1.87. (p<0.001).In the last 30 days of death, a higher proportion of blacks had ≥ 2 ED visits 28% vs 13%(p<.0001), ≥ 2 hospital admission 23% vs 13%(p=0.001), any ICU admission 29% vs 16%(p=0.0002), chemotherapy in the last 14 days 30% vs 20%(p=0.001), ≥ 14 hospitalized days 35% vs 21%(p<0.001), and hospital deaths 46% vs 32%(p=0.001) compared to whites. More whites enrolled in hospice compared to blacks 53% vs 45% (p<0.001). Correlation analysis using Fit Y by X model between CSA (score ≤ 3 and >3) and other variables showed statistically significant difference between whites vs blacks p <0.001, females vs males p=0.0006, not married vs married p<0.0001, and no family support vs family support p<0.0001. Conclusions: Male, unmarried and black patients were associated with higher CSA. Patients who were white, married and with family support had high likelihood of enrolling in hospice. [Table: see text]

Racial and social disparities on aggressiveness of end-of-life cancer care in a rural academic center

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Background: Aggressive cancer care at the end of life (EOL) can impact quality of life and have major economic burden. The purpose of this study was to determine the aggressiveness of EOL cancer care, and its relation to race, gender and social factors in Eastern North Carolina with a high rural and minority population. Methods: This is a retrospective analysis of 401 stage 4 solid tumor patients who died between 2011 and 2014 at Vidant Medical Center. Aggressiveness of care was calculated by a composite score adopted from Earle et al. Scores range from 0 to 7 with higher scores indicating more aggressive EOL care. 1 point was given to each indicator of aggressiveness in the last 30 days of life: ED visits ≥2, hospital admissions ≥2, any ICU admission, hospitalized days ≥14, new chemotherapy, hospice care ≤ 3 days, and any chemotherapy in the last 14 days. Results: Among 401 patients, 217 (54%) were white and 178 (44%) were black. The mean composite score for aggressiveness (CSA) for whites was 1.18 and for blacks it was 1.87 (p<0.001). In the last 30 days of life, a higher proportion of blacks had ≥ 2 ED visits 28% vs 13%(p<.0001), ≥ 2 hospital admission 23% vs 13%(p=0.001), any ICU admission 29% vs 16%(p=0.0002), chemotherapy in the last 14 days 30% vs 20%(p=0.001), and ≥ 14 hospitalized days 35% vs 21%(p<0.001) compared to whites. More whites were enrolled in hospice compared to blacks 53% vs 45% (p<0.001). Correlation analysis using Fit Y by X model showed statistically significant differences between CSA (score ≤ 3 and >3) and other variables such as whites vs blacks p <0.001, females vs males p=0.0006, not married vs married p<0.0001, and no family support vs family support p<0.0001. Conclusions: Male, unmarried and black patients were associated with higher CSA. Patients who were white, married and with family support had higher likelihood of enrolling in hospice. [Table: see text]

National population-based study of racial variation in characteristics and outcomes of young breast cancer patients: Analysis of temporal trends

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Background: Breast cancer outcomes correlate with racial and socioeconomic status. Efforts to reduce disparities in breast cancer among vulnerable populations has had limited success. We sought to examine trends of racial and socioeconomic factors and its impact on outcome in young breast cancer patients. Methods: Using the Surveillance, Epidemiology, and End Results database, we identified female patients aged 20-35 with invasive breast cancer diagnosed from 1990-2012. We performed univariate, multivariate and survival analysis. Variables included patient age, race, stage, receptor status, surgery type and year of diagnosis. Results: A total of 18,999 women were identified. Mean age was 31.7. 80.8% were white and 19.1% were black. A higher percentage of blacks had stage III/IV disease (34% v 27%) and ≥ 4 positive nodes (19% v 16%) compared to whites. 54% of whites were ER receptor positive while 46% of blacks were ER receptor positive (p<0.0001). Analysis of American Community Survey attributes indicated white patents were more likely to live in counties where ≤15% of households were below the poverty line (64% v 45%) and where ≤15% of the population had less than a high school education (35% v 28%) compared to blacks. 31.2% were diagnosed in 1990-2000 while 68.7% were diagnosed in 2001-2012. 5 year disease specific survival (DSS) was 79.1% among all patients diagnosed from 1990-2000 and 84.2% among patients diagnosed from 2001-2012 (p<0.0001). In each time period, white patients had significant difference in 5 year DSS compared to black patients. While the 5 year DSS for white patients improved from 80.9% to 86.3% (p<0.0001), the 5 year DSS improvement for black patients from 1990-2000 to 2001-2012 did not reach statistical significance (71.3% vs 75.7%, p=0.24). Conclusions: Demographic and economic factors are associated with outcomes in young breast cancer patients. Absolute DSS has improved over consecutive time periods, but the improvement was not significant among blacks. More effort is needed to evaluate and address disparity in these patients. [Table: see text]