ASCO Lung Cancer

The addition of nivolumab to neoadjuvant chemotherapy did not impede the feasibility or timing of surgery in patients with resectable lung cancer, according to results from the phase 3 CheckMate 816 trial.

Adding nivolumab to chemotherapy was tolerable and did not increase the rate of surgical complications, investigator Jonathan Spicer, FRCPC, MD, PhD, of McGill University, Montreal, said in his presentation at the annual meeting of the American Society of Clinical Oncology.

His presentation comes about 2 months after the reporting of primary endpoint results of CheckMate 816 (NCT02998528). CheckMate 816 demonstrated that adding nivolumab to neoadjuvant chemotherapy significantly improved pathological complete response (pCR) in patients with resectable non–small cell lung cancer (NSCLC), according to results presented earlier at the American Association for Cancer Research annual meeting.

“The safety and surgical outcome data reported thus far from CheckMate 816, along with significant improvement in pathological complete response, support nivolumab in combination with chemotherapy as an attractive neoadjuvant option for patients with resectable NSCLC,” said Dr. Spicer (Abstract 8503).
 

Building on previous experience

The CheckMate 816 study builds on extensive experience in advanced NSCLC that has consistently shown better outcomes, including overall survival, with combinations of chemotherapy and immuno-oncology (IO) agents, compared to chemotherapy alone, said discussant Valerie W. Rusch, MD, of Memorial Sloan Kettering Cancer Center in New York.

Dr. Rusch called out “salient and interesting results” regarding surgical management in CheckMate 816, including a lower rate of surgery cancellations and shorter surgical duration in the chemotherapy-plus-IO arm, compared to the chemotherapy-alone arm.

Furthermore, fewer patients required a pneumonectomy and more patients had a complete resection in the chemotherapy-plus-IO arm, compared to chemotherapy alone, she noted.

“These excellent surgical results, along with the data previously presented at AACR regarding the primary endpoint, help to establish a new standard of neoadjuvant care,” Dr. Rusch said in her presentation.
 

Study details

CheckMate 816 included 358 patients with newly diagnosed, resectable, stage IB-IIIA NSCLC, Eastern Cooperative Oncology Group (ECOG) performance status of 0-1, and no known EGFR mutations or ALK alterations. Patients were randomized to receive nivolumab and platinum-doublet chemotherapy (nivolumab/chemotherapy) or chemotherapy alone every 3 weeks, with surgery to be performed within 6 weeks of the last dose of neoadjuvant treatment.

The median age of patients was 64 years in the nivolumab/chemotherapy arm and 65 years in the chemotherapy-alone arm. About one-third of patients had ECOG performance status of one, and about half had squamous tumor histology, Dr. Spicer said in his report. Almost two-thirds of patients had stage IIIA disease.

In the study results previously presented at the AACR meeting, both pCR and major pathologic response were significantly better following neoadjuvant chemotherapy and IO treatment, compared to chemotherapy alone.

In the intention-to-treat analysis, 24.0% of patients treated with nivolumab/chemotherapy achieved a pCR, compared to 2.2% in the chemotherapy arm, amounting to an approximate 12-fold increase in pCR, Dr. Spicer said. Similarly, the rate of major pathologic response in the intention-to-treat analysis was 36.9% and 8.9% for the nivolumab/chemotherapy and chemotherapy arms, respectively.
 

Surgical results

In his ASCO presentation, Dr. Spicer reported that definitive surgery was canceled in 16% of patients in the nivolumab/chemotherapy arm, and 21% of the chemotherapy arm. Reasons for surgery cancellation generally included patients declining surgery, unresectable disease, and poor lung function. “Cancellation of surgery due to neoadjuvant therapy toxicity was rare,” Dr. Spicer said in his presentation.

Among patients who did proceed to surgery, the median duration of the procedure was 184 minutes in the nivolumab/chemotherapy arm and 217 minutes in the chemotherapy arm. That half-hour difference in favor of the combination arm suggests that the complexity of surgery was not increased by the addition of nivolumab, Dr. Spicer said.

Median time to surgery was about 5 weeks in both arms, which was “well within accepted standards for a neoadjuvant therapeutic approach,” Dr. Spicer said. Most delays beyond 6 weeks were due to administrative issues, and occurred in similar proportions (21% of the nivolumab/chemotherapy arm and 18% of the chemotherapy arm).

The addition of nivolumab to chemotherapy improved pCR rates regardless of baseline stage of disease, according to Dr. Spicer. Furthermore, the depth of pathological regression in the primary tumor was “dramatically different” across stage groupings, he said. Median residual viable tumor percentage in stage IB/II patients was 28% for nivolumab/chemotherapy and 79% for chemotherapy, and in stage IIIA patients, it was 8% for nivolumab/chemotherapy and 70% for chemotherapy.

Overall, thoracotomy was the most frequent surgical approach in this international phase 3 trial, Dr. Spicer said. However, among patients with stage IIIA disease, minimally invasive approaches were used 30% of the time in the nivolumab/chemotherapy arm and 19% in the chemotherapy arm. Conversely, the rate of conversion from a minimally invasive to open approach in patients with stage IIIA disease was 11% for nivolumab/chemotherapy and 20% for chemotherapy alone.

Lobectomy was more frequent in the nivolumab/chemotherapy arm (77%) compared to the chemotherapy arm (61%), a difference that Dr. Spicer described as clinically important. He said the difference appears to be attributable to a lower rate of pneumonectomy in the nivolumab/chemotherapy arm (17%) than in the chemotherapy arm (25%).

Despite less extensive lung resection being required, the rate of R0 resection was numerically higher in the nivolumab/chemotherapy arm (83%) than in the chemotherapy arm (78%), said Dr. Spicer.

Length of hospital stay was “within expected ranges” from geographic regions represented in the trial, Dr. Spicer said. Median length of stay was 4.0 and 6.0 days, respectively, for nivolumab/chemotherapy and chemotherapy alone in North America, 9.5 and 13.0 days in Europe, and 11.0 and 13.0 days in Asia.

Likewise, 90-day surgical complications were well within expected ranges, according to the investigator, with anemia, pain, and wound complications being the most commonly reported. Rates were generally similar between study arms, other than a twofold higher rate of pain in the chemotherapy arm, possibly due to the lower rate of minimally invasive surgery or higher rate of conversion to an open procedure, compared to the nivolumab/chemotherapy arm, he said.
 

Awaiting survival

Rates of 30- and 90-day mortality are expected to be evaluated when survival endpoints are available, according to Dr. Spicer. Beyond pCR rate, event-free survival is also a primary endpoint of the study, while overall survival is a secondary endpoint.

The study was supported by Bristol Myers Squibb. Dr. Spicer reported disclosures related to AstraZeneca, Bristol Myers Squibb Foundation, Merck, and Roche. Dr. Rusch reported research funding with Genelux and Genentech, and travel expenses from Intuitive Surgical.

The addition of nivolumab to neoadjuvant chemotherapy did not impede the feasibility or timing of surgery in patients with resectable lung cancer, according to results from the phase 3 CheckMate 816 trial.

Adding nivolumab to chemotherapy was tolerable and did not increase the rate of surgical complications, investigator Jonathan Spicer, FRCPC, MD, PhD, of McGill University, Montreal, said in his presentation at the annual meeting of the American Society of Clinical Oncology.

His presentation comes about 2 months after the reporting of primary endpoint results of CheckMate 816 (NCT02998528). CheckMate 816 demonstrated that adding nivolumab to neoadjuvant chemotherapy significantly improved pathological complete response (pCR) in patients with resectable non–small cell lung cancer (NSCLC), according to results presented earlier at the American Association for Cancer Research annual meeting.

“The safety and surgical outcome data reported thus far from CheckMate 816, along with significant improvement in pathological complete response, support nivolumab in combination with chemotherapy as an attractive neoadjuvant option for patients with resectable NSCLC,” said Dr. Spicer (Abstract 8503).
 

Building on previous experience

The CheckMate 816 study builds on extensive experience in advanced NSCLC that has consistently shown better outcomes, including overall survival, with combinations of chemotherapy and immuno-oncology (IO) agents, compared to chemotherapy alone, said discussant Valerie W. Rusch, MD, of Memorial Sloan Kettering Cancer Center in New York.

Dr. Rusch called out “salient and interesting results” regarding surgical management in CheckMate 816, including a lower rate of surgery cancellations and shorter surgical duration in the chemotherapy-plus-IO arm, compared to the chemotherapy-alone arm.

Furthermore, fewer patients required a pneumonectomy and more patients had a complete resection in the chemotherapy-plus-IO arm, compared to chemotherapy alone, she noted.

“These excellent surgical results, along with the data previously presented at AACR regarding the primary endpoint, help to establish a new standard of neoadjuvant care,” Dr. Rusch said in her presentation.
 

Study details

CheckMate 816 included 358 patients with newly diagnosed, resectable, stage IB-IIIA NSCLC, Eastern Cooperative Oncology Group (ECOG) performance status of 0-1, and no known EGFR mutations or ALK alterations. Patients were randomized to receive nivolumab and platinum-doublet chemotherapy (nivolumab/chemotherapy) or chemotherapy alone every 3 weeks, with surgery to be performed within 6 weeks of the last dose of neoadjuvant treatment.

The median age of patients was 64 years in the nivolumab/chemotherapy arm and 65 years in the chemotherapy-alone arm. About one-third of patients had ECOG performance status of one, and about half had squamous tumor histology, Dr. Spicer said in his report. Almost two-thirds of patients had stage IIIA disease.

In the study results previously presented at the AACR meeting, both pCR and major pathologic response were significantly better following neoadjuvant chemotherapy and IO treatment, compared to chemotherapy alone.

In the intention-to-treat analysis, 24.0% of patients treated with nivolumab/chemotherapy achieved a pCR, compared to 2.2% in the chemotherapy arm, amounting to an approximate 12-fold increase in pCR, Dr. Spicer said. Similarly, the rate of major pathologic response in the intention-to-treat analysis was 36.9% and 8.9% for the nivolumab/chemotherapy and chemotherapy arms, respectively.
 

Surgical results

In his ASCO presentation, Dr. Spicer reported that definitive surgery was canceled in 16% of patients in the nivolumab/chemotherapy arm, and 21% of the chemotherapy arm. Reasons for surgery cancellation generally included patients declining surgery, unresectable disease, and poor lung function. “Cancellation of surgery due to neoadjuvant therapy toxicity was rare,” Dr. Spicer said in his presentation.

Among patients who did proceed to surgery, the median duration of the procedure was 184 minutes in the nivolumab/chemotherapy arm and 217 minutes in the chemotherapy arm. That half-hour difference in favor of the combination arm suggests that the complexity of surgery was not increased by the addition of nivolumab, Dr. Spicer said.

Median time to surgery was about 5 weeks in both arms, which was “well within accepted standards for a neoadjuvant therapeutic approach,” Dr. Spicer said. Most delays beyond 6 weeks were due to administrative issues, and occurred in similar proportions (21% of the nivolumab/chemotherapy arm and 18% of the chemotherapy arm).

The addition of nivolumab to chemotherapy improved pCR rates regardless of baseline stage of disease, according to Dr. Spicer. Furthermore, the depth of pathological regression in the primary tumor was “dramatically different” across stage groupings, he said. Median residual viable tumor percentage in stage IB/II patients was 28% for nivolumab/chemotherapy and 79% for chemotherapy, and in stage IIIA patients, it was 8% for nivolumab/chemotherapy and 70% for chemotherapy.

Overall, thoracotomy was the most frequent surgical approach in this international phase 3 trial, Dr. Spicer said. However, among patients with stage IIIA disease, minimally invasive approaches were used 30% of the time in the nivolumab/chemotherapy arm and 19% in the chemotherapy arm. Conversely, the rate of conversion from a minimally invasive to open approach in patients with stage IIIA disease was 11% for nivolumab/chemotherapy and 20% for chemotherapy alone.

Lobectomy was more frequent in the nivolumab/chemotherapy arm (77%) compared to the chemotherapy arm (61%), a difference that Dr. Spicer described as clinically important. He said the difference appears to be attributable to a lower rate of pneumonectomy in the nivolumab/chemotherapy arm (17%) than in the chemotherapy arm (25%).

Despite less extensive lung resection being required, the rate of R0 resection was numerically higher in the nivolumab/chemotherapy arm (83%) than in the chemotherapy arm (78%), said Dr. Spicer.

Length of hospital stay was “within expected ranges” from geographic regions represented in the trial, Dr. Spicer said. Median length of stay was 4.0 and 6.0 days, respectively, for nivolumab/chemotherapy and chemotherapy alone in North America, 9.5 and 13.0 days in Europe, and 11.0 and 13.0 days in Asia.

Likewise, 90-day surgical complications were well within expected ranges, according to the investigator, with anemia, pain, and wound complications being the most commonly reported. Rates were generally similar between study arms, other than a twofold higher rate of pain in the chemotherapy arm, possibly due to the lower rate of minimally invasive surgery or higher rate of conversion to an open procedure, compared to the nivolumab/chemotherapy arm, he said.
 

Awaiting survival

Rates of 30- and 90-day mortality are expected to be evaluated when survival endpoints are available, according to Dr. Spicer. Beyond pCR rate, event-free survival is also a primary endpoint of the study, while overall survival is a secondary endpoint.

The study was supported by Bristol Myers Squibb. Dr. Spicer reported disclosures related to AstraZeneca, Bristol Myers Squibb Foundation, Merck, and Roche. Dr. Rusch reported research funding with Genelux and Genentech, and travel expenses from Intuitive Surgical.

The addition of nivolumab to neoadjuvant chemotherapy did not impede the feasibility or timing of surgery in patients with resectable lung cancer, according to results from the phase 3 CheckMate 816 trial.

Adding nivolumab to chemotherapy was tolerable and did not increase the rate of surgical complications, investigator Jonathan Spicer, FRCPC, MD, PhD, of McGill University, Montreal, said in his presentation at the annual meeting of the American Society of Clinical Oncology.

His presentation comes about 2 months after the reporting of primary endpoint results of CheckMate 816 (NCT02998528). CheckMate 816 demonstrated that adding nivolumab to neoadjuvant chemotherapy significantly improved pathological complete response (pCR) in patients with resectable non–small cell lung cancer (NSCLC), according to results presented earlier at the American Association for Cancer Research annual meeting.

“The safety and surgical outcome data reported thus far from CheckMate 816, along with significant improvement in pathological complete response, support nivolumab in combination with chemotherapy as an attractive neoadjuvant option for patients with resectable NSCLC,” said Dr. Spicer (Abstract 8503).
 

Building on previous experience

The CheckMate 816 study builds on extensive experience in advanced NSCLC that has consistently shown better outcomes, including overall survival, with combinations of chemotherapy and immuno-oncology (IO) agents, compared to chemotherapy alone, said discussant Valerie W. Rusch, MD, of Memorial Sloan Kettering Cancer Center in New York.

Dr. Rusch called out “salient and interesting results” regarding surgical management in CheckMate 816, including a lower rate of surgery cancellations and shorter surgical duration in the chemotherapy-plus-IO arm, compared to the chemotherapy-alone arm.

Furthermore, fewer patients required a pneumonectomy and more patients had a complete resection in the chemotherapy-plus-IO arm, compared to chemotherapy alone, she noted.

“These excellent surgical results, along with the data previously presented at AACR regarding the primary endpoint, help to establish a new standard of neoadjuvant care,” Dr. Rusch said in her presentation.
 

Study details

CheckMate 816 included 358 patients with newly diagnosed, resectable, stage IB-IIIA NSCLC, Eastern Cooperative Oncology Group (ECOG) performance status of 0-1, and no known EGFR mutations or ALK alterations. Patients were randomized to receive nivolumab and platinum-doublet chemotherapy (nivolumab/chemotherapy) or chemotherapy alone every 3 weeks, with surgery to be performed within 6 weeks of the last dose of neoadjuvant treatment.

The median age of patients was 64 years in the nivolumab/chemotherapy arm and 65 years in the chemotherapy-alone arm. About one-third of patients had ECOG performance status of one, and about half had squamous tumor histology, Dr. Spicer said in his report. Almost two-thirds of patients had stage IIIA disease.

In the study results previously presented at the AACR meeting, both pCR and major pathologic response were significantly better following neoadjuvant chemotherapy and IO treatment, compared to chemotherapy alone.

In the intention-to-treat analysis, 24.0% of patients treated with nivolumab/chemotherapy achieved a pCR, compared to 2.2% in the chemotherapy arm, amounting to an approximate 12-fold increase in pCR, Dr. Spicer said. Similarly, the rate of major pathologic response in the intention-to-treat analysis was 36.9% and 8.9% for the nivolumab/chemotherapy and chemotherapy arms, respectively.
 

Surgical results

In his ASCO presentation, Dr. Spicer reported that definitive surgery was canceled in 16% of patients in the nivolumab/chemotherapy arm, and 21% of the chemotherapy arm. Reasons for surgery cancellation generally included patients declining surgery, unresectable disease, and poor lung function. “Cancellation of surgery due to neoadjuvant therapy toxicity was rare,” Dr. Spicer said in his presentation.

Among patients who did proceed to surgery, the median duration of the procedure was 184 minutes in the nivolumab/chemotherapy arm and 217 minutes in the chemotherapy arm. That half-hour difference in favor of the combination arm suggests that the complexity of surgery was not increased by the addition of nivolumab, Dr. Spicer said.

Median time to surgery was about 5 weeks in both arms, which was “well within accepted standards for a neoadjuvant therapeutic approach,” Dr. Spicer said. Most delays beyond 6 weeks were due to administrative issues, and occurred in similar proportions (21% of the nivolumab/chemotherapy arm and 18% of the chemotherapy arm).

The addition of nivolumab to chemotherapy improved pCR rates regardless of baseline stage of disease, according to Dr. Spicer. Furthermore, the depth of pathological regression in the primary tumor was “dramatically different” across stage groupings, he said. Median residual viable tumor percentage in stage IB/II patients was 28% for nivolumab/chemotherapy and 79% for chemotherapy, and in stage IIIA patients, it was 8% for nivolumab/chemotherapy and 70% for chemotherapy.

Overall, thoracotomy was the most frequent surgical approach in this international phase 3 trial, Dr. Spicer said. However, among patients with stage IIIA disease, minimally invasive approaches were used 30% of the time in the nivolumab/chemotherapy arm and 19% in the chemotherapy arm. Conversely, the rate of conversion from a minimally invasive to open approach in patients with stage IIIA disease was 11% for nivolumab/chemotherapy and 20% for chemotherapy alone.

Lobectomy was more frequent in the nivolumab/chemotherapy arm (77%) compared to the chemotherapy arm (61%), a difference that Dr. Spicer described as clinically important. He said the difference appears to be attributable to a lower rate of pneumonectomy in the nivolumab/chemotherapy arm (17%) than in the chemotherapy arm (25%).

Despite less extensive lung resection being required, the rate of R0 resection was numerically higher in the nivolumab/chemotherapy arm (83%) than in the chemotherapy arm (78%), said Dr. Spicer.

Length of hospital stay was “within expected ranges” from geographic regions represented in the trial, Dr. Spicer said. Median length of stay was 4.0 and 6.0 days, respectively, for nivolumab/chemotherapy and chemotherapy alone in North America, 9.5 and 13.0 days in Europe, and 11.0 and 13.0 days in Asia.

Likewise, 90-day surgical complications were well within expected ranges, according to the investigator, with anemia, pain, and wound complications being the most commonly reported. Rates were generally similar between study arms, other than a twofold higher rate of pain in the chemotherapy arm, possibly due to the lower rate of minimally invasive surgery or higher rate of conversion to an open procedure, compared to the nivolumab/chemotherapy arm, he said.
 

Awaiting survival

Rates of 30- and 90-day mortality are expected to be evaluated when survival endpoints are available, according to Dr. Spicer. Beyond pCR rate, event-free survival is also a primary endpoint of the study, while overall survival is a secondary endpoint.

The study was supported by Bristol Myers Squibb. Dr. Spicer reported disclosures related to AstraZeneca, Bristol Myers Squibb Foundation, Merck, and Roche. Dr. Rusch reported research funding with Genelux and Genentech, and travel expenses from Intuitive Surgical.

A simple nasal swab may help in the diagnosis of lung cancer in smokers who have undergone CT screening and had lung nodules detected on the scan.  

Only about 5% of the nearly 1.6 million lung nodules identified as incidental findings on low-dose CT screening tests will turn out to be malignant. The new test helps to distinguish between benign and malignant nodules, say researchers reporting a validation study.  

The results show that the test identified those at low risk for cancer with a sensitivity of 96.3% and specificity of 41.7%, as well as identifying those as high risk, with a specificity of 90.4% and sensitivity of 58.2%.

The Percepta nasal swab is a first-of-its-kind genomic test, says the manufacturer Veracyte.

It is based on “field of injury” technology, which examines genomic changes in the lining of the respiratory tract for evidence of active cancer cells, coupled with a machine learning model that includes factors such as age, gender, and smoking history.

Veracyte hopes to begin to make the test available to a select number of sites in the second half of 2021. “The test is intended to be performed in the physician’s office on patients referred with suspicious lung nodules found on CT scans,” said Giulia C. Kennedy, PhD, chief scientific officer and chief medical officer at Veracyte. “This could include patients with nodules found through screening programs, as well as incidentally.”

“It will be made available as a laboratory developed test in the U.S. through Veracyte’s centralized CLIA laboratory,” she said in an interview. “In global markets, we will offer the test as an IVD product that can be performed on the nCounter instrument by laboratories locally. Outside of the United States, the test will require a CE mark, which we are equipped to support.”

Results with the test were presented during the American Society of Clinical Oncology (ASCO) 2021 Annual Meeting, which was held virtually this year.

It was first tested in a training set, which consisted of more than 1,100 patients. All were current or former smokers who had a lung nodule detected on chest CT scanning and were followed for up to 1 year or until a final diagnosis of lung cancer or benign disease.

Brushings of the nasal epithelium were prospectively collected in patients with lung nodules from multiple cohorts.

A total of 502 genes were used in the classifier, and performance was evaluated in an independent clinical validation set consisting of 249 patients.

The test identified true benign patients as low risk with 41.7% specificity and 96.3% sensitivity, resulting in a negative predictive value (NPV) of 97.1% in a population with a cancer prevalence of 25%. The risk of malignancy for patients in this low-risk group was less than 3% (1-NPV), and for this group, clinical guidelines recommend surveillance.  

Patients with true malignancies were identified as high risk, with 58.2% sensitivity and 90.4% specificity, resulting in a positive predictive value of 67.0% in a population with 25% cancer prevalence. The risk of malignancy for patients deemed to be high risk by the classifier was 67.0%, which exceeds the current guideline threshold for consideration of surgical resection or other ablative therapy if a staging evaluation confirms early stage disease, the authors point out.  

The remaining patients, who did not meet the stringent cut-offs for low or high risk, were identified as intermediate risk. In this population, the prevalence of malignancy for patients identified as intermediate risk was 20.7%, which is consistent with guidelines that provide a range for intermediate-risk patients as between 5% and 65% for whom diagnostic biopsy is recommended.
 

Help guide decisions, more data needed

Approached by this news organization for independent comment, Alexander Spira, MD, PhD, medical oncologist, Virginia Cancer Specialists, Fairfax, explained that the study provides an interesting way to look at a common finding and lung nodules and to predict whether further workup should be done.

“This could provide a role in reassurance that patients who fall into the low-risk category could be observed with serial imaging rather than proceeding to immediate biopsy,” he said. “It falls in under the ‘field of injury’ principle.”

Dr. Spira noted that although the low-risk group appears to have a negative predictive value of >90%, it doesn’t mean that the patient would require no further workup. “It would require CT surveillance rather than proceeding to immediate biopsy, and at this point it does appear promising, but I would want further follow-up in terms of outcomes,” he said.

“This does not apply to nonsmokers, which is of increasing prevalence, but with the increased use of CT screening for patients with a history of tobacco use, it may indeed have a role.”

He also pointed out that while the idea is to avoid biopsies, the smaller lesions are the ones that are concerning. “They are often tough to get at, and it would also depend on patient choice and anxiety as well, given the chance of being in that low percentage that the test misses,” said Dr. Spira. “Lastly, many pulmonologists are ordering PET scans in lieu of a biopsy, and this may also help.”

The bottom line is that this may help guide clinical decisions, but more data are needed. “Even in the low-risk category, 9.4% of patients had a malignancy, which is still a high miss rate,” he added.

The study was funded by Veracyte. Dr. Kennedy is employed by Veracyte. Dr. Spira has reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

A simple nasal swab may help in the diagnosis of lung cancer in smokers who have undergone CT screening and had lung nodules detected on the scan.  

Only about 5% of the nearly 1.6 million lung nodules identified as incidental findings on low-dose CT screening tests will turn out to be malignant. The new test helps to distinguish between benign and malignant nodules, say researchers reporting a validation study.  

The results show that the test identified those at low risk for cancer with a sensitivity of 96.3% and specificity of 41.7%, as well as identifying those as high risk, with a specificity of 90.4% and sensitivity of 58.2%.

The Percepta nasal swab is a first-of-its-kind genomic test, says the manufacturer Veracyte.

It is based on “field of injury” technology, which examines genomic changes in the lining of the respiratory tract for evidence of active cancer cells, coupled with a machine learning model that includes factors such as age, gender, and smoking history.

Veracyte hopes to begin to make the test available to a select number of sites in the second half of 2021. “The test is intended to be performed in the physician’s office on patients referred with suspicious lung nodules found on CT scans,” said Giulia C. Kennedy, PhD, chief scientific officer and chief medical officer at Veracyte. “This could include patients with nodules found through screening programs, as well as incidentally.”

“It will be made available as a laboratory developed test in the U.S. through Veracyte’s centralized CLIA laboratory,” she said in an interview. “In global markets, we will offer the test as an IVD product that can be performed on the nCounter instrument by laboratories locally. Outside of the United States, the test will require a CE mark, which we are equipped to support.”

Results with the test were presented during the American Society of Clinical Oncology (ASCO) 2021 Annual Meeting, which was held virtually this year.

It was first tested in a training set, which consisted of more than 1,100 patients. All were current or former smokers who had a lung nodule detected on chest CT scanning and were followed for up to 1 year or until a final diagnosis of lung cancer or benign disease.

Brushings of the nasal epithelium were prospectively collected in patients with lung nodules from multiple cohorts.

A total of 502 genes were used in the classifier, and performance was evaluated in an independent clinical validation set consisting of 249 patients.

The test identified true benign patients as low risk with 41.7% specificity and 96.3% sensitivity, resulting in a negative predictive value (NPV) of 97.1% in a population with a cancer prevalence of 25%. The risk of malignancy for patients in this low-risk group was less than 3% (1-NPV), and for this group, clinical guidelines recommend surveillance.  

Patients with true malignancies were identified as high risk, with 58.2% sensitivity and 90.4% specificity, resulting in a positive predictive value of 67.0% in a population with 25% cancer prevalence. The risk of malignancy for patients deemed to be high risk by the classifier was 67.0%, which exceeds the current guideline threshold for consideration of surgical resection or other ablative therapy if a staging evaluation confirms early stage disease, the authors point out.  

The remaining patients, who did not meet the stringent cut-offs for low or high risk, were identified as intermediate risk. In this population, the prevalence of malignancy for patients identified as intermediate risk was 20.7%, which is consistent with guidelines that provide a range for intermediate-risk patients as between 5% and 65% for whom diagnostic biopsy is recommended.
 

Help guide decisions, more data needed

Approached by this news organization for independent comment, Alexander Spira, MD, PhD, medical oncologist, Virginia Cancer Specialists, Fairfax, explained that the study provides an interesting way to look at a common finding and lung nodules and to predict whether further workup should be done.

“This could provide a role in reassurance that patients who fall into the low-risk category could be observed with serial imaging rather than proceeding to immediate biopsy,” he said. “It falls in under the ‘field of injury’ principle.”

Dr. Spira noted that although the low-risk group appears to have a negative predictive value of >90%, it doesn’t mean that the patient would require no further workup. “It would require CT surveillance rather than proceeding to immediate biopsy, and at this point it does appear promising, but I would want further follow-up in terms of outcomes,” he said.

“This does not apply to nonsmokers, which is of increasing prevalence, but with the increased use of CT screening for patients with a history of tobacco use, it may indeed have a role.”

He also pointed out that while the idea is to avoid biopsies, the smaller lesions are the ones that are concerning. “They are often tough to get at, and it would also depend on patient choice and anxiety as well, given the chance of being in that low percentage that the test misses,” said Dr. Spira. “Lastly, many pulmonologists are ordering PET scans in lieu of a biopsy, and this may also help.”

The bottom line is that this may help guide clinical decisions, but more data are needed. “Even in the low-risk category, 9.4% of patients had a malignancy, which is still a high miss rate,” he added.

The study was funded by Veracyte. Dr. Kennedy is employed by Veracyte. Dr. Spira has reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

A simple nasal swab may help in the diagnosis of lung cancer in smokers who have undergone CT screening and had lung nodules detected on the scan.  

Only about 5% of the nearly 1.6 million lung nodules identified as incidental findings on low-dose CT screening tests will turn out to be malignant. The new test helps to distinguish between benign and malignant nodules, say researchers reporting a validation study.  

The results show that the test identified those at low risk for cancer with a sensitivity of 96.3% and specificity of 41.7%, as well as identifying those as high risk, with a specificity of 90.4% and sensitivity of 58.2%.

The Percepta nasal swab is a first-of-its-kind genomic test, says the manufacturer Veracyte.

It is based on “field of injury” technology, which examines genomic changes in the lining of the respiratory tract for evidence of active cancer cells, coupled with a machine learning model that includes factors such as age, gender, and smoking history.

Veracyte hopes to begin to make the test available to a select number of sites in the second half of 2021. “The test is intended to be performed in the physician’s office on patients referred with suspicious lung nodules found on CT scans,” said Giulia C. Kennedy, PhD, chief scientific officer and chief medical officer at Veracyte. “This could include patients with nodules found through screening programs, as well as incidentally.”

“It will be made available as a laboratory developed test in the U.S. through Veracyte’s centralized CLIA laboratory,” she said in an interview. “In global markets, we will offer the test as an IVD product that can be performed on the nCounter instrument by laboratories locally. Outside of the United States, the test will require a CE mark, which we are equipped to support.”

Results with the test were presented during the American Society of Clinical Oncology (ASCO) 2021 Annual Meeting, which was held virtually this year.

It was first tested in a training set, which consisted of more than 1,100 patients. All were current or former smokers who had a lung nodule detected on chest CT scanning and were followed for up to 1 year or until a final diagnosis of lung cancer or benign disease.

Brushings of the nasal epithelium were prospectively collected in patients with lung nodules from multiple cohorts.

A total of 502 genes were used in the classifier, and performance was evaluated in an independent clinical validation set consisting of 249 patients.

The test identified true benign patients as low risk with 41.7% specificity and 96.3% sensitivity, resulting in a negative predictive value (NPV) of 97.1% in a population with a cancer prevalence of 25%. The risk of malignancy for patients in this low-risk group was less than 3% (1-NPV), and for this group, clinical guidelines recommend surveillance.  

Patients with true malignancies were identified as high risk, with 58.2% sensitivity and 90.4% specificity, resulting in a positive predictive value of 67.0% in a population with 25% cancer prevalence. The risk of malignancy for patients deemed to be high risk by the classifier was 67.0%, which exceeds the current guideline threshold for consideration of surgical resection or other ablative therapy if a staging evaluation confirms early stage disease, the authors point out.  

The remaining patients, who did not meet the stringent cut-offs for low or high risk, were identified as intermediate risk. In this population, the prevalence of malignancy for patients identified as intermediate risk was 20.7%, which is consistent with guidelines that provide a range for intermediate-risk patients as between 5% and 65% for whom diagnostic biopsy is recommended.
 

Help guide decisions, more data needed

Approached by this news organization for independent comment, Alexander Spira, MD, PhD, medical oncologist, Virginia Cancer Specialists, Fairfax, explained that the study provides an interesting way to look at a common finding and lung nodules and to predict whether further workup should be done.

“This could provide a role in reassurance that patients who fall into the low-risk category could be observed with serial imaging rather than proceeding to immediate biopsy,” he said. “It falls in under the ‘field of injury’ principle.”

Dr. Spira noted that although the low-risk group appears to have a negative predictive value of >90%, it doesn’t mean that the patient would require no further workup. “It would require CT surveillance rather than proceeding to immediate biopsy, and at this point it does appear promising, but I would want further follow-up in terms of outcomes,” he said.

“This does not apply to nonsmokers, which is of increasing prevalence, but with the increased use of CT screening for patients with a history of tobacco use, it may indeed have a role.”

He also pointed out that while the idea is to avoid biopsies, the smaller lesions are the ones that are concerning. “They are often tough to get at, and it would also depend on patient choice and anxiety as well, given the chance of being in that low percentage that the test misses,” said Dr. Spira. “Lastly, many pulmonologists are ordering PET scans in lieu of a biopsy, and this may also help.”

The bottom line is that this may help guide clinical decisions, but more data are needed. “Even in the low-risk category, 9.4% of patients had a malignancy, which is still a high miss rate,” he added.

The study was funded by Veracyte. Dr. Kennedy is employed by Veracyte. Dr. Spira has reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Lung cancer patients could soon have their risk of dying over the following 3 months accurately predicted by analyzing their urine samples, allowing them to better prepare for their end of life, say U.K. researchers.

Dr. Seamus Coyle, consultant in palliative medicine, the Clatterbridge Cancer Centre, Liverpool, and colleagues studied urine samples from more than 100 lung cancer patients, deriving a model based on their metabolite profile.

This allowed patients to be divided into high- and low-risk groups for dying over the following 3 months, with an accuracy of 88%.

The model “predicts dying … for every single day for the last 3 months of life,” Dr. Coyle said.

“That’s an outstanding prediction,” Dr. Coyle added, “based on the fact that people actively die over 2 to 3 days on average,” while “some die over a day.”

He continued: “It’s the only test that predicts dying within the last 2 weeks of life, and that’s what I’m passionate about: The earlier recognition of dying.”

The research was presented at the 2021 American Society of Clinical Oncology Annual Meeting on June 4.
 

‘Promising and important pilot study’

Dr. Nathan Pennell, an ASCO expert, told this news organization that “predicting the actual ‘time’ someone has left is more of an art than a science.”

“For people who may be closer to death, this would potentially allow more focus on supportive care and allow families and patients to plan more accurately for supporting their loved one through the dying process.”

He continued that “while this is a promising and important pilot study, there is more work to be done before this could be used in practice.”

For example, the treatment status of the patients was not clear.

“Were these patients all in hospice, or were some undergoing treatment which, if effective, could ‘rescue’ them from their poor prognostic state?”

Dr. Pennell continued: “Would measuring kidney function be just as good? Is this something that could be intervened upon?

“For example, if someone has a high-risk score for dying, could medical intervention to treat an infection or some other modifiable action change that ‘fate’?”
 

Death ‘difficult to predict’

Dr. Coyle began by saying that, while for him recognizing that a patient is dying is the start of good end of life care, “recognizing dying accurately, when someone is in the last days of life, is difficult.”

He noted that the 2019 National Audit of Care at the End of Life found that people were recognized to be dying at median of 34 hours before death, with 20% recognized in the last 8 hours.

Moreover, 50% of people who are dying “are unconscious and unable to be involved in any conversation that [is] pertinent to them.”

In an attempt to better predict the onset of dying, the researchers conducted a prospective, longitudinal study in which 424 urine samples were collected from 162 lung cancer patients from six centers.

Of those, 63 patients gave a sample within the last 28 days of life, and 29 within the last week of life.

Urine samples were analyzed using a liquid chromatography quadrupole time-of-flight mass spectrometer for 112 patients, who had a median age of 71 years and a range of 47-89 years, and 40.2% were female. The most common diagnosis was non–small cell lung cancer, in 55.4%, while 19.6% had small cell lung cancer.

Performing Cox Lasso regression analysis on the “hundreds of metabolites” identified in the urine samples, the team developed an End of Life Metabolome (ELM) that predicted an individual’s risk of dying over the following 3 months.

Kaplan-Meier analysis allowed the patients to be divided into five risk groups based on their ELM (P < .001 for trend), which showed that all patients in the lowest-risk group were still alive after more than 2 months following the urine sample.

In contrast, more than 50% of patients in the highest-risk group died within 1 week of their urine sample being taken, and 100% had died within 3 weeks.

Calculating the area under the receiver operating characteristic curve revealed that the ELM was able to predict the risk of dying for every day for the last 3 months of life with an accuracy of 88%.

ELM is being validated in a new cohort of lung cancer patients and it is being assessed in multiple cancers.

The study was funded by the Wellcome Trust UK and North West Cancer Research UK.

No relevant financial relationships were declared.

A version of this article first appeared on Medscape.com.

Lung cancer patients could soon have their risk of dying over the following 3 months accurately predicted by analyzing their urine samples, allowing them to better prepare for their end of life, say U.K. researchers.

Dr. Seamus Coyle, consultant in palliative medicine, the Clatterbridge Cancer Centre, Liverpool, and colleagues studied urine samples from more than 100 lung cancer patients, deriving a model based on their metabolite profile.

This allowed patients to be divided into high- and low-risk groups for dying over the following 3 months, with an accuracy of 88%.

The model “predicts dying … for every single day for the last 3 months of life,” Dr. Coyle said.

“That’s an outstanding prediction,” Dr. Coyle added, “based on the fact that people actively die over 2 to 3 days on average,” while “some die over a day.”

He continued: “It’s the only test that predicts dying within the last 2 weeks of life, and that’s what I’m passionate about: The earlier recognition of dying.”

The research was presented at the 2021 American Society of Clinical Oncology Annual Meeting on June 4.
 

‘Promising and important pilot study’

Dr. Nathan Pennell, an ASCO expert, told this news organization that “predicting the actual ‘time’ someone has left is more of an art than a science.”

“For people who may be closer to death, this would potentially allow more focus on supportive care and allow families and patients to plan more accurately for supporting their loved one through the dying process.”

He continued that “while this is a promising and important pilot study, there is more work to be done before this could be used in practice.”

For example, the treatment status of the patients was not clear.

“Were these patients all in hospice, or were some undergoing treatment which, if effective, could ‘rescue’ them from their poor prognostic state?”

Dr. Pennell continued: “Would measuring kidney function be just as good? Is this something that could be intervened upon?

“For example, if someone has a high-risk score for dying, could medical intervention to treat an infection or some other modifiable action change that ‘fate’?”
 

Death ‘difficult to predict’

Dr. Coyle began by saying that, while for him recognizing that a patient is dying is the start of good end of life care, “recognizing dying accurately, when someone is in the last days of life, is difficult.”

He noted that the 2019 National Audit of Care at the End of Life found that people were recognized to be dying at median of 34 hours before death, with 20% recognized in the last 8 hours.

Moreover, 50% of people who are dying “are unconscious and unable to be involved in any conversation that [is] pertinent to them.”

In an attempt to better predict the onset of dying, the researchers conducted a prospective, longitudinal study in which 424 urine samples were collected from 162 lung cancer patients from six centers.

Of those, 63 patients gave a sample within the last 28 days of life, and 29 within the last week of life.

Urine samples were analyzed using a liquid chromatography quadrupole time-of-flight mass spectrometer for 112 patients, who had a median age of 71 years and a range of 47-89 years, and 40.2% were female. The most common diagnosis was non–small cell lung cancer, in 55.4%, while 19.6% had small cell lung cancer.

Performing Cox Lasso regression analysis on the “hundreds of metabolites” identified in the urine samples, the team developed an End of Life Metabolome (ELM) that predicted an individual’s risk of dying over the following 3 months.

Kaplan-Meier analysis allowed the patients to be divided into five risk groups based on their ELM (P < .001 for trend), which showed that all patients in the lowest-risk group were still alive after more than 2 months following the urine sample.

In contrast, more than 50% of patients in the highest-risk group died within 1 week of their urine sample being taken, and 100% had died within 3 weeks.

Calculating the area under the receiver operating characteristic curve revealed that the ELM was able to predict the risk of dying for every day for the last 3 months of life with an accuracy of 88%.

ELM is being validated in a new cohort of lung cancer patients and it is being assessed in multiple cancers.

The study was funded by the Wellcome Trust UK and North West Cancer Research UK.

No relevant financial relationships were declared.

A version of this article first appeared on Medscape.com.

Lung cancer patients could soon have their risk of dying over the following 3 months accurately predicted by analyzing their urine samples, allowing them to better prepare for their end of life, say U.K. researchers.

Dr. Seamus Coyle, consultant in palliative medicine, the Clatterbridge Cancer Centre, Liverpool, and colleagues studied urine samples from more than 100 lung cancer patients, deriving a model based on their metabolite profile.

This allowed patients to be divided into high- and low-risk groups for dying over the following 3 months, with an accuracy of 88%.

The model “predicts dying … for every single day for the last 3 months of life,” Dr. Coyle said.

“That’s an outstanding prediction,” Dr. Coyle added, “based on the fact that people actively die over 2 to 3 days on average,” while “some die over a day.”

He continued: “It’s the only test that predicts dying within the last 2 weeks of life, and that’s what I’m passionate about: The earlier recognition of dying.”

The research was presented at the 2021 American Society of Clinical Oncology Annual Meeting on June 4.
 

‘Promising and important pilot study’

Dr. Nathan Pennell, an ASCO expert, told this news organization that “predicting the actual ‘time’ someone has left is more of an art than a science.”

“For people who may be closer to death, this would potentially allow more focus on supportive care and allow families and patients to plan more accurately for supporting their loved one through the dying process.”

He continued that “while this is a promising and important pilot study, there is more work to be done before this could be used in practice.”

For example, the treatment status of the patients was not clear.

“Were these patients all in hospice, or were some undergoing treatment which, if effective, could ‘rescue’ them from their poor prognostic state?”

Dr. Pennell continued: “Would measuring kidney function be just as good? Is this something that could be intervened upon?

“For example, if someone has a high-risk score for dying, could medical intervention to treat an infection or some other modifiable action change that ‘fate’?”
 

Death ‘difficult to predict’

Dr. Coyle began by saying that, while for him recognizing that a patient is dying is the start of good end of life care, “recognizing dying accurately, when someone is in the last days of life, is difficult.”

He noted that the 2019 National Audit of Care at the End of Life found that people were recognized to be dying at median of 34 hours before death, with 20% recognized in the last 8 hours.

Moreover, 50% of people who are dying “are unconscious and unable to be involved in any conversation that [is] pertinent to them.”

In an attempt to better predict the onset of dying, the researchers conducted a prospective, longitudinal study in which 424 urine samples were collected from 162 lung cancer patients from six centers.

Of those, 63 patients gave a sample within the last 28 days of life, and 29 within the last week of life.

Urine samples were analyzed using a liquid chromatography quadrupole time-of-flight mass spectrometer for 112 patients, who had a median age of 71 years and a range of 47-89 years, and 40.2% were female. The most common diagnosis was non–small cell lung cancer, in 55.4%, while 19.6% had small cell lung cancer.

Performing Cox Lasso regression analysis on the “hundreds of metabolites” identified in the urine samples, the team developed an End of Life Metabolome (ELM) that predicted an individual’s risk of dying over the following 3 months.

Kaplan-Meier analysis allowed the patients to be divided into five risk groups based on their ELM (P < .001 for trend), which showed that all patients in the lowest-risk group were still alive after more than 2 months following the urine sample.

In contrast, more than 50% of patients in the highest-risk group died within 1 week of their urine sample being taken, and 100% had died within 3 weeks.

Calculating the area under the receiver operating characteristic curve revealed that the ELM was able to predict the risk of dying for every day for the last 3 months of life with an accuracy of 88%.

ELM is being validated in a new cohort of lung cancer patients and it is being assessed in multiple cancers.

The study was funded by the Wellcome Trust UK and North West Cancer Research UK.

No relevant financial relationships were declared.

A version of this article first appeared on Medscape.com.

After decades of off-label use, vinorelbine finally has a randomized clinical trial supporting its efficacy as a second-line treatment of mesothelioma, an investigator reported at the annual meeting of the American Society of Clinical Oncology.

However, the development of other treatment regimens, and notably immuno-oncology approaches, are pushing this classic chemotherapy option to later lines of therapy in patients with malignant pleural mesothelioma (MPM), a speaker said at the meeting.

Adding vinorelbine to active symptom control statistically improved progression-free survival (PFS), among patients with MPM who had prior platinum-based therapy, according to results of the randomized Vinorelbine in Mesothelioma (VIM) trial.

Median PFS reached 4.2 months in the vinorelbine arm, versus 2.8 months for active symptom control alone, study results show.

That finding , coupled with safety results, supports the off-label use of vinorelbine as a treatment option for patients with relapsed MPM, according to investigator Dean Anthony Fennell, FRCP, PhD, of the University of Leicester (England).

“Vinorelbine appears to be a safe and effective treatment and could be considered as a treatment option for patients with relapsed mesothelioma,” Prof. Fennell said in his presentation at ASCO (Abstract 8507).
 

Changing status

While that welcome pronouncement was a long time coming, there are now other promising treatment approaches that relegate vinorelbine to a “lower priority” in the treatment algorithm, said discussant Anna K. Nowak, MBBS, FRACP, PhD, of the University of Western Australia, Nedlands.

In October 2020, the U.S. Food and Drug Administration approved the combination of ipilimumab and nivolumab for the first-line treatment of unresectable malignant pleural mesothelioma, on the basis of results from CHECKMATE-743, a randomized, open-label trial.

“Certainly, we know now that first-line ipilimumab and nivolumab is of very substantial benefit to these patients, and we still have clinical trials open in this space as well,” Prof. Nowak said in her discussion at ASCO.

There is “no doubt” that many patients with mesothelioma should at some point receive an IO agent, particularly now with recently reported randomized clinical trial evidence of an overall survival benefit, she added.

“This really pushes vinorelbine out to be a third- or fourth-line treatment,” she added, “and we know that there are usually diminishing returns from using chemotherapies further down the treatment algorithm.”
 

Trial details

The VIM trial described at ASCO by Prof. Fennell was a randomized, controlled phase 2 including 154 patients with MPM that had progressed after first-line chemotherapy.

“Vinorelbine has shown useful clinical activity in single-arm phase two studies, however, the specific efficacy of vinorelbine has not been evaluated in an appropriately controlled randomized trial,” Prof. Fennell said in this presentation.

Patients in the trial were randomized 2:1 to either vinorelbine plus active supportive care or active supportive care alone. Vinorelbine was given initially at 60 mg/m² weekly every 21 days, escalated to 80 mg/m² from cycle 2.

The median age of patients in VIM was approximately 71 years, and about 80% were male.

More partial responses were seen in the vinorelbine arm, at 3.1% of patients, compared with 1.8% for active supportive care, according to Prof. Fennell. Likewise, the rate of stable disease was higher in the vinorelbine arm, at 62.2%, versus 46.4% in the control arm.

The primary outcome of the study, PFS, was significantly improved in the vinorelbine arm, according to Dr. Fennell. The median PFS was 4.2 months in the vinorelbine arm and 2.8 months in the supportive care arm (P = .002), translating into a hazard ratio of 0.60 (95% confidence interval, 0.41-0.86), Prof. Fennell reported.

The most common grade 3-4 adverse event was neutropenia, occurring in 12.5% of the vinorelbine-treated patients and no patients managed with supportive care alone, according to the report. Other grade 3-4 adverse events occurred in fewer than 10% of patients and included dyspnea, lower respiratory infection, lymphopenia, and fatigue, among others.

Overall survival (OS) was not statistically different between vinorelbine and supportive care arms, with median OS of 9.3 months and 9.1 months, respectively.

However, a number of patients in the control arm went on to receive subsequent therapy, including 15 (or about 27%) who went into CONFIRM, a randomized phase 3 trial that, as recently reported, met its coprimary endpoints of improve OS and PFS with nivolumab vs. placebo in relapsed malignant mesothelioma.

Investigators also sought to test the hypothesis that BRCA1-negative patients might be chemoresistant, based in part on preclinical models demonstrating that BRCA1 predicted sensitivity to vinorelbine. However, there was no difference in PFS by BRCA1 expression in the VIM study, according to Prof. Fennell.

Taken together, findings of the VIM trial suggest vinorelbine is a “modestly active” agent with low cost and acceptable toxicity, according to Prof. Nowak.

“It is incumbent on us to have clear discussions with our patients on the risks and benefits of trying this as a subsequent-line therapy, in the context of this evidence that was generated as a second-line therapy,” she said in her discussant remarks on the study.

“I would say that it is a lower priority in our algorithm than cisplatin and pemetrexed, or of course, immuno-oncology agents,” she added.

Dr. Fennell reported disclosures related to AstraZeneca, Astex Therapeutics, Bayer, and multiple other pharmaceutical companies. Dr. Nowak reported disclosures with AstraZeneca, Atara Biotherapeutics, Boehringer Ingelheim, and multiple other pharmaceutical companies.

After decades of off-label use, vinorelbine finally has a randomized clinical trial supporting its efficacy as a second-line treatment of mesothelioma, an investigator reported at the annual meeting of the American Society of Clinical Oncology.

However, the development of other treatment regimens, and notably immuno-oncology approaches, are pushing this classic chemotherapy option to later lines of therapy in patients with malignant pleural mesothelioma (MPM), a speaker said at the meeting.

Adding vinorelbine to active symptom control statistically improved progression-free survival (PFS), among patients with MPM who had prior platinum-based therapy, according to results of the randomized Vinorelbine in Mesothelioma (VIM) trial.

Median PFS reached 4.2 months in the vinorelbine arm, versus 2.8 months for active symptom control alone, study results show.

That finding , coupled with safety results, supports the off-label use of vinorelbine as a treatment option for patients with relapsed MPM, according to investigator Dean Anthony Fennell, FRCP, PhD, of the University of Leicester (England).

“Vinorelbine appears to be a safe and effective treatment and could be considered as a treatment option for patients with relapsed mesothelioma,” Prof. Fennell said in his presentation at ASCO (Abstract 8507).
 

Changing status

While that welcome pronouncement was a long time coming, there are now other promising treatment approaches that relegate vinorelbine to a “lower priority” in the treatment algorithm, said discussant Anna K. Nowak, MBBS, FRACP, PhD, of the University of Western Australia, Nedlands.

In October 2020, the U.S. Food and Drug Administration approved the combination of ipilimumab and nivolumab for the first-line treatment of unresectable malignant pleural mesothelioma, on the basis of results from CHECKMATE-743, a randomized, open-label trial.

“Certainly, we know now that first-line ipilimumab and nivolumab is of very substantial benefit to these patients, and we still have clinical trials open in this space as well,” Prof. Nowak said in her discussion at ASCO.

There is “no doubt” that many patients with mesothelioma should at some point receive an IO agent, particularly now with recently reported randomized clinical trial evidence of an overall survival benefit, she added.

“This really pushes vinorelbine out to be a third- or fourth-line treatment,” she added, “and we know that there are usually diminishing returns from using chemotherapies further down the treatment algorithm.”
 

Trial details

The VIM trial described at ASCO by Prof. Fennell was a randomized, controlled phase 2 including 154 patients with MPM that had progressed after first-line chemotherapy.

“Vinorelbine has shown useful clinical activity in single-arm phase two studies, however, the specific efficacy of vinorelbine has not been evaluated in an appropriately controlled randomized trial,” Prof. Fennell said in this presentation.

Patients in the trial were randomized 2:1 to either vinorelbine plus active supportive care or active supportive care alone. Vinorelbine was given initially at 60 mg/m² weekly every 21 days, escalated to 80 mg/m² from cycle 2.

The median age of patients in VIM was approximately 71 years, and about 80% were male.

More partial responses were seen in the vinorelbine arm, at 3.1% of patients, compared with 1.8% for active supportive care, according to Prof. Fennell. Likewise, the rate of stable disease was higher in the vinorelbine arm, at 62.2%, versus 46.4% in the control arm.

The primary outcome of the study, PFS, was significantly improved in the vinorelbine arm, according to Dr. Fennell. The median PFS was 4.2 months in the vinorelbine arm and 2.8 months in the supportive care arm (P = .002), translating into a hazard ratio of 0.60 (95% confidence interval, 0.41-0.86), Prof. Fennell reported.

The most common grade 3-4 adverse event was neutropenia, occurring in 12.5% of the vinorelbine-treated patients and no patients managed with supportive care alone, according to the report. Other grade 3-4 adverse events occurred in fewer than 10% of patients and included dyspnea, lower respiratory infection, lymphopenia, and fatigue, among others.

Overall survival (OS) was not statistically different between vinorelbine and supportive care arms, with median OS of 9.3 months and 9.1 months, respectively.

However, a number of patients in the control arm went on to receive subsequent therapy, including 15 (or about 27%) who went into CONFIRM, a randomized phase 3 trial that, as recently reported, met its coprimary endpoints of improve OS and PFS with nivolumab vs. placebo in relapsed malignant mesothelioma.

Investigators also sought to test the hypothesis that BRCA1-negative patients might be chemoresistant, based in part on preclinical models demonstrating that BRCA1 predicted sensitivity to vinorelbine. However, there was no difference in PFS by BRCA1 expression in the VIM study, according to Prof. Fennell.

Taken together, findings of the VIM trial suggest vinorelbine is a “modestly active” agent with low cost and acceptable toxicity, according to Prof. Nowak.

“It is incumbent on us to have clear discussions with our patients on the risks and benefits of trying this as a subsequent-line therapy, in the context of this evidence that was generated as a second-line therapy,” she said in her discussant remarks on the study.

“I would say that it is a lower priority in our algorithm than cisplatin and pemetrexed, or of course, immuno-oncology agents,” she added.

Dr. Fennell reported disclosures related to AstraZeneca, Astex Therapeutics, Bayer, and multiple other pharmaceutical companies. Dr. Nowak reported disclosures with AstraZeneca, Atara Biotherapeutics, Boehringer Ingelheim, and multiple other pharmaceutical companies.

After decades of off-label use, vinorelbine finally has a randomized clinical trial supporting its efficacy as a second-line treatment of mesothelioma, an investigator reported at the annual meeting of the American Society of Clinical Oncology.

However, the development of other treatment regimens, and notably immuno-oncology approaches, are pushing this classic chemotherapy option to later lines of therapy in patients with malignant pleural mesothelioma (MPM), a speaker said at the meeting.

Adding vinorelbine to active symptom control statistically improved progression-free survival (PFS), among patients with MPM who had prior platinum-based therapy, according to results of the randomized Vinorelbine in Mesothelioma (VIM) trial.

Median PFS reached 4.2 months in the vinorelbine arm, versus 2.8 months for active symptom control alone, study results show.

That finding , coupled with safety results, supports the off-label use of vinorelbine as a treatment option for patients with relapsed MPM, according to investigator Dean Anthony Fennell, FRCP, PhD, of the University of Leicester (England).

“Vinorelbine appears to be a safe and effective treatment and could be considered as a treatment option for patients with relapsed mesothelioma,” Prof. Fennell said in his presentation at ASCO (Abstract 8507).
 

Changing status

While that welcome pronouncement was a long time coming, there are now other promising treatment approaches that relegate vinorelbine to a “lower priority” in the treatment algorithm, said discussant Anna K. Nowak, MBBS, FRACP, PhD, of the University of Western Australia, Nedlands.

In October 2020, the U.S. Food and Drug Administration approved the combination of ipilimumab and nivolumab for the first-line treatment of unresectable malignant pleural mesothelioma, on the basis of results from CHECKMATE-743, a randomized, open-label trial.

“Certainly, we know now that first-line ipilimumab and nivolumab is of very substantial benefit to these patients, and we still have clinical trials open in this space as well,” Prof. Nowak said in her discussion at ASCO.

There is “no doubt” that many patients with mesothelioma should at some point receive an IO agent, particularly now with recently reported randomized clinical trial evidence of an overall survival benefit, she added.

“This really pushes vinorelbine out to be a third- or fourth-line treatment,” she added, “and we know that there are usually diminishing returns from using chemotherapies further down the treatment algorithm.”
 

Trial details

The VIM trial described at ASCO by Prof. Fennell was a randomized, controlled phase 2 including 154 patients with MPM that had progressed after first-line chemotherapy.

“Vinorelbine has shown useful clinical activity in single-arm phase two studies, however, the specific efficacy of vinorelbine has not been evaluated in an appropriately controlled randomized trial,” Prof. Fennell said in this presentation.

Patients in the trial were randomized 2:1 to either vinorelbine plus active supportive care or active supportive care alone. Vinorelbine was given initially at 60 mg/m² weekly every 21 days, escalated to 80 mg/m² from cycle 2.

The median age of patients in VIM was approximately 71 years, and about 80% were male.

More partial responses were seen in the vinorelbine arm, at 3.1% of patients, compared with 1.8% for active supportive care, according to Prof. Fennell. Likewise, the rate of stable disease was higher in the vinorelbine arm, at 62.2%, versus 46.4% in the control arm.

The primary outcome of the study, PFS, was significantly improved in the vinorelbine arm, according to Dr. Fennell. The median PFS was 4.2 months in the vinorelbine arm and 2.8 months in the supportive care arm (P = .002), translating into a hazard ratio of 0.60 (95% confidence interval, 0.41-0.86), Prof. Fennell reported.

The most common grade 3-4 adverse event was neutropenia, occurring in 12.5% of the vinorelbine-treated patients and no patients managed with supportive care alone, according to the report. Other grade 3-4 adverse events occurred in fewer than 10% of patients and included dyspnea, lower respiratory infection, lymphopenia, and fatigue, among others.

Overall survival (OS) was not statistically different between vinorelbine and supportive care arms, with median OS of 9.3 months and 9.1 months, respectively.

However, a number of patients in the control arm went on to receive subsequent therapy, including 15 (or about 27%) who went into CONFIRM, a randomized phase 3 trial that, as recently reported, met its coprimary endpoints of improve OS and PFS with nivolumab vs. placebo in relapsed malignant mesothelioma.

Investigators also sought to test the hypothesis that BRCA1-negative patients might be chemoresistant, based in part on preclinical models demonstrating that BRCA1 predicted sensitivity to vinorelbine. However, there was no difference in PFS by BRCA1 expression in the VIM study, according to Prof. Fennell.

Taken together, findings of the VIM trial suggest vinorelbine is a “modestly active” agent with low cost and acceptable toxicity, according to Prof. Nowak.

“It is incumbent on us to have clear discussions with our patients on the risks and benefits of trying this as a subsequent-line therapy, in the context of this evidence that was generated as a second-line therapy,” she said in her discussant remarks on the study.

“I would say that it is a lower priority in our algorithm than cisplatin and pemetrexed, or of course, immuno-oncology agents,” she added.

Dr. Fennell reported disclosures related to AstraZeneca, Astex Therapeutics, Bayer, and multiple other pharmaceutical companies. Dr. Nowak reported disclosures with AstraZeneca, Atara Biotherapeutics, Boehringer Ingelheim, and multiple other pharmaceutical companies.

The first KRAS inhibitor approved for the treatment of lung cancer provided a clinically meaningful overall survival benefit in an updated analysis of a phase 2 study.

Treatment with sotorasib yielded a median overall survival (OS) of 12.5 months in patients with previously treated KRAS p.G12C-mutated non-small cell lung cancer (NSCLC), according to an analysis of the phase 2 CodeBreaK 100 trial data presented at the American Society of Clinical Oncology Annual Meeting.

Median progression-free survival (PFS) was 6.8 months in this update, which included a median follow-up of more than 15 months, according to investigator Ferdinandos Skoulidis, MD, PhD, assistant professor of thoracic/head and neck medical oncology at the University of Texas MD Anderson Cancer Center in Houston.

Efficacy responses

The confirmed objective response rate was 37.1%, including a 3.2% complete response rate and a median duration of response of 11.1 months, according to the report by Dr. Skoulidis.

In exploratory analyses, the benefit of sotorasib was consistent across patient subgroups, Dr. Skoulidis said in his presentation (Abstract 9003).

In particular, efficacy was observed in subgroups with co-occurring mutations in TP53, STK11, and KEAP1, which are molecular indicators of suboptimal outcomes on standard systemic treatments, according to Dr. Skoulidis.

This update on the registrational phase 2 CodeBreaK100 trial, published concurrently in the New England Journal of Medicine , came just one week after the U.S. Food and Drug Administration (FDA) granted accelerated approval to sotorasib.

Sotorasib was approved for the treatment of patients with previously treated KRAS G12C‑mutated locally advanced or metastatic NSCLC on the basis of previously reported results from CodeBreaK100.

This sotorasib indication represents a “historic milestone,” Dr. Skoulidis said in an interview.

No previously studied selective KRAS inhibitor has been approved despite scientific research efforts that stretch back nearly four decades, he explained.

“In a way, one can say that we have dealt KRAS-mutant lung cancer a knockdown blow, however, I should point out that the fight is not over,” he added.

“These clinical results will no doubt spearhead and galvanize further efforts to develop even more effective therapeutic combinations in the future, as well as identify and either forestall or overcome the eventual development of acquired resistance,” he said.
 

Only 1 out of 8 patients

The KRAS p.G12C mutation is present in about 13% of lung adenocarcinomas, or about one in every eight patients with nonsquamous NSCLC, Dr. Skoulidis said in the interview.

“We are estimating that this is in the region of 13,000 patients newly diagnosed every year in the U.S., and approximately 13,000 patients or so that are currently being treated in the second- or third-line setting,” he said.

The CodeBreaK100 trial included 126 patients with locally advanced or metastatic NSCLC and KRAS p.G12C mutation who had progressed on prior systemic therapies. About 43% had one prior line of treatment, while 35% had two lines, and 22% had three lines. A total of 81% had previously received both platinum-based chemotherapy and PD-1/PD-L1 axis inhibitors.

Most treatment-related adverse events in the study were grade 1-2 and generally manageable, according to Dr. Skoulidis. About 20% of patients experienced grade 3 treatment-related adverse events, which were mostly diarrhea or increases in aspartate aminotransferase and alanine aminotransferase levels. A grade 4 treatment-related adverse event, pneumonitis and dyspnea, was reported in one patient or approximately 1%.
 

Confirmatory trial

Although CodeBreak100 is not a randomized trial, the median OS of 12.5 months compares favorably to median OS times in the range of 7.9-10.3 months reported in randomized phase 3 clinical trials and subgroup analysis of randomized phase 3 trials of docetaxel for patients with KRAS-mutant lung adenocarcinoma, Dr. Skoulidis said in a question-and-answer session.

A confirmatory phase 3 CodeBreaK200 trial of sotorasib versus docetaxel in patients with previously treated KRAS p.G12C-mutated NSCLC is underway. That trial is evaluating PFS as a primary endpoint and OS as a secondary endpoint.

“If the same magnitude of benefit, 12.5 months median overall survival, is confirmed in the larger phase 3 clinical trial, as a clinician I would consider that beneficial for patients, compared to the standard of care,” Dr. Skoulidis said during the session.
 

Mature data

The updated analysis of the phase 2 CodeBreaK100 study is notable for its mature OS data, updated safety and the first molecular subgroup analyses, according to discussant Christine Marie Lovly, MD, PhD, of the division of hematology-oncology at Vanderbilt University Medical Center in Nashville.

“The objective response rate was 37.1%,” she added. “This is a little bit lower than we’re used to for targeted therapies, but remember, this is a different mutation and a very different class of drugs.”

The KRAS G12C inhibitors, several of which are under clinical development, are not tyrosine kinase inhibitors (TKIs), but rather allele-specific inhibitors that target mutant KRAS, trapping it in an inactive conformation, she explained.

Dr. Lovly referenced the exploratory analyses demonstrating efficacy in molecularly defined subgroups, calling it “interesting” that there was no difference in objective response rate between TP53 wild type and mutant tumors.

“We do have data that mutant TP53 seems to confer inferior outcomes for EGFR TKI-directed therapy in patients with EGFR-mutant lung cancer,” she said.

CodeBreaK100 was supported by Amgen, Inc. and partly by a National Institutes of Health Cancer Center Support Grant at Memorial Sloan Kettering Cancer Center.

Dr. Skoulidis reported honoraria from Bristol-Myers Squibb; research funding from AIMM Therapeutics and Amgen; and travel, accommodations, or expenses from Tango Therapeutics. Dr. Lovly reported disclosures related to Amgen, AstraZeneca, Genentech, Novartis, and Pfizer, among others.

The first KRAS inhibitor approved for the treatment of lung cancer provided a clinically meaningful overall survival benefit in an updated analysis of a phase 2 study.

Treatment with sotorasib yielded a median overall survival (OS) of 12.5 months in patients with previously treated KRAS p.G12C-mutated non-small cell lung cancer (NSCLC), according to an analysis of the phase 2 CodeBreaK 100 trial data presented at the American Society of Clinical Oncology Annual Meeting.

Median progression-free survival (PFS) was 6.8 months in this update, which included a median follow-up of more than 15 months, according to investigator Ferdinandos Skoulidis, MD, PhD, assistant professor of thoracic/head and neck medical oncology at the University of Texas MD Anderson Cancer Center in Houston.

Efficacy responses

The confirmed objective response rate was 37.1%, including a 3.2% complete response rate and a median duration of response of 11.1 months, according to the report by Dr. Skoulidis.

In exploratory analyses, the benefit of sotorasib was consistent across patient subgroups, Dr. Skoulidis said in his presentation (Abstract 9003).

In particular, efficacy was observed in subgroups with co-occurring mutations in TP53, STK11, and KEAP1, which are molecular indicators of suboptimal outcomes on standard systemic treatments, according to Dr. Skoulidis.

This update on the registrational phase 2 CodeBreaK100 trial, published concurrently in the New England Journal of Medicine , came just one week after the U.S. Food and Drug Administration (FDA) granted accelerated approval to sotorasib.

Sotorasib was approved for the treatment of patients with previously treated KRAS G12C‑mutated locally advanced or metastatic NSCLC on the basis of previously reported results from CodeBreaK100.

This sotorasib indication represents a “historic milestone,” Dr. Skoulidis said in an interview.

No previously studied selective KRAS inhibitor has been approved despite scientific research efforts that stretch back nearly four decades, he explained.

“In a way, one can say that we have dealt KRAS-mutant lung cancer a knockdown blow, however, I should point out that the fight is not over,” he added.

“These clinical results will no doubt spearhead and galvanize further efforts to develop even more effective therapeutic combinations in the future, as well as identify and either forestall or overcome the eventual development of acquired resistance,” he said.
 

Only 1 out of 8 patients

The KRAS p.G12C mutation is present in about 13% of lung adenocarcinomas, or about one in every eight patients with nonsquamous NSCLC, Dr. Skoulidis said in the interview.

“We are estimating that this is in the region of 13,000 patients newly diagnosed every year in the U.S., and approximately 13,000 patients or so that are currently being treated in the second- or third-line setting,” he said.

The CodeBreaK100 trial included 126 patients with locally advanced or metastatic NSCLC and KRAS p.G12C mutation who had progressed on prior systemic therapies. About 43% had one prior line of treatment, while 35% had two lines, and 22% had three lines. A total of 81% had previously received both platinum-based chemotherapy and PD-1/PD-L1 axis inhibitors.

Most treatment-related adverse events in the study were grade 1-2 and generally manageable, according to Dr. Skoulidis. About 20% of patients experienced grade 3 treatment-related adverse events, which were mostly diarrhea or increases in aspartate aminotransferase and alanine aminotransferase levels. A grade 4 treatment-related adverse event, pneumonitis and dyspnea, was reported in one patient or approximately 1%.
 

Confirmatory trial

Although CodeBreak100 is not a randomized trial, the median OS of 12.5 months compares favorably to median OS times in the range of 7.9-10.3 months reported in randomized phase 3 clinical trials and subgroup analysis of randomized phase 3 trials of docetaxel for patients with KRAS-mutant lung adenocarcinoma, Dr. Skoulidis said in a question-and-answer session.

A confirmatory phase 3 CodeBreaK200 trial of sotorasib versus docetaxel in patients with previously treated KRAS p.G12C-mutated NSCLC is underway. That trial is evaluating PFS as a primary endpoint and OS as a secondary endpoint.

“If the same magnitude of benefit, 12.5 months median overall survival, is confirmed in the larger phase 3 clinical trial, as a clinician I would consider that beneficial for patients, compared to the standard of care,” Dr. Skoulidis said during the session.
 

Mature data

The updated analysis of the phase 2 CodeBreaK100 study is notable for its mature OS data, updated safety and the first molecular subgroup analyses, according to discussant Christine Marie Lovly, MD, PhD, of the division of hematology-oncology at Vanderbilt University Medical Center in Nashville.

“The objective response rate was 37.1%,” she added. “This is a little bit lower than we’re used to for targeted therapies, but remember, this is a different mutation and a very different class of drugs.”

The KRAS G12C inhibitors, several of which are under clinical development, are not tyrosine kinase inhibitors (TKIs), but rather allele-specific inhibitors that target mutant KRAS, trapping it in an inactive conformation, she explained.

Dr. Lovly referenced the exploratory analyses demonstrating efficacy in molecularly defined subgroups, calling it “interesting” that there was no difference in objective response rate between TP53 wild type and mutant tumors.

“We do have data that mutant TP53 seems to confer inferior outcomes for EGFR TKI-directed therapy in patients with EGFR-mutant lung cancer,” she said.

CodeBreaK100 was supported by Amgen, Inc. and partly by a National Institutes of Health Cancer Center Support Grant at Memorial Sloan Kettering Cancer Center.

Dr. Skoulidis reported honoraria from Bristol-Myers Squibb; research funding from AIMM Therapeutics and Amgen; and travel, accommodations, or expenses from Tango Therapeutics. Dr. Lovly reported disclosures related to Amgen, AstraZeneca, Genentech, Novartis, and Pfizer, among others.

The first KRAS inhibitor approved for the treatment of lung cancer provided a clinically meaningful overall survival benefit in an updated analysis of a phase 2 study.

Treatment with sotorasib yielded a median overall survival (OS) of 12.5 months in patients with previously treated KRAS p.G12C-mutated non-small cell lung cancer (NSCLC), according to an analysis of the phase 2 CodeBreaK 100 trial data presented at the American Society of Clinical Oncology Annual Meeting.

Median progression-free survival (PFS) was 6.8 months in this update, which included a median follow-up of more than 15 months, according to investigator Ferdinandos Skoulidis, MD, PhD, assistant professor of thoracic/head and neck medical oncology at the University of Texas MD Anderson Cancer Center in Houston.

Efficacy responses

The confirmed objective response rate was 37.1%, including a 3.2% complete response rate and a median duration of response of 11.1 months, according to the report by Dr. Skoulidis.

In exploratory analyses, the benefit of sotorasib was consistent across patient subgroups, Dr. Skoulidis said in his presentation (Abstract 9003).

In particular, efficacy was observed in subgroups with co-occurring mutations in TP53, STK11, and KEAP1, which are molecular indicators of suboptimal outcomes on standard systemic treatments, according to Dr. Skoulidis.

This update on the registrational phase 2 CodeBreaK100 trial, published concurrently in the New England Journal of Medicine , came just one week after the U.S. Food and Drug Administration (FDA) granted accelerated approval to sotorasib.

Sotorasib was approved for the treatment of patients with previously treated KRAS G12C‑mutated locally advanced or metastatic NSCLC on the basis of previously reported results from CodeBreaK100.

This sotorasib indication represents a “historic milestone,” Dr. Skoulidis said in an interview.

No previously studied selective KRAS inhibitor has been approved despite scientific research efforts that stretch back nearly four decades, he explained.

“In a way, one can say that we have dealt KRAS-mutant lung cancer a knockdown blow, however, I should point out that the fight is not over,” he added.

“These clinical results will no doubt spearhead and galvanize further efforts to develop even more effective therapeutic combinations in the future, as well as identify and either forestall or overcome the eventual development of acquired resistance,” he said.
 

Only 1 out of 8 patients

The KRAS p.G12C mutation is present in about 13% of lung adenocarcinomas, or about one in every eight patients with nonsquamous NSCLC, Dr. Skoulidis said in the interview.

“We are estimating that this is in the region of 13,000 patients newly diagnosed every year in the U.S., and approximately 13,000 patients or so that are currently being treated in the second- or third-line setting,” he said.

The CodeBreaK100 trial included 126 patients with locally advanced or metastatic NSCLC and KRAS p.G12C mutation who had progressed on prior systemic therapies. About 43% had one prior line of treatment, while 35% had two lines, and 22% had three lines. A total of 81% had previously received both platinum-based chemotherapy and PD-1/PD-L1 axis inhibitors.

Most treatment-related adverse events in the study were grade 1-2 and generally manageable, according to Dr. Skoulidis. About 20% of patients experienced grade 3 treatment-related adverse events, which were mostly diarrhea or increases in aspartate aminotransferase and alanine aminotransferase levels. A grade 4 treatment-related adverse event, pneumonitis and dyspnea, was reported in one patient or approximately 1%.
 

Confirmatory trial

Although CodeBreak100 is not a randomized trial, the median OS of 12.5 months compares favorably to median OS times in the range of 7.9-10.3 months reported in randomized phase 3 clinical trials and subgroup analysis of randomized phase 3 trials of docetaxel for patients with KRAS-mutant lung adenocarcinoma, Dr. Skoulidis said in a question-and-answer session.

A confirmatory phase 3 CodeBreaK200 trial of sotorasib versus docetaxel in patients with previously treated KRAS p.G12C-mutated NSCLC is underway. That trial is evaluating PFS as a primary endpoint and OS as a secondary endpoint.

“If the same magnitude of benefit, 12.5 months median overall survival, is confirmed in the larger phase 3 clinical trial, as a clinician I would consider that beneficial for patients, compared to the standard of care,” Dr. Skoulidis said during the session.
 

Mature data

The updated analysis of the phase 2 CodeBreaK100 study is notable for its mature OS data, updated safety and the first molecular subgroup analyses, according to discussant Christine Marie Lovly, MD, PhD, of the division of hematology-oncology at Vanderbilt University Medical Center in Nashville.

“The objective response rate was 37.1%,” she added. “This is a little bit lower than we’re used to for targeted therapies, but remember, this is a different mutation and a very different class of drugs.”

The KRAS G12C inhibitors, several of which are under clinical development, are not tyrosine kinase inhibitors (TKIs), but rather allele-specific inhibitors that target mutant KRAS, trapping it in an inactive conformation, she explained.

Dr. Lovly referenced the exploratory analyses demonstrating efficacy in molecularly defined subgroups, calling it “interesting” that there was no difference in objective response rate between TP53 wild type and mutant tumors.

“We do have data that mutant TP53 seems to confer inferior outcomes for EGFR TKI-directed therapy in patients with EGFR-mutant lung cancer,” she said.

CodeBreaK100 was supported by Amgen, Inc. and partly by a National Institutes of Health Cancer Center Support Grant at Memorial Sloan Kettering Cancer Center.

Dr. Skoulidis reported honoraria from Bristol-Myers Squibb; research funding from AIMM Therapeutics and Amgen; and travel, accommodations, or expenses from Tango Therapeutics. Dr. Lovly reported disclosures related to Amgen, AstraZeneca, Genentech, Novartis, and Pfizer, among others.

Lung cancer patients treated in community practices are not being comprehensively tested for biomarkers that could guide choice of first-line therapy, a recent retrospective analysis shows.

Less than half of patients with previously untreated non-small cell lung cancer (NSCLC) in a network of community practices underwent testing for all five biomarkers evaluated in the study, which was presented at the annual meeting of the American Society of Clinical Oncology (Abstract 9004).

Almost all of the 3,474 patients in the study (90%) had been tested for at least one biomarker, according to investigator Makenzi Colleen Evangelist, MD, an oncologist with New York Oncology Hematology, a practice in the US Oncology Network.

Only 46% were tested for all five biomarkers—ALK, BRAF, EGFR, ROS1, and PD-L1.

“While the proportion of patients tested for all five biomarkers increased over time, testing rates remain low at approximately 50%,” Dr. Evangelist said in a presentation of the results at the meeting.

This gap in testing illustrates “significant implementation challenges” that exist despite tremendous advances in biomarker-driven drug development and the technology to detect the mutations that can guide therapy, said Christine Marie Lovly, MD, PhD, the invited discussant for the study. “I would strongly argue that we have to apply what we already have to get equity, while still pushing the science forward,” said Dr. Lovly of the division of hematology-oncology at Vanderbilt University Medical Center in Nashville.

“We don’t want to miss the low-hanging fruit,” Dr. Lovly said. “We have to be able to make sure every patient with an EGFR mutation gets an EGFR tyrosine kinase inhibitor, and so forth, for all the other biomarkers that we test for.”
 

Real-world testing

The retrospective analysis of real-world biomarker testing patterns presented by Dr. Evangelist is the first of three protocols in the MYLUNG Consortium, a collaborative research study being conducted over a five-year period, according to the US Oncology Network.

The review of electronic health records included patients with metastatic NSCLC starting first-line systemic therapy between April 2018 and March 2020 in the US Oncology Network of community practices.

Rates of biomarker testing were highest for PD-L1, which was done for 83% of patients, the data show. EGFR and ALK testing were performed in 70% of patients, while ROS1 was evaluated in 68%. BRAF testing was done in 55% of patients. Testing rates appeared to be numerically higher for lung cancers with nonsquamous histology, according to Dr. Evangelist.

Over time, rates of specific biomarker testing were essentially unchanged, though a significant difference was seen for BRAF testing over time. BRAF was evaluated in 54% of patients starting therapy from April 2018 through September 2018, and 59%-62% in subsequent time periods (P = .005).

The proportion of patients tested for all five biomarkers was 44% in the April-September 2018 time period, and 50%-53% in subsequent time periods, the data show (P = .0056).

The proportion of patients tested with next-generation sequencing rose from 33% to 45% between 2018 and 2020, suggesting that comprehensive testing is increasing, according to Dr. Evangelist.

The turnaround time from testing orders to results was approximately 2 weeks, underscoring a need to get test results to oncologists sooner so they can consider biomarker data as they develop a treatment plan, the US Oncology Network said in a press release that described the study.

Median time from diagnosis to treatment in the study was approximately 5 weeks, which is “a concern for patients anxiously waiting for treatment,” the press release said.
 

Raising awareness

This study should serve to raise awareness that not all NSCLC patients who should be tested are being tested, study co-author Nicholas Robert, MD, said in an interview.

“There is a great line – ‘right drug, right patient, right time’ – and we’re not meeting that,” said Dr. Robert, vice president of medical affairs for Ontada, an oncology insights and technology company that is part of McKesson, which acquired the US Oncology Network in 2010.

The hope is that general oncologists will begin thinking of biomarker testing in NSCLC as being essential in the same way hormone receptor and HER2 testing are in breast cancer, according to Dr. Robert.

“You would never think about treating anyone with breast cancer without those variables,” he said. “We’d like to think that the general oncologist feels the same way about biomarkers in non-small cell cancer, that it’s something that should be done routinely across the board.”

The next phase of the MYLUNG Consortium study will prospectively evaluate biomarker test-ordering practices, turnaround times, and treatment decision making in approximately 1,000 patients from 11 sites, while the final phase will evaluate interventions to improve biomarker testing and access to therapies in up to 7,500 patients at 20 sites, according to the US Oncology Network.

Dr. Evangelist reported a consulting or advisory role with Takeda and AstraZeneca. Dr. Robert reported employment, leadership, and stock/ownership interest disclosures related to McKesson, along with other disclosures related to Johnson & Johnson, Oncolytics Biotech, Bristol-Myers Squibb, Roche, Advi, Boehringer Ingelheim, and New Century Health. Dr. Lovly reported disclosures related to Amgen, AstraZeneca, Genentech, Novartis, and Pfizer, among others.

Lung cancer patients treated in community practices are not being comprehensively tested for biomarkers that could guide choice of first-line therapy, a recent retrospective analysis shows.

Less than half of patients with previously untreated non-small cell lung cancer (NSCLC) in a network of community practices underwent testing for all five biomarkers evaluated in the study, which was presented at the annual meeting of the American Society of Clinical Oncology (Abstract 9004).

Almost all of the 3,474 patients in the study (90%) had been tested for at least one biomarker, according to investigator Makenzi Colleen Evangelist, MD, an oncologist with New York Oncology Hematology, a practice in the US Oncology Network.

Only 46% were tested for all five biomarkers—ALK, BRAF, EGFR, ROS1, and PD-L1.

“While the proportion of patients tested for all five biomarkers increased over time, testing rates remain low at approximately 50%,” Dr. Evangelist said in a presentation of the results at the meeting.

This gap in testing illustrates “significant implementation challenges” that exist despite tremendous advances in biomarker-driven drug development and the technology to detect the mutations that can guide therapy, said Christine Marie Lovly, MD, PhD, the invited discussant for the study. “I would strongly argue that we have to apply what we already have to get equity, while still pushing the science forward,” said Dr. Lovly of the division of hematology-oncology at Vanderbilt University Medical Center in Nashville.

“We don’t want to miss the low-hanging fruit,” Dr. Lovly said. “We have to be able to make sure every patient with an EGFR mutation gets an EGFR tyrosine kinase inhibitor, and so forth, for all the other biomarkers that we test for.”
 

Real-world testing

The retrospective analysis of real-world biomarker testing patterns presented by Dr. Evangelist is the first of three protocols in the MYLUNG Consortium, a collaborative research study being conducted over a five-year period, according to the US Oncology Network.

The review of electronic health records included patients with metastatic NSCLC starting first-line systemic therapy between April 2018 and March 2020 in the US Oncology Network of community practices.

Rates of biomarker testing were highest for PD-L1, which was done for 83% of patients, the data show. EGFR and ALK testing were performed in 70% of patients, while ROS1 was evaluated in 68%. BRAF testing was done in 55% of patients. Testing rates appeared to be numerically higher for lung cancers with nonsquamous histology, according to Dr. Evangelist.

Over time, rates of specific biomarker testing were essentially unchanged, though a significant difference was seen for BRAF testing over time. BRAF was evaluated in 54% of patients starting therapy from April 2018 through September 2018, and 59%-62% in subsequent time periods (P = .005).

The proportion of patients tested for all five biomarkers was 44% in the April-September 2018 time period, and 50%-53% in subsequent time periods, the data show (P = .0056).

The proportion of patients tested with next-generation sequencing rose from 33% to 45% between 2018 and 2020, suggesting that comprehensive testing is increasing, according to Dr. Evangelist.

The turnaround time from testing orders to results was approximately 2 weeks, underscoring a need to get test results to oncologists sooner so they can consider biomarker data as they develop a treatment plan, the US Oncology Network said in a press release that described the study.

Median time from diagnosis to treatment in the study was approximately 5 weeks, which is “a concern for patients anxiously waiting for treatment,” the press release said.
 

Raising awareness

This study should serve to raise awareness that not all NSCLC patients who should be tested are being tested, study co-author Nicholas Robert, MD, said in an interview.

“There is a great line – ‘right drug, right patient, right time’ – and we’re not meeting that,” said Dr. Robert, vice president of medical affairs for Ontada, an oncology insights and technology company that is part of McKesson, which acquired the US Oncology Network in 2010.

The hope is that general oncologists will begin thinking of biomarker testing in NSCLC as being essential in the same way hormone receptor and HER2 testing are in breast cancer, according to Dr. Robert.

“You would never think about treating anyone with breast cancer without those variables,” he said. “We’d like to think that the general oncologist feels the same way about biomarkers in non-small cell cancer, that it’s something that should be done routinely across the board.”

The next phase of the MYLUNG Consortium study will prospectively evaluate biomarker test-ordering practices, turnaround times, and treatment decision making in approximately 1,000 patients from 11 sites, while the final phase will evaluate interventions to improve biomarker testing and access to therapies in up to 7,500 patients at 20 sites, according to the US Oncology Network.

Dr. Evangelist reported a consulting or advisory role with Takeda and AstraZeneca. Dr. Robert reported employment, leadership, and stock/ownership interest disclosures related to McKesson, along with other disclosures related to Johnson & Johnson, Oncolytics Biotech, Bristol-Myers Squibb, Roche, Advi, Boehringer Ingelheim, and New Century Health. Dr. Lovly reported disclosures related to Amgen, AstraZeneca, Genentech, Novartis, and Pfizer, among others.

Lung cancer patients treated in community practices are not being comprehensively tested for biomarkers that could guide choice of first-line therapy, a recent retrospective analysis shows.

Less than half of patients with previously untreated non-small cell lung cancer (NSCLC) in a network of community practices underwent testing for all five biomarkers evaluated in the study, which was presented at the annual meeting of the American Society of Clinical Oncology (Abstract 9004).

Almost all of the 3,474 patients in the study (90%) had been tested for at least one biomarker, according to investigator Makenzi Colleen Evangelist, MD, an oncologist with New York Oncology Hematology, a practice in the US Oncology Network.

Only 46% were tested for all five biomarkers—ALK, BRAF, EGFR, ROS1, and PD-L1.

“While the proportion of patients tested for all five biomarkers increased over time, testing rates remain low at approximately 50%,” Dr. Evangelist said in a presentation of the results at the meeting.

This gap in testing illustrates “significant implementation challenges” that exist despite tremendous advances in biomarker-driven drug development and the technology to detect the mutations that can guide therapy, said Christine Marie Lovly, MD, PhD, the invited discussant for the study. “I would strongly argue that we have to apply what we already have to get equity, while still pushing the science forward,” said Dr. Lovly of the division of hematology-oncology at Vanderbilt University Medical Center in Nashville.

“We don’t want to miss the low-hanging fruit,” Dr. Lovly said. “We have to be able to make sure every patient with an EGFR mutation gets an EGFR tyrosine kinase inhibitor, and so forth, for all the other biomarkers that we test for.”
 

Real-world testing

The retrospective analysis of real-world biomarker testing patterns presented by Dr. Evangelist is the first of three protocols in the MYLUNG Consortium, a collaborative research study being conducted over a five-year period, according to the US Oncology Network.

The review of electronic health records included patients with metastatic NSCLC starting first-line systemic therapy between April 2018 and March 2020 in the US Oncology Network of community practices.

Rates of biomarker testing were highest for PD-L1, which was done for 83% of patients, the data show. EGFR and ALK testing were performed in 70% of patients, while ROS1 was evaluated in 68%. BRAF testing was done in 55% of patients. Testing rates appeared to be numerically higher for lung cancers with nonsquamous histology, according to Dr. Evangelist.

Over time, rates of specific biomarker testing were essentially unchanged, though a significant difference was seen for BRAF testing over time. BRAF was evaluated in 54% of patients starting therapy from April 2018 through September 2018, and 59%-62% in subsequent time periods (P = .005).

The proportion of patients tested for all five biomarkers was 44% in the April-September 2018 time period, and 50%-53% in subsequent time periods, the data show (P = .0056).

The proportion of patients tested with next-generation sequencing rose from 33% to 45% between 2018 and 2020, suggesting that comprehensive testing is increasing, according to Dr. Evangelist.

The turnaround time from testing orders to results was approximately 2 weeks, underscoring a need to get test results to oncologists sooner so they can consider biomarker data as they develop a treatment plan, the US Oncology Network said in a press release that described the study.

Median time from diagnosis to treatment in the study was approximately 5 weeks, which is “a concern for patients anxiously waiting for treatment,” the press release said.
 

Raising awareness

This study should serve to raise awareness that not all NSCLC patients who should be tested are being tested, study co-author Nicholas Robert, MD, said in an interview.

“There is a great line – ‘right drug, right patient, right time’ – and we’re not meeting that,” said Dr. Robert, vice president of medical affairs for Ontada, an oncology insights and technology company that is part of McKesson, which acquired the US Oncology Network in 2010.

The hope is that general oncologists will begin thinking of biomarker testing in NSCLC as being essential in the same way hormone receptor and HER2 testing are in breast cancer, according to Dr. Robert.

“You would never think about treating anyone with breast cancer without those variables,” he said. “We’d like to think that the general oncologist feels the same way about biomarkers in non-small cell cancer, that it’s something that should be done routinely across the board.”

The next phase of the MYLUNG Consortium study will prospectively evaluate biomarker test-ordering practices, turnaround times, and treatment decision making in approximately 1,000 patients from 11 sites, while the final phase will evaluate interventions to improve biomarker testing and access to therapies in up to 7,500 patients at 20 sites, according to the US Oncology Network.

Dr. Evangelist reported a consulting or advisory role with Takeda and AstraZeneca. Dr. Robert reported employment, leadership, and stock/ownership interest disclosures related to McKesson, along with other disclosures related to Johnson & Johnson, Oncolytics Biotech, Bristol-Myers Squibb, Roche, Advi, Boehringer Ingelheim, and New Century Health. Dr. Lovly reported disclosures related to Amgen, AstraZeneca, Genentech, Novartis, and Pfizer, among others.

Experiencing an immune-related adverse event during checkpoint inhibitor treatment may predict outcomes in patients with non-small cell lung cancer, exploratory analyses of phase 3 trials suggest.

Immune-related adverse events (irAEs) were tied to longer overall survival (OS) in exploratory pooled analyses of three phase 3 clinical trials evaluating atezolizumab-based regimens, according to investigator Mark A. Socinski, MD, of AdventHealth Cancer Institute, Orlando, Fla.

Median OS approached 26 months for patients who received first-line atezolizumab and experienced an irAE, compared with just 13 months for those who did not experience an irAE, according to results reported at the American Society of Clinical Oncology Annual Meeting (Abstract 9002).

Atezolizumab-treated patients with grade 3 or greater irAEs had the shortest OS, shorter than those atezolizumab-treated patients who experienced grade 1-2 irAEs or no irAEs at all. That short OS may be due to treatment interruptions or discontinuations, said Dr. Socinski.

“Data from these analyses suggest an association between irAEs and efficacy in patients with [non-small cell cancer] NSCLC,” he stated in his presentation of the results.
 

A lot more to learn about irAEs

Similar linkages between irAEs and outcomes were observed in pooled analyses of patients enrolled in the control arms of the phase 3 trials, with a median OS of about 20 months for control patients experiencing an irAE, versus about 13 months for those who did not.

That linkage in the control arm prompted a question from an ASCO attendee about why an effect of irAEs, commonly associated with immune checkpoint inhibitor therapy, would be evident in analyses of patients who did not receive those agents.

In his response, Dr. Socinski characterized the finding as “a surprise” and said the finding may either reflect how adverse events are characterized or how chemotherapy impacts the immune system.

“I don’t know that our definition of irAEs is perfect,” he said, “and maybe we don’t understand what impact chemotherapy may have on the immune system, and may actually engender what historically we’ve always seen as an adverse event, but didn’t necessarily classify as an immune-related adverse event.”

More work is needed to better understand the connection between irAES and outcomes, and whether anything can be done as a result of that improved understanding, said discussant Mary Weber Redman, PhD.

“The question is, ‘what is actionable?’” added Dr. Redman, a biostatistician at the Fred Hutchinson Cancer Research Center, Seattle.

A firmer understanding of the relationship between irAEs and outcomes could change how clinicians monitor patients for irAEs, lead to better prediction of which patients may experience higher grade irAEs, and ultimately impact treatment selection potentially to avoid those higher grade events, Dr. Redman said in her remarks.

“Doing these types of analyses are quite important, because we have to look at the breadth of information that we have to be able to interpret that and think about what are future questions,” she said in the question-and-answer session accompanying Dr. Socinski’s presentation.

“I think the key is that we shouldn’t use these analyses to be definitive, but we should use them as to be hypothesis generating,” she added.
 

More evidence to link irAEs and outcomes

Immune-related AEs caused by off-target immune and inflammatory activity have been reported in up to 80% of patients receiving immune checkpoint inhibitors as monotherapy and up to 95% in combination regimens, Dr. Socinski said in his presentation.

“Increasing evidence suggests that the occurrence of immune-related adverse events with PD-L1 or PD-1 inhibitor therapy may be predictive of improved outcomes in cancers such as NSCLC, “ he added.

In their exploratory pooled analyses, Dr. Socinski and co-investigators looked at data from the phase 3 IMpower130 and IMpower132 trials, which evaluated first-line atezolizumab and chemotherapy for NSCLC, and the phase 3 IMpower150 trial, which evaluated atezolizumab plus chemotherapy with or without bevacizumab.

In all, they analyzed data for 1,557 atezolizumab-treated patients, and 900 patients who had been in the control arms of the studies.

Forty-eight percent of atezolizumab-treated patients experienced irAEs of any grade, while 11% experienced irAEs of grade 3-5, according to the presented data. In the control arm, 32% experienced irAEs of any grade and 5% experienced grade 3-5 irAEs.

The most common irAEs of any grade were rash, hepatitis, and hypothyroidism, occurring in 28%, 15%, and 12% of atezolizumab-treated patients, respectively.

Median OS in the atezolizumab arm was 25.7 months for patients with irAEs and 13.0 for patients with no irAEs, with a hazard ratio (HR) of 0.69 using a time-dependent Cox model.

Median OS in the control arm was 20.2 months for patients with irAEs and 12.8 months for patients with no irAEs, with an HR of 0.82.

The overall response rate (ORR) in the atezolizumab arm was 61.1% for patients with irAEs and 37.2% for those without irAEs; in the control arm, ORR was 42.2% for patients with irAEs and 34.0% for those with no irAEs.

Atezolizumab-treated patients who experienced grade 3-5 irAEs had the shortest OS, according to Dr. Socinski. The HRs for OS at 1, 3, 6, and 12 months in atezolizumab-treated patients with grade 3-5 irAEs (compared with those without irAEs) ranged from 1.25 to 0.87. By contrast, HRs at those time points for patients with grade 1-2 irAEs ranged from 0.78 to 0.72, Dr. Socinski said.

Dr. Socinski reported disclosures related to AstraZeneca/MedImmune, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Genentech, Guardant Health, Janssen, Lilly, Merck, Novartis, Roche/Genentech, and Spectrum Pharmaceuticals. Dr. Redman reported a consulting or advisory role with AstraZeneca.

Experiencing an immune-related adverse event during checkpoint inhibitor treatment may predict outcomes in patients with non-small cell lung cancer, exploratory analyses of phase 3 trials suggest.

Immune-related adverse events (irAEs) were tied to longer overall survival (OS) in exploratory pooled analyses of three phase 3 clinical trials evaluating atezolizumab-based regimens, according to investigator Mark A. Socinski, MD, of AdventHealth Cancer Institute, Orlando, Fla.

Median OS approached 26 months for patients who received first-line atezolizumab and experienced an irAE, compared with just 13 months for those who did not experience an irAE, according to results reported at the American Society of Clinical Oncology Annual Meeting (Abstract 9002).

Atezolizumab-treated patients with grade 3 or greater irAEs had the shortest OS, shorter than those atezolizumab-treated patients who experienced grade 1-2 irAEs or no irAEs at all. That short OS may be due to treatment interruptions or discontinuations, said Dr. Socinski.

“Data from these analyses suggest an association between irAEs and efficacy in patients with [non-small cell cancer] NSCLC,” he stated in his presentation of the results.
 

A lot more to learn about irAEs

Similar linkages between irAEs and outcomes were observed in pooled analyses of patients enrolled in the control arms of the phase 3 trials, with a median OS of about 20 months for control patients experiencing an irAE, versus about 13 months for those who did not.

That linkage in the control arm prompted a question from an ASCO attendee about why an effect of irAEs, commonly associated with immune checkpoint inhibitor therapy, would be evident in analyses of patients who did not receive those agents.

In his response, Dr. Socinski characterized the finding as “a surprise” and said the finding may either reflect how adverse events are characterized or how chemotherapy impacts the immune system.

“I don’t know that our definition of irAEs is perfect,” he said, “and maybe we don’t understand what impact chemotherapy may have on the immune system, and may actually engender what historically we’ve always seen as an adverse event, but didn’t necessarily classify as an immune-related adverse event.”

More work is needed to better understand the connection between irAES and outcomes, and whether anything can be done as a result of that improved understanding, said discussant Mary Weber Redman, PhD.

“The question is, ‘what is actionable?’” added Dr. Redman, a biostatistician at the Fred Hutchinson Cancer Research Center, Seattle.

A firmer understanding of the relationship between irAEs and outcomes could change how clinicians monitor patients for irAEs, lead to better prediction of which patients may experience higher grade irAEs, and ultimately impact treatment selection potentially to avoid those higher grade events, Dr. Redman said in her remarks.

“Doing these types of analyses are quite important, because we have to look at the breadth of information that we have to be able to interpret that and think about what are future questions,” she said in the question-and-answer session accompanying Dr. Socinski’s presentation.

“I think the key is that we shouldn’t use these analyses to be definitive, but we should use them as to be hypothesis generating,” she added.
 

More evidence to link irAEs and outcomes

Immune-related AEs caused by off-target immune and inflammatory activity have been reported in up to 80% of patients receiving immune checkpoint inhibitors as monotherapy and up to 95% in combination regimens, Dr. Socinski said in his presentation.

“Increasing evidence suggests that the occurrence of immune-related adverse events with PD-L1 or PD-1 inhibitor therapy may be predictive of improved outcomes in cancers such as NSCLC, “ he added.

In their exploratory pooled analyses, Dr. Socinski and co-investigators looked at data from the phase 3 IMpower130 and IMpower132 trials, which evaluated first-line atezolizumab and chemotherapy for NSCLC, and the phase 3 IMpower150 trial, which evaluated atezolizumab plus chemotherapy with or without bevacizumab.

In all, they analyzed data for 1,557 atezolizumab-treated patients, and 900 patients who had been in the control arms of the studies.

Forty-eight percent of atezolizumab-treated patients experienced irAEs of any grade, while 11% experienced irAEs of grade 3-5, according to the presented data. In the control arm, 32% experienced irAEs of any grade and 5% experienced grade 3-5 irAEs.

The most common irAEs of any grade were rash, hepatitis, and hypothyroidism, occurring in 28%, 15%, and 12% of atezolizumab-treated patients, respectively.

Median OS in the atezolizumab arm was 25.7 months for patients with irAEs and 13.0 for patients with no irAEs, with a hazard ratio (HR) of 0.69 using a time-dependent Cox model.

Median OS in the control arm was 20.2 months for patients with irAEs and 12.8 months for patients with no irAEs, with an HR of 0.82.

The overall response rate (ORR) in the atezolizumab arm was 61.1% for patients with irAEs and 37.2% for those without irAEs; in the control arm, ORR was 42.2% for patients with irAEs and 34.0% for those with no irAEs.

Atezolizumab-treated patients who experienced grade 3-5 irAEs had the shortest OS, according to Dr. Socinski. The HRs for OS at 1, 3, 6, and 12 months in atezolizumab-treated patients with grade 3-5 irAEs (compared with those without irAEs) ranged from 1.25 to 0.87. By contrast, HRs at those time points for patients with grade 1-2 irAEs ranged from 0.78 to 0.72, Dr. Socinski said.

Dr. Socinski reported disclosures related to AstraZeneca/MedImmune, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Genentech, Guardant Health, Janssen, Lilly, Merck, Novartis, Roche/Genentech, and Spectrum Pharmaceuticals. Dr. Redman reported a consulting or advisory role with AstraZeneca.

Experiencing an immune-related adverse event during checkpoint inhibitor treatment may predict outcomes in patients with non-small cell lung cancer, exploratory analyses of phase 3 trials suggest.

Immune-related adverse events (irAEs) were tied to longer overall survival (OS) in exploratory pooled analyses of three phase 3 clinical trials evaluating atezolizumab-based regimens, according to investigator Mark A. Socinski, MD, of AdventHealth Cancer Institute, Orlando, Fla.

Median OS approached 26 months for patients who received first-line atezolizumab and experienced an irAE, compared with just 13 months for those who did not experience an irAE, according to results reported at the American Society of Clinical Oncology Annual Meeting (Abstract 9002).

Atezolizumab-treated patients with grade 3 or greater irAEs had the shortest OS, shorter than those atezolizumab-treated patients who experienced grade 1-2 irAEs or no irAEs at all. That short OS may be due to treatment interruptions or discontinuations, said Dr. Socinski.

“Data from these analyses suggest an association between irAEs and efficacy in patients with [non-small cell cancer] NSCLC,” he stated in his presentation of the results.
 

A lot more to learn about irAEs

Similar linkages between irAEs and outcomes were observed in pooled analyses of patients enrolled in the control arms of the phase 3 trials, with a median OS of about 20 months for control patients experiencing an irAE, versus about 13 months for those who did not.

That linkage in the control arm prompted a question from an ASCO attendee about why an effect of irAEs, commonly associated with immune checkpoint inhibitor therapy, would be evident in analyses of patients who did not receive those agents.

In his response, Dr. Socinski characterized the finding as “a surprise” and said the finding may either reflect how adverse events are characterized or how chemotherapy impacts the immune system.

“I don’t know that our definition of irAEs is perfect,” he said, “and maybe we don’t understand what impact chemotherapy may have on the immune system, and may actually engender what historically we’ve always seen as an adverse event, but didn’t necessarily classify as an immune-related adverse event.”

More work is needed to better understand the connection between irAES and outcomes, and whether anything can be done as a result of that improved understanding, said discussant Mary Weber Redman, PhD.

“The question is, ‘what is actionable?’” added Dr. Redman, a biostatistician at the Fred Hutchinson Cancer Research Center, Seattle.

A firmer understanding of the relationship between irAEs and outcomes could change how clinicians monitor patients for irAEs, lead to better prediction of which patients may experience higher grade irAEs, and ultimately impact treatment selection potentially to avoid those higher grade events, Dr. Redman said in her remarks.

“Doing these types of analyses are quite important, because we have to look at the breadth of information that we have to be able to interpret that and think about what are future questions,” she said in the question-and-answer session accompanying Dr. Socinski’s presentation.

“I think the key is that we shouldn’t use these analyses to be definitive, but we should use them as to be hypothesis generating,” she added.
 

More evidence to link irAEs and outcomes

Immune-related AEs caused by off-target immune and inflammatory activity have been reported in up to 80% of patients receiving immune checkpoint inhibitors as monotherapy and up to 95% in combination regimens, Dr. Socinski said in his presentation.

“Increasing evidence suggests that the occurrence of immune-related adverse events with PD-L1 or PD-1 inhibitor therapy may be predictive of improved outcomes in cancers such as NSCLC, “ he added.

In their exploratory pooled analyses, Dr. Socinski and co-investigators looked at data from the phase 3 IMpower130 and IMpower132 trials, which evaluated first-line atezolizumab and chemotherapy for NSCLC, and the phase 3 IMpower150 trial, which evaluated atezolizumab plus chemotherapy with or without bevacizumab.

In all, they analyzed data for 1,557 atezolizumab-treated patients, and 900 patients who had been in the control arms of the studies.

Forty-eight percent of atezolizumab-treated patients experienced irAEs of any grade, while 11% experienced irAEs of grade 3-5, according to the presented data. In the control arm, 32% experienced irAEs of any grade and 5% experienced grade 3-5 irAEs.

The most common irAEs of any grade were rash, hepatitis, and hypothyroidism, occurring in 28%, 15%, and 12% of atezolizumab-treated patients, respectively.

Median OS in the atezolizumab arm was 25.7 months for patients with irAEs and 13.0 for patients with no irAEs, with a hazard ratio (HR) of 0.69 using a time-dependent Cox model.

Median OS in the control arm was 20.2 months for patients with irAEs and 12.8 months for patients with no irAEs, with an HR of 0.82.

The overall response rate (ORR) in the atezolizumab arm was 61.1% for patients with irAEs and 37.2% for those without irAEs; in the control arm, ORR was 42.2% for patients with irAEs and 34.0% for those with no irAEs.

Atezolizumab-treated patients who experienced grade 3-5 irAEs had the shortest OS, according to Dr. Socinski. The HRs for OS at 1, 3, 6, and 12 months in atezolizumab-treated patients with grade 3-5 irAEs (compared with those without irAEs) ranged from 1.25 to 0.87. By contrast, HRs at those time points for patients with grade 1-2 irAEs ranged from 0.78 to 0.72, Dr. Socinski said.

Dr. Socinski reported disclosures related to AstraZeneca/MedImmune, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Genentech, Guardant Health, Janssen, Lilly, Merck, Novartis, Roche/Genentech, and Spectrum Pharmaceuticals. Dr. Redman reported a consulting or advisory role with AstraZeneca.

Immunotherapy has already had a huge impact on treatment of patients with later stages of non–small cell lung cancer (NSCLC): new clinical data are now showing benefits in patients with earlier stage disease.

Patients with stage IB-IIIA NSCLC showed a markedly improved disease-free survival (DFS) when atezolizumab (Tecentriq) was added onto adjuvant chemotherapy following resection, according to results from an interim analysis of the IMpower010 study.

Notably, the benefit with atezolizumab versus best supportive care was greatest in patients with expression of programmed death–ligand 1 (PD-L1) on their tumor, in whom the DFS improvement was a significant 34%.

This is the “first global phase 3 trial using an immune checkpoint inhibitor to show a disease-free survival outcome in early-stage NSCLC,” said lead researcher Heather Wakelee, MD, professor of medicine and chief of the division of oncology at Stanford (Calif.) University Medical Center.

She was speaking at a press briefing ahead of the American Society of Clinical Oncology annual meeting, where the results will be presented on June 6.

Dr. Wakelee added that the “planned analysis for disease-free survival and overall survival in the intention-to-treat populations will continue with longer-term follow-up.”

Asked whether the drug could be recommended for these patients based on the current results, Dr. Wakelee said that “obviously we need approval” for this use from the Food and Drug Administration, but she added that “the FDA has approved other agents, particularly most recently osimertinib [Tagrisso], based on a disease-free survival endpoint.”

These new results show that the benefit with atezolizumab plus chemotherapy is “more profound” than with chemotherapy plus best supportive care, “and therefore, to me, it would be something I would want to offer my patients in that setting.”

Dr. Wakelee also emphasized the importance of screening for lung cancer, so that the disease is detected at earlier stages “when it is potentially curable.”

She also stressed the importance of biomarker testing for patients with resected disease “to look for EGFR mutations, which can be treated with EGFR [tyrosine kinase inhibitors] and also, at some point, to check for PD-L1 ... because, in this trial, the vast majority of benefit” appeared to be in those with PD-L1 expression on their tumors.

Julie R. Gralow, MD, ASCO chief medical officer and executive vice president, said that “immune checkpoint inhibitors have certainly changed the treatment landscape for many types of cancers” and the current study “is the first time we’ve seen an immunotherapy that’s effective in treating early-stage NSCLC.”

“This is an important advance in understanding the role of immunotherapy in earlier stage lung cancer” and “potentially a step forward for many patients.”
 

Study details 

The standard of care for many stage IB-IIIA NSCLC patients “has not changed for many years,” despite “significant progress” having been made in the treatment of more advanced disease, Dr. Wakelee commented.

Consequently, the majority of patients with resected NSCLC continue to receive adjuvant platinum-based chemotherapy, which has been shown to reduce the risk of disease recurrence by 16% in those with completely resected disease.

The new study set out to examine the benefit of adding atezolizumab to adjuvant chemotherapy in the global phase 3 IMpower010 study.

Patients had to have stage IB-IIIA NSCLC, with stage IB tumors at least 4 cm in size, and tumor tissue available for PD-L1 analysis. Following complete resection, 1,280 patients were given up to four cycles of adjuvant platinum-based chemotherapy.

Of those, 1,005 patients were then randomly assigned 1:1 to receive either 16 cycles of atezolizumab 1,200 mg IV every 3 weeks or best supportive care.

The interim results show that, after a median follow-up of 32.8 months, the addition of atezolizumab significantly reduced the risk of recurrence or death versus best supportive care in patients whose tumors had PD-L1 expression of at least 1%, at a hazard ratio of 0.66 (P = .004).

At 24 months, the DFS rate was 74.6% among patients given atezolizumab versus 61% in those receiving best supportive care, reducing to 60% and 48.2%, respectively, at 36 months.

When looking across all randomized patients, the addition of atezolizumab was associated with a smaller reduction in the risk of recurrence of death versus best supportive care, at a hazard ratio of 0.79 after a median follow-up of 32.2 months (P = .02).

On the intention to treat analysis, the reduction in the risk of recurrence or death with atezolizumab was of borderline significance, at a hazard ratio of 0.81 after a median follow-up of 32.2 months (P = .04).

Dr. Wakelee pointed out that patients with stage IB disease, who represented around 12% of those in the trial, “tend to do better and we require longer time to see some of the disease recurrence outcomes,” and so these results are “preliminary.”

She also emphasized that the overall survival data are not yet mature and survival was not formally tested in the current analysis.

In terms of safety, the adverse event profile with atezolizumab was consistent with previous reports, the investigators noted in the abstract. However, Dr. Wakelee said at the briefing that “we had to stop treatment with atezolizumab in 18% of patients because of toxicity.”

All-grade adverse events were reported in 70.7% of the best supportive care group versus 92.7% among those given atezolizumab, while grade 3-4 adverse events were reported in 11.5% and 21.8% of patients, respectively.

The study was funded by Hoffmann–La Roche. Dr. Wakelee reported relationships with AstraZeneca, Blueprint Medicines, Daiichi Sankyo, Helsinn Therapeutics, Janssen Oncology, Mirati Therapeutics, Xcovery, ACEA Biosciences, Arrys Therapeutics, AstraZeneca/MedImmune, Bristol-Myers Squibb, Celgene, Clovis Oncology, Exelixis, Genentech/Roche, Gilead Sciences, Merck, Novartis, Pharmacyclics, Seattle Genetics, and Xcovery. She also reports uncompensated relationships with Genentech/Roche, Merck, and Takeda. Dr. Gralow reported relationships with AstraZeneca, Genentech, Sandoz, and Immunomedics.

A version of this article first appeared on Medscape.com.

Immunotherapy has already had a huge impact on treatment of patients with later stages of non–small cell lung cancer (NSCLC): new clinical data are now showing benefits in patients with earlier stage disease.

Patients with stage IB-IIIA NSCLC showed a markedly improved disease-free survival (DFS) when atezolizumab (Tecentriq) was added onto adjuvant chemotherapy following resection, according to results from an interim analysis of the IMpower010 study.

Notably, the benefit with atezolizumab versus best supportive care was greatest in patients with expression of programmed death–ligand 1 (PD-L1) on their tumor, in whom the DFS improvement was a significant 34%.

This is the “first global phase 3 trial using an immune checkpoint inhibitor to show a disease-free survival outcome in early-stage NSCLC,” said lead researcher Heather Wakelee, MD, professor of medicine and chief of the division of oncology at Stanford (Calif.) University Medical Center.

She was speaking at a press briefing ahead of the American Society of Clinical Oncology annual meeting, where the results will be presented on June 6.

Dr. Wakelee added that the “planned analysis for disease-free survival and overall survival in the intention-to-treat populations will continue with longer-term follow-up.”

Asked whether the drug could be recommended for these patients based on the current results, Dr. Wakelee said that “obviously we need approval” for this use from the Food and Drug Administration, but she added that “the FDA has approved other agents, particularly most recently osimertinib [Tagrisso], based on a disease-free survival endpoint.”

These new results show that the benefit with atezolizumab plus chemotherapy is “more profound” than with chemotherapy plus best supportive care, “and therefore, to me, it would be something I would want to offer my patients in that setting.”

Dr. Wakelee also emphasized the importance of screening for lung cancer, so that the disease is detected at earlier stages “when it is potentially curable.”

She also stressed the importance of biomarker testing for patients with resected disease “to look for EGFR mutations, which can be treated with EGFR [tyrosine kinase inhibitors] and also, at some point, to check for PD-L1 ... because, in this trial, the vast majority of benefit” appeared to be in those with PD-L1 expression on their tumors.

Julie R. Gralow, MD, ASCO chief medical officer and executive vice president, said that “immune checkpoint inhibitors have certainly changed the treatment landscape for many types of cancers” and the current study “is the first time we’ve seen an immunotherapy that’s effective in treating early-stage NSCLC.”

“This is an important advance in understanding the role of immunotherapy in earlier stage lung cancer” and “potentially a step forward for many patients.”
 

Study details 

The standard of care for many stage IB-IIIA NSCLC patients “has not changed for many years,” despite “significant progress” having been made in the treatment of more advanced disease, Dr. Wakelee commented.

Consequently, the majority of patients with resected NSCLC continue to receive adjuvant platinum-based chemotherapy, which has been shown to reduce the risk of disease recurrence by 16% in those with completely resected disease.

The new study set out to examine the benefit of adding atezolizumab to adjuvant chemotherapy in the global phase 3 IMpower010 study.

Patients had to have stage IB-IIIA NSCLC, with stage IB tumors at least 4 cm in size, and tumor tissue available for PD-L1 analysis. Following complete resection, 1,280 patients were given up to four cycles of adjuvant platinum-based chemotherapy.

Of those, 1,005 patients were then randomly assigned 1:1 to receive either 16 cycles of atezolizumab 1,200 mg IV every 3 weeks or best supportive care.

The interim results show that, after a median follow-up of 32.8 months, the addition of atezolizumab significantly reduced the risk of recurrence or death versus best supportive care in patients whose tumors had PD-L1 expression of at least 1%, at a hazard ratio of 0.66 (P = .004).

At 24 months, the DFS rate was 74.6% among patients given atezolizumab versus 61% in those receiving best supportive care, reducing to 60% and 48.2%, respectively, at 36 months.

When looking across all randomized patients, the addition of atezolizumab was associated with a smaller reduction in the risk of recurrence of death versus best supportive care, at a hazard ratio of 0.79 after a median follow-up of 32.2 months (P = .02).

On the intention to treat analysis, the reduction in the risk of recurrence or death with atezolizumab was of borderline significance, at a hazard ratio of 0.81 after a median follow-up of 32.2 months (P = .04).

Dr. Wakelee pointed out that patients with stage IB disease, who represented around 12% of those in the trial, “tend to do better and we require longer time to see some of the disease recurrence outcomes,” and so these results are “preliminary.”

She also emphasized that the overall survival data are not yet mature and survival was not formally tested in the current analysis.

In terms of safety, the adverse event profile with atezolizumab was consistent with previous reports, the investigators noted in the abstract. However, Dr. Wakelee said at the briefing that “we had to stop treatment with atezolizumab in 18% of patients because of toxicity.”

All-grade adverse events were reported in 70.7% of the best supportive care group versus 92.7% among those given atezolizumab, while grade 3-4 adverse events were reported in 11.5% and 21.8% of patients, respectively.

The study was funded by Hoffmann–La Roche. Dr. Wakelee reported relationships with AstraZeneca, Blueprint Medicines, Daiichi Sankyo, Helsinn Therapeutics, Janssen Oncology, Mirati Therapeutics, Xcovery, ACEA Biosciences, Arrys Therapeutics, AstraZeneca/MedImmune, Bristol-Myers Squibb, Celgene, Clovis Oncology, Exelixis, Genentech/Roche, Gilead Sciences, Merck, Novartis, Pharmacyclics, Seattle Genetics, and Xcovery. She also reports uncompensated relationships with Genentech/Roche, Merck, and Takeda. Dr. Gralow reported relationships with AstraZeneca, Genentech, Sandoz, and Immunomedics.

A version of this article first appeared on Medscape.com.

Immunotherapy has already had a huge impact on treatment of patients with later stages of non–small cell lung cancer (NSCLC): new clinical data are now showing benefits in patients with earlier stage disease.

Patients with stage IB-IIIA NSCLC showed a markedly improved disease-free survival (DFS) when atezolizumab (Tecentriq) was added onto adjuvant chemotherapy following resection, according to results from an interim analysis of the IMpower010 study.

Notably, the benefit with atezolizumab versus best supportive care was greatest in patients with expression of programmed death–ligand 1 (PD-L1) on their tumor, in whom the DFS improvement was a significant 34%.

This is the “first global phase 3 trial using an immune checkpoint inhibitor to show a disease-free survival outcome in early-stage NSCLC,” said lead researcher Heather Wakelee, MD, professor of medicine and chief of the division of oncology at Stanford (Calif.) University Medical Center.

She was speaking at a press briefing ahead of the American Society of Clinical Oncology annual meeting, where the results will be presented on June 6.

Dr. Wakelee added that the “planned analysis for disease-free survival and overall survival in the intention-to-treat populations will continue with longer-term follow-up.”

Asked whether the drug could be recommended for these patients based on the current results, Dr. Wakelee said that “obviously we need approval” for this use from the Food and Drug Administration, but she added that “the FDA has approved other agents, particularly most recently osimertinib [Tagrisso], based on a disease-free survival endpoint.”

These new results show that the benefit with atezolizumab plus chemotherapy is “more profound” than with chemotherapy plus best supportive care, “and therefore, to me, it would be something I would want to offer my patients in that setting.”

Dr. Wakelee also emphasized the importance of screening for lung cancer, so that the disease is detected at earlier stages “when it is potentially curable.”

She also stressed the importance of biomarker testing for patients with resected disease “to look for EGFR mutations, which can be treated with EGFR [tyrosine kinase inhibitors] and also, at some point, to check for PD-L1 ... because, in this trial, the vast majority of benefit” appeared to be in those with PD-L1 expression on their tumors.

Julie R. Gralow, MD, ASCO chief medical officer and executive vice president, said that “immune checkpoint inhibitors have certainly changed the treatment landscape for many types of cancers” and the current study “is the first time we’ve seen an immunotherapy that’s effective in treating early-stage NSCLC.”

“This is an important advance in understanding the role of immunotherapy in earlier stage lung cancer” and “potentially a step forward for many patients.”
 

Study details 

The standard of care for many stage IB-IIIA NSCLC patients “has not changed for many years,” despite “significant progress” having been made in the treatment of more advanced disease, Dr. Wakelee commented.

Consequently, the majority of patients with resected NSCLC continue to receive adjuvant platinum-based chemotherapy, which has been shown to reduce the risk of disease recurrence by 16% in those with completely resected disease.

The new study set out to examine the benefit of adding atezolizumab to adjuvant chemotherapy in the global phase 3 IMpower010 study.

Patients had to have stage IB-IIIA NSCLC, with stage IB tumors at least 4 cm in size, and tumor tissue available for PD-L1 analysis. Following complete resection, 1,280 patients were given up to four cycles of adjuvant platinum-based chemotherapy.

Of those, 1,005 patients were then randomly assigned 1:1 to receive either 16 cycles of atezolizumab 1,200 mg IV every 3 weeks or best supportive care.

The interim results show that, after a median follow-up of 32.8 months, the addition of atezolizumab significantly reduced the risk of recurrence or death versus best supportive care in patients whose tumors had PD-L1 expression of at least 1%, at a hazard ratio of 0.66 (P = .004).

At 24 months, the DFS rate was 74.6% among patients given atezolizumab versus 61% in those receiving best supportive care, reducing to 60% and 48.2%, respectively, at 36 months.

When looking across all randomized patients, the addition of atezolizumab was associated with a smaller reduction in the risk of recurrence of death versus best supportive care, at a hazard ratio of 0.79 after a median follow-up of 32.2 months (P = .02).

On the intention to treat analysis, the reduction in the risk of recurrence or death with atezolizumab was of borderline significance, at a hazard ratio of 0.81 after a median follow-up of 32.2 months (P = .04).

Dr. Wakelee pointed out that patients with stage IB disease, who represented around 12% of those in the trial, “tend to do better and we require longer time to see some of the disease recurrence outcomes,” and so these results are “preliminary.”

She also emphasized that the overall survival data are not yet mature and survival was not formally tested in the current analysis.

In terms of safety, the adverse event profile with atezolizumab was consistent with previous reports, the investigators noted in the abstract. However, Dr. Wakelee said at the briefing that “we had to stop treatment with atezolizumab in 18% of patients because of toxicity.”

All-grade adverse events were reported in 70.7% of the best supportive care group versus 92.7% among those given atezolizumab, while grade 3-4 adverse events were reported in 11.5% and 21.8% of patients, respectively.

The study was funded by Hoffmann–La Roche. Dr. Wakelee reported relationships with AstraZeneca, Blueprint Medicines, Daiichi Sankyo, Helsinn Therapeutics, Janssen Oncology, Mirati Therapeutics, Xcovery, ACEA Biosciences, Arrys Therapeutics, AstraZeneca/MedImmune, Bristol-Myers Squibb, Celgene, Clovis Oncology, Exelixis, Genentech/Roche, Gilead Sciences, Merck, Novartis, Pharmacyclics, Seattle Genetics, and Xcovery. She also reports uncompensated relationships with Genentech/Roche, Merck, and Takeda. Dr. Gralow reported relationships with AstraZeneca, Genentech, Sandoz, and Immunomedics.

A version of this article first appeared on Medscape.com.

Presented during the ASCO 2020 plenary session, the results of the phase 3 ADAURA trial will prove practice-changing, according to Dr. Mark Kris of Memorial Sloan Kettering Cancer Center. Over 600 patients whose resected tumors were found to have EGFR mutations were treated with osimertinib. The results more than doubled disease-free survival rates, from 44% to 90% at 2 years.

Among other adjuvant trials, the phase 2 VISION study looked at tepotinib, a once-daily, highly selective oral MET inhibitor. The study showed durable responses coupled with acceptable side effects. The drug has been given fast-track status by the US Food and Drug Administration.

Dr. Kris notes that the DESTINY study introduces trastuzumab deruxtecan, an antibody-drug conjugate, as a promising new class of drugs for lung cancer patients. Interim results presented at ASCO further support the HER2 mutation as another potential target for patients with lung cancer.

Finally, the phase 2 CITYSCAPE study provides preliminary evidence for a new checkpoint inhibitor. The monoclonal antibody tiragolumab was developed to block TIGIT. The study showed that the combination of tiragolumab and atezolizumab can improve both rates of response and time to disease recurrence — results Dr. Kris considers encouraging for patients with advanced lung cancer.

Mark G. Kris, MD

Mark G. Kris, MD, Professor, Department of Medicine, Weill Cornell Medical College; Attending Physician, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY.

Presented during the ASCO 2020 plenary session, the results of the phase 3 ADAURA trial will prove practice-changing, according to Dr. Mark Kris of Memorial Sloan Kettering Cancer Center. Over 600 patients whose resected tumors were found to have EGFR mutations were treated with osimertinib. The results more than doubled disease-free survival rates, from 44% to 90% at 2 years.

Among other adjuvant trials, the phase 2 VISION study looked at tepotinib, a once-daily, highly selective oral MET inhibitor. The study showed durable responses coupled with acceptable side effects. The drug has been given fast-track status by the US Food and Drug Administration.

Dr. Kris notes that the DESTINY study introduces trastuzumab deruxtecan, an antibody-drug conjugate, as a promising new class of drugs for lung cancer patients. Interim results presented at ASCO further support the HER2 mutation as another potential target for patients with lung cancer.

Finally, the phase 2 CITYSCAPE study provides preliminary evidence for a new checkpoint inhibitor. The monoclonal antibody tiragolumab was developed to block TIGIT. The study showed that the combination of tiragolumab and atezolizumab can improve both rates of response and time to disease recurrence — results Dr. Kris considers encouraging for patients with advanced lung cancer.

Mark G. Kris, MD

Mark G. Kris, MD, Professor, Department of Medicine, Weill Cornell Medical College; Attending Physician, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY.

Presented during the ASCO 2020 plenary session, the results of the phase 3 ADAURA trial will prove practice-changing, according to Dr. Mark Kris of Memorial Sloan Kettering Cancer Center. Over 600 patients whose resected tumors were found to have EGFR mutations were treated with osimertinib. The results more than doubled disease-free survival rates, from 44% to 90% at 2 years.

Among other adjuvant trials, the phase 2 VISION study looked at tepotinib, a once-daily, highly selective oral MET inhibitor. The study showed durable responses coupled with acceptable side effects. The drug has been given fast-track status by the US Food and Drug Administration.

Dr. Kris notes that the DESTINY study introduces trastuzumab deruxtecan, an antibody-drug conjugate, as a promising new class of drugs for lung cancer patients. Interim results presented at ASCO further support the HER2 mutation as another potential target for patients with lung cancer.

Finally, the phase 2 CITYSCAPE study provides preliminary evidence for a new checkpoint inhibitor. The monoclonal antibody tiragolumab was developed to block TIGIT. The study showed that the combination of tiragolumab and atezolizumab can improve both rates of response and time to disease recurrence — results Dr. Kris considers encouraging for patients with advanced lung cancer.

Mark G. Kris, MD

Mark G. Kris, MD, Professor, Department of Medicine, Weill Cornell Medical College; Attending Physician, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY.

Adding tiragolumab to first-line treatment with atezolizumab improves outcomes in patients with PD-L1–positive non–small cell lung cancer (NSCLC), according to updated results from the phase 2 CITYSCAPE study.

Patients who received tiragolumab, an anti-TIGIT antibody, in combination with atezolizumab, a PD-L1 inhibitor, had superior overall response rates (ORR) and progression-free survival (PFS), when compared with results of patients who received placebo with atezolizumab.

Melissa L. Johnson, MD, of the Sarah Cannon Research Institute in Nashville, Tenn., presented these results as part of the American Society of Clinical Oncology virtual scientific program.

Dr. Johnson explained that TIGIT is an immunomodulatory receptor present on activated T cells and natural killer cells in multiple cancers, including NSCLC.

“TIGIT inhibits T cells and natural killer cells by binding to its ligand PVR on tumor cells and antigen-presenting cells,” she said. “TIGIT expression strongly correlates with PD-1 expression, sometimes on the same tumor-infiltrating T cells in lung cancer. So the hypothesis of this trial was that anti-TIGIT antibodies, which prevent TIGIT from binding to its ligand, could restore the antitumor response and could complement the activity of anti–PD-L1/PD-1 antibodies.”

Dr. Johnson noted that combination anti–TIGIT/PD-L1 antibody treatment synergistically improved tumor control and prolonged survival over either antibody alone in preclinical models (Cancer Cell. 2014 Dec 8;26[6]:923-937). In addition, tiragolumab has been evaluated in a phase 1 study, both as monotherapy and in combination with atezolizumab, in multiple solid tumors (NCT02794571).

The phase 2 CITYSCAPE study (NCT03563716) was initiated to confirm the efficacy and safety of tiragolumab plus atezolizumab versus placebo plus atezolizumab for the first-line treatment of NSCLC, Dr. Johnson said.

CITYSCAPE enrolled 135 patients with chemotherapy-naive, PD-L1–positive, locally advanced or metastatic NSCLC. Patients did not have EGFR or ALK alterations.

Half of patients (n = 68) were randomized to receive tiragolumab at 600 mg plus atezolizumab at 1,200 mg, both given on day 1 of every 3-week cycle. The other half of patients (n = 67) were randomized to receive atezolizumab at the same dose and schedule plus placebo.
 

ORR and PFS

The study’s primary analysis was conducted in June 2019 at a median follow-up of 5.9 months. At that time, the ORR and PFS data showed an early benefit with tiragolumab. The ORR was 31% in the tiragolumab arm and 16% in the placebo arm. The median PFS was 5.42 months and 3.58 months, respectively (hazard ratio, 0.57).

With an additional 6 months of follow-up, the tiragolumab benefit persisted, Dr. Johnson said. The updated ORR in the intent-to-treat population was 37% in the tiragolumab arm and 21% in the placebo arm. The median PFS was 5.6 months and 3.9 months, respectively (HR, 0.58).

The tiragolumab combination showed “clinically meaningful” improvements in ORR and PFS, Dr. Johnson said. She also noted “a greater magnitude of improvement” was seen in patients with a PD-L1 tumor proportion score of 50% or greater.

There were 29 patients in each treatment arm with a PD-L1 tumor proportion score of 50% or greater. Among these patients, the ORR was 66% in the tiragolumab arm and 24% in the placebo arm. The median PFS was not reached and 4.1 months, respectively (HR, 0.30).

There were no significant differences in ORR or PFS among patients with PD-L1 tumor proportion scores below 50%, Dr. Johnson noted.

She added that duration of response and overall survival data are not yet mature and will be presented at a future conference.
 

Adverse events

As reported in the primary analysis, tiragolumab plus atezolizumab had a tolerable safety profile, Dr. Johnson said.

“Despite a near doubling of the median treatment duration [at the updated analysis], there were similar numbers of any-cause adverse events, grade 3-5 adverse events, and serious adverse events,” she said.

Overall, adverse events occurred in 99% of patients in the tiragolumab arm and 96% of those in the placebo arm. Rates of grade 3-5 adverse events were 48% and 44%, respectively. Rates of serious adverse events were 37% and 35%, respectively.

A higher frequency of adverse events in the tiragolumab arm was related to an increase in immune-related events, including infusion reactions, pruritus, rash, arthralgia, and nephritis. This makes sense because the patients in that group were receiving two active immunotherapies, Dr. Johnson said.
 

Data inspire cautious optimism

The safety and activity of tiragolumab plus atezolizumab are “to be confirmed in an ongoing phase 3 study called SKYSCRAPER-01 [NCT04294810],” Dr. Johnson said.

Invited discussant Grace K. Dy, MD, of Roswell Park Comprehensive Cancer Center in Buffalo, N.Y., said the ORRs in CITYSCAPE have “generated a lot of buzz,” but she urged caution pending phase 3 results.

“While we are all excited by the data and want to see a winner, we should be careful, as speed can also crash and burn,” she said. “We have plenty of examples of promising studies that collapsed in later phase trials.”

There is room, however, for cautious optimism that the combination is a promising advance “as long as no prognostic or confounding variable is determined later on to be nonrandomly distributed between the groups to account for the difference seen,” Dr. Dy said.

She also noted that “the distribution of favorable or unfavorable mutations between the groups is unknown, and understanding this will be relevant.”

Preclinical data suggest the presence of DNM1 expression is crucial for maximizing the effect of TIGIT blockade, and tumor MHC class 1 expression appears to be reduced alongside reductions in DNM1 expression in the intratumoral natural kill cells in lung cancer specimens, Dr. Dy explained.

“Assessment of these biomarkers will be instructive,” she said. “More recent data also appear to implicate a paradoxical role of soluble CD155 or PVR ligand in actually inhibiting DNM1, so the effect of systemic TIGIT blockade may be mitigated if there is rebound increase of counterbalancing signals by increased secretion of soluble CD155, and we look forward to more data in the future regarding this.”

CITYSCAPE was sponsored by Genentech. Dr. Johnson disclosed relationships with Genentech and numerous other companies. Dr. Dy disclosed relationships with AstraZeneca, GlaxoSmithKline, Takeda, Amgen, Bristol-Myers Squibb, Regeneron, and Tesaro.

sworcester@mdedge.com

SOURCE: Rodriguez-Abreu D et al. ASCO 2020, Abstract 9503.

Adding tiragolumab to first-line treatment with atezolizumab improves outcomes in patients with PD-L1–positive non–small cell lung cancer (NSCLC), according to updated results from the phase 2 CITYSCAPE study.

Patients who received tiragolumab, an anti-TIGIT antibody, in combination with atezolizumab, a PD-L1 inhibitor, had superior overall response rates (ORR) and progression-free survival (PFS), when compared with results of patients who received placebo with atezolizumab.

Melissa L. Johnson, MD, of the Sarah Cannon Research Institute in Nashville, Tenn., presented these results as part of the American Society of Clinical Oncology virtual scientific program.

Dr. Johnson explained that TIGIT is an immunomodulatory receptor present on activated T cells and natural killer cells in multiple cancers, including NSCLC.

“TIGIT inhibits T cells and natural killer cells by binding to its ligand PVR on tumor cells and antigen-presenting cells,” she said. “TIGIT expression strongly correlates with PD-1 expression, sometimes on the same tumor-infiltrating T cells in lung cancer. So the hypothesis of this trial was that anti-TIGIT antibodies, which prevent TIGIT from binding to its ligand, could restore the antitumor response and could complement the activity of anti–PD-L1/PD-1 antibodies.”

Dr. Johnson noted that combination anti–TIGIT/PD-L1 antibody treatment synergistically improved tumor control and prolonged survival over either antibody alone in preclinical models (Cancer Cell. 2014 Dec 8;26[6]:923-937). In addition, tiragolumab has been evaluated in a phase 1 study, both as monotherapy and in combination with atezolizumab, in multiple solid tumors (NCT02794571).

The phase 2 CITYSCAPE study (NCT03563716) was initiated to confirm the efficacy and safety of tiragolumab plus atezolizumab versus placebo plus atezolizumab for the first-line treatment of NSCLC, Dr. Johnson said.

CITYSCAPE enrolled 135 patients with chemotherapy-naive, PD-L1–positive, locally advanced or metastatic NSCLC. Patients did not have EGFR or ALK alterations.

Half of patients (n = 68) were randomized to receive tiragolumab at 600 mg plus atezolizumab at 1,200 mg, both given on day 1 of every 3-week cycle. The other half of patients (n = 67) were randomized to receive atezolizumab at the same dose and schedule plus placebo.
 

ORR and PFS

The study’s primary analysis was conducted in June 2019 at a median follow-up of 5.9 months. At that time, the ORR and PFS data showed an early benefit with tiragolumab. The ORR was 31% in the tiragolumab arm and 16% in the placebo arm. The median PFS was 5.42 months and 3.58 months, respectively (hazard ratio, 0.57).

With an additional 6 months of follow-up, the tiragolumab benefit persisted, Dr. Johnson said. The updated ORR in the intent-to-treat population was 37% in the tiragolumab arm and 21% in the placebo arm. The median PFS was 5.6 months and 3.9 months, respectively (HR, 0.58).

The tiragolumab combination showed “clinically meaningful” improvements in ORR and PFS, Dr. Johnson said. She also noted “a greater magnitude of improvement” was seen in patients with a PD-L1 tumor proportion score of 50% or greater.

There were 29 patients in each treatment arm with a PD-L1 tumor proportion score of 50% or greater. Among these patients, the ORR was 66% in the tiragolumab arm and 24% in the placebo arm. The median PFS was not reached and 4.1 months, respectively (HR, 0.30).

There were no significant differences in ORR or PFS among patients with PD-L1 tumor proportion scores below 50%, Dr. Johnson noted.

She added that duration of response and overall survival data are not yet mature and will be presented at a future conference.
 

Adverse events

As reported in the primary analysis, tiragolumab plus atezolizumab had a tolerable safety profile, Dr. Johnson said.

“Despite a near doubling of the median treatment duration [at the updated analysis], there were similar numbers of any-cause adverse events, grade 3-5 adverse events, and serious adverse events,” she said.

Overall, adverse events occurred in 99% of patients in the tiragolumab arm and 96% of those in the placebo arm. Rates of grade 3-5 adverse events were 48% and 44%, respectively. Rates of serious adverse events were 37% and 35%, respectively.

A higher frequency of adverse events in the tiragolumab arm was related to an increase in immune-related events, including infusion reactions, pruritus, rash, arthralgia, and nephritis. This makes sense because the patients in that group were receiving two active immunotherapies, Dr. Johnson said.
 

Data inspire cautious optimism

The safety and activity of tiragolumab plus atezolizumab are “to be confirmed in an ongoing phase 3 study called SKYSCRAPER-01 [NCT04294810],” Dr. Johnson said.

Invited discussant Grace K. Dy, MD, of Roswell Park Comprehensive Cancer Center in Buffalo, N.Y., said the ORRs in CITYSCAPE have “generated a lot of buzz,” but she urged caution pending phase 3 results.

“While we are all excited by the data and want to see a winner, we should be careful, as speed can also crash and burn,” she said. “We have plenty of examples of promising studies that collapsed in later phase trials.”

There is room, however, for cautious optimism that the combination is a promising advance “as long as no prognostic or confounding variable is determined later on to be nonrandomly distributed between the groups to account for the difference seen,” Dr. Dy said.

She also noted that “the distribution of favorable or unfavorable mutations between the groups is unknown, and understanding this will be relevant.”

Preclinical data suggest the presence of DNM1 expression is crucial for maximizing the effect of TIGIT blockade, and tumor MHC class 1 expression appears to be reduced alongside reductions in DNM1 expression in the intratumoral natural kill cells in lung cancer specimens, Dr. Dy explained.

“Assessment of these biomarkers will be instructive,” she said. “More recent data also appear to implicate a paradoxical role of soluble CD155 or PVR ligand in actually inhibiting DNM1, so the effect of systemic TIGIT blockade may be mitigated if there is rebound increase of counterbalancing signals by increased secretion of soluble CD155, and we look forward to more data in the future regarding this.”

CITYSCAPE was sponsored by Genentech. Dr. Johnson disclosed relationships with Genentech and numerous other companies. Dr. Dy disclosed relationships with AstraZeneca, GlaxoSmithKline, Takeda, Amgen, Bristol-Myers Squibb, Regeneron, and Tesaro.

sworcester@mdedge.com

SOURCE: Rodriguez-Abreu D et al. ASCO 2020, Abstract 9503.

Adding tiragolumab to first-line treatment with atezolizumab improves outcomes in patients with PD-L1–positive non–small cell lung cancer (NSCLC), according to updated results from the phase 2 CITYSCAPE study.

Patients who received tiragolumab, an anti-TIGIT antibody, in combination with atezolizumab, a PD-L1 inhibitor, had superior overall response rates (ORR) and progression-free survival (PFS), when compared with results of patients who received placebo with atezolizumab.

Melissa L. Johnson, MD, of the Sarah Cannon Research Institute in Nashville, Tenn., presented these results as part of the American Society of Clinical Oncology virtual scientific program.

Dr. Johnson explained that TIGIT is an immunomodulatory receptor present on activated T cells and natural killer cells in multiple cancers, including NSCLC.

“TIGIT inhibits T cells and natural killer cells by binding to its ligand PVR on tumor cells and antigen-presenting cells,” she said. “TIGIT expression strongly correlates with PD-1 expression, sometimes on the same tumor-infiltrating T cells in lung cancer. So the hypothesis of this trial was that anti-TIGIT antibodies, which prevent TIGIT from binding to its ligand, could restore the antitumor response and could complement the activity of anti–PD-L1/PD-1 antibodies.”

Dr. Johnson noted that combination anti–TIGIT/PD-L1 antibody treatment synergistically improved tumor control and prolonged survival over either antibody alone in preclinical models (Cancer Cell. 2014 Dec 8;26[6]:923-937). In addition, tiragolumab has been evaluated in a phase 1 study, both as monotherapy and in combination with atezolizumab, in multiple solid tumors (NCT02794571).

The phase 2 CITYSCAPE study (NCT03563716) was initiated to confirm the efficacy and safety of tiragolumab plus atezolizumab versus placebo plus atezolizumab for the first-line treatment of NSCLC, Dr. Johnson said.

CITYSCAPE enrolled 135 patients with chemotherapy-naive, PD-L1–positive, locally advanced or metastatic NSCLC. Patients did not have EGFR or ALK alterations.

Half of patients (n = 68) were randomized to receive tiragolumab at 600 mg plus atezolizumab at 1,200 mg, both given on day 1 of every 3-week cycle. The other half of patients (n = 67) were randomized to receive atezolizumab at the same dose and schedule plus placebo.
 

ORR and PFS

The study’s primary analysis was conducted in June 2019 at a median follow-up of 5.9 months. At that time, the ORR and PFS data showed an early benefit with tiragolumab. The ORR was 31% in the tiragolumab arm and 16% in the placebo arm. The median PFS was 5.42 months and 3.58 months, respectively (hazard ratio, 0.57).

With an additional 6 months of follow-up, the tiragolumab benefit persisted, Dr. Johnson said. The updated ORR in the intent-to-treat population was 37% in the tiragolumab arm and 21% in the placebo arm. The median PFS was 5.6 months and 3.9 months, respectively (HR, 0.58).

The tiragolumab combination showed “clinically meaningful” improvements in ORR and PFS, Dr. Johnson said. She also noted “a greater magnitude of improvement” was seen in patients with a PD-L1 tumor proportion score of 50% or greater.

There were 29 patients in each treatment arm with a PD-L1 tumor proportion score of 50% or greater. Among these patients, the ORR was 66% in the tiragolumab arm and 24% in the placebo arm. The median PFS was not reached and 4.1 months, respectively (HR, 0.30).

There were no significant differences in ORR or PFS among patients with PD-L1 tumor proportion scores below 50%, Dr. Johnson noted.

She added that duration of response and overall survival data are not yet mature and will be presented at a future conference.
 

Adverse events

As reported in the primary analysis, tiragolumab plus atezolizumab had a tolerable safety profile, Dr. Johnson said.

“Despite a near doubling of the median treatment duration [at the updated analysis], there were similar numbers of any-cause adverse events, grade 3-5 adverse events, and serious adverse events,” she said.

Overall, adverse events occurred in 99% of patients in the tiragolumab arm and 96% of those in the placebo arm. Rates of grade 3-5 adverse events were 48% and 44%, respectively. Rates of serious adverse events were 37% and 35%, respectively.

A higher frequency of adverse events in the tiragolumab arm was related to an increase in immune-related events, including infusion reactions, pruritus, rash, arthralgia, and nephritis. This makes sense because the patients in that group were receiving two active immunotherapies, Dr. Johnson said.
 

Data inspire cautious optimism

The safety and activity of tiragolumab plus atezolizumab are “to be confirmed in an ongoing phase 3 study called SKYSCRAPER-01 [NCT04294810],” Dr. Johnson said.

Invited discussant Grace K. Dy, MD, of Roswell Park Comprehensive Cancer Center in Buffalo, N.Y., said the ORRs in CITYSCAPE have “generated a lot of buzz,” but she urged caution pending phase 3 results.

“While we are all excited by the data and want to see a winner, we should be careful, as speed can also crash and burn,” she said. “We have plenty of examples of promising studies that collapsed in later phase trials.”

There is room, however, for cautious optimism that the combination is a promising advance “as long as no prognostic or confounding variable is determined later on to be nonrandomly distributed between the groups to account for the difference seen,” Dr. Dy said.

She also noted that “the distribution of favorable or unfavorable mutations between the groups is unknown, and understanding this will be relevant.”

Preclinical data suggest the presence of DNM1 expression is crucial for maximizing the effect of TIGIT blockade, and tumor MHC class 1 expression appears to be reduced alongside reductions in DNM1 expression in the intratumoral natural kill cells in lung cancer specimens, Dr. Dy explained.

“Assessment of these biomarkers will be instructive,” she said. “More recent data also appear to implicate a paradoxical role of soluble CD155 or PVR ligand in actually inhibiting DNM1, so the effect of systemic TIGIT blockade may be mitigated if there is rebound increase of counterbalancing signals by increased secretion of soluble CD155, and we look forward to more data in the future regarding this.”

CITYSCAPE was sponsored by Genentech. Dr. Johnson disclosed relationships with Genentech and numerous other companies. Dr. Dy disclosed relationships with AstraZeneca, GlaxoSmithKline, Takeda, Amgen, Bristol-Myers Squibb, Regeneron, and Tesaro.

sworcester@mdedge.com

SOURCE: Rodriguez-Abreu D et al. ASCO 2020, Abstract 9503.