Patient-Reported Outcomes with Durvalumab With or Without Tremelimumab Versus Standard Chemotherapy as First-Line Treatment of Metastatic Non-Small-Cell Lung Cancer (MYSTIC)
BACKGROUND:The phase 3 MYSTIC study of durvalumab Â± tremelimumab versus chemotherapy in metastatic non-small-cell lung cancer (NSCLC) patients with tumor cell (TC) programmed cell death ligand 1 (PD-L1) expression â‰¥ 25% did not meet its primary endpoints. We report patient-reported outcomes (PROs). PATIENTS AND METHODS/METHODS:Treatment-naÃ¯ve patients were randomized (1:1:1) to durvalumab, durvalumabâ€¯+â€¯tremelimumab, or chemotherapy. PROs were assessed in patients with PD-L1 TC â‰¥ 25% using EORTC Quality of Life Questionnaire (QLQ)-C30/LC13. Changes from baseline (12 months) for prespecified PRO endpoints of interest were analyzed by mixed model for repeated measures (MMRM) and time to deterioration (TTD) by stratified log-rank tests. RESULTS:There were no between-arm differences in baseline PROs (Nâ€¯=â€¯488). Between-arm differences in MMRM-adjusted mean changes from baseline favored at least one of the durvalumab-containing arms versus chemotherapy (nominal P < .01) for C30 fatigue: durvalumab (-9.5; 99% confidence interval [CI], -17.0 to -2.0), durvalumabâ€¯+â€¯tremelimumab (-11.7; 99% CI, -19.4 to -4.1); and for C30 appetite loss: durvalumab (-11.9; 99% CI, -21.1 to -2.7). TTD was longer with at least one of the durvalumab-containing arms versus chemotherapy (nominal P < .01) for global health status/quality of life: durvalumab (hazard ratio [HR]â€¯=â€¯0.7; 95% CI, 0.5-1.0), durvalumabâ€¯+â€¯tremelimumab (HRâ€¯=â€¯0.7; 95% CI, 0.5-1.0); and for physical functioning: durvalumab (HRâ€¯=â€¯0.6; 95% CI, 0.4-0.8), durvalumabâ€¯+â€¯tremelimumab (HRâ€¯=â€¯0.6; 95% CI, 0.5-0.9) (both C30); as well as for the key symptoms of dyspnea: durvalumab (HRâ€¯=â€¯0.6; 95% CI, 0.5-0.9), durvalumabâ€¯+â€¯tremelimumab (HRâ€¯=â€¯0.7; 95% CI, 0.5-1.0) (both LC13); fatigue: durvalumabâ€¯+â€¯tremelimumab (HRâ€¯=â€¯0.6; 95% CI, 0.4-0.8); and appetite loss: durvalumab (HRâ€¯=â€¯0.5; 95% CI, 0.4-0.7), durvalumabâ€¯+â€¯tremelimumab (HRâ€¯=â€¯0.7; 95% CI, 0.5-0.9) (both C30). CONCLUSION/CONCLUSIONS:Durvalumab Â± tremelimumab versus chemotherapy reduced symptom burden and improved TTD of PROs, suggesting it had no detrimental effects on quality of life in metastatic NSCLC patients.
Randomized Phase 2 Studies of Checkpoint Inhibitors Alone or in Combination With Pegilodecakin in Patients With Metastatic NSCLC (CYPRESS 1 and CYPRESS 2)
INTRODUCTION/BACKGROUND:Checkpoint inhibitors (CPIs) have been approved to treat metastatic NSCLC. PegilodecakinÂ + CPI suggested promising efficacy in phase 1 IVY, providing rationale for randomized phase 2 trials CYPRESS 1 and CYPRESS 2. METHODS:CYPRESS 1 (NÂ = 101) and CYPRESS 2 (NÂ = 52) included Eastern Cooperative Oncology Group performance status of 0 to 1 and first-line/second-line metastatic NSCLC, respectively, without known EGFR/ALK mutations. Patients were randomized 1:1; control arms received pembrolizumab (CYPRESS 1) or nivolumab (CYPRESS 2); experimental arms received pegilodecakinÂ + CPI. Patients had programmed death-ligand 1 tumor proportion score of greater than or equal to 50% (CYPRESS 1) or 0% to 49% (CYPRESS 2). Primary end point was objective response rate (ORR) per investigator. Secondary end points included progression-free survival (PFS), overall survival (OS), and safety. Exploratory end points included immune activation biomarkers. RESULTS:Median follow-up for CYPRESS 1 and CYPRESS 2 was 10.0 and 11.6 months, respectively. Results for pegilodecakinÂ + pembrolizumab versus pembrolizumab were as follows: ORR per investigator 47% versus 44% (ORÂ = 1.1, 95% confidence interval [CI]: 0.5-2.5); median PFS 6.3 versus 6.1 months (hazard ratio [HR]Â = 0.937, 95% CI: 0.54-1.625); and median OS 16.3 months versus not reached (HRÂ = 1.507, 95% CI: 0.708-3.209). Results per blinded independent central review were consistent. Treatment discontinuation rate owing to adverse events (AEs) doubled in the experimental arm (32% versus 15%). AEs with grade greater than or equal to 3 treatment-related AEs (62% versus 19%) included anemia (20% versus 0%) and thrombocytopenia (12% versus 2%). Results for pegilodecakinÂ + nivolumab versus nivolumab were as follows: ORR per investigator 15% versus 12% (ORÂ = 1.2, 95% CI: 0.3-5.9); median PFS 1.9 versus 1.9 months (HRÂ = 1.006, 95% CI: 0.519-1.951); and median OS 6.7 versus 10.7 months (HRÂ = 1.871, 95% CI: 0.772-4.532). AEs with grade greater than or equal to 3 treatment-related AEs (70.4% versus 16.7%) included anemia (40.7% versus 0%), fatigue (18% versus 0%), and thrombocytopenia (14.8% versus 0%). Biomarker data suggested activation of immunostimulatory signals of interleukin-10R pathway in pegilodecakin-containing arms. CONCLUSIONS:Despite evidence of biological effect in peripheral blood, adding pegilodecakin to CPI did not improve ORR, PFS, or OS, in first-line/second-line NSCLC. PegilodecakinÂ + CPI has been found to have overall higher toxicity compared with CPI alone, leading to doubling of treatment discontinuation rate owing to AEs.
Considerations for the Management of Oncology Patients During the COVID-19 Pandemic
Worldwide incidence and mortality due to the coronavirus disease 2019 (COVID-19) pandemic is greatest in the United States, with the initial epicenter in New York. In Nassau County, New York, where we practice, our institution has had more than 2500 cases and has discharged from the hospital more than 1000 patients. As many academic and private institutions have swiftly shifted their clinical and research priorities to address the pandemic, data are emerging regarding both the impact of malignancy on COVID-19 outcomes as well as the challenges faced in assuring that cancer care remains unimpeded. Of concern, recent studies of cancer patients primarily in China and Italy have suggested that advanced malignancy is associated with increased susceptibility to severe COVID-19 infection. At present, more than 500 clinical trials are underway investigating the pathogenesis and treatment of COVID-19, including expanded use of oncology drugs, such as small molecular inhibitors of cytokine pathways. Here, we begin by reviewing the latest understanding of COVID-19 pathophysiology and then focus our attention on the impact of this virus on hematologic and oncologic practice. Finally, we highlight ongoing investigational treatment approaches that are so relevant to the care of oncology patients during this extraordinary pandemic.
Durvalumab With or Without Tremelimumab vs Standard Chemotherapy in First-line Treatment of Metastatic Non-Small Cell Lung Cancer: The MYSTIC Phase 3 Randomized Clinical Trial
Importance/UNASSIGNED:Checkpoint inhibitors targeting programmed cell death 1 or its ligand (PD-L1) as monotherapies or in combination with anti-cytotoxic T-lymphocyte-associated antigen 4 have shown clinical activity in patients with metastatic non-small cell lung cancer. Objective/UNASSIGNED:To compare durvalumab, with or without tremelimumab, with chemotherapy as a first-line treatment for patients with metastatic non-small cell lung cancer. Design, Setting, and Participants/UNASSIGNED:This open-label, phase 3 randomized clinical trial (MYSTIC) was conducted at 203 cancer treatment centers in 17 countries. Patients with treatment-naive, metastatic non-small cell lung cancer who had no sensitizing EGFR or ALK genetic alterations were randomized to receive treatment with durvalumab, durvalumab plus tremelimumab, or chemotherapy. Data were collected from July 21, 2015, to October 30, 2018. Interventions/UNASSIGNED:Patients were randomized (1:1:1) to receive treatment with durvalumab (20 mg/kg every 4 weeks), durvalumab (20 mg/kg every 4 weeks) plus tremelimumab (1 mg/kg every 4 weeks, up to 4 doses), or platinum-based doublet chemotherapy. Main Outcomes and Measures/UNASSIGNED:The primary end points, assessed in patients with â‰¥25% of tumor cells expressing PD-L1, were overall survival (OS) for durvalumab vs chemotherapy, and OS and progression-free survival (PFS) for durvalumab plus tremelimumab vs chemotherapy. Analysis of blood tumor mutational burden (bTMB) was exploratory. Results/UNASSIGNED:Between July 21, 2015, and June 8, 2016, 1118 patients were randomized. Baseline demographic and disease characteristics were balanced between treatment groups. Among 488 patients with â‰¥25% of tumor cells expressing PD-L1, median OS was 16.3 months (95% CI, 12.2-20.8) with durvalumab vs 12.9 months (95% CI, 10.5-15.0) with chemotherapy (hazard ratio [HR], 0.76; 97.54% CI, 0.56-1.02; Pâ€‰=â€‰.04 [nonsignificant]). Median OS was 11.9 months (95% CI, 9.0-17.7) with durvalumab plus tremelimumab (HR vs chemotherapy, 0.85; 98.77% CI, 0.61-1.17; Pâ€‰=â€‰.20). Median PFS was 3.9 months (95% CI, 2.8-5.0) with durvalumab plus tremelimumab vs 5.4 months (95% CI, 4.6-5.8) with chemotherapy (HR, 1.05; 99.5% CI, 0.72-1.53; Pâ€‰=â€‰.71). Among 809 patients with evaluable bTMB, those with a bTMB â‰¥20 mutations per megabase showed improved OS for durvalumab plus tremelimumab vs chemotherapy (median OS, 21.9 months [95% CI, 11.4-32.8] vs 10.0 months [95% CI, 8.1-11.7]; HR, 0.49; 95% CI, 0.32-0.74). Treatment-related adverse events of grade 3 or higher occurred in 55 (14.9%) of 369 patients who received treatment with durvalumab, 85 (22.9%) of 371 patients who received treatment with durvalumab plus tremelimumab, and 119 (33.8%) of 352 patients who received treatment with chemotherapy. These adverse events led to death in 2 (0.5%), 6 (1.6%), and 3 (0.9%) patients, respectively. Conclusions and Relevance/UNASSIGNED:The phase 3 MYSTIC study did not meet its primary end points of improved OS with durvalumab vs chemotherapy or improved OS or PFS with durvalumab plus tremelimumab vs chemotherapy in patients with â‰¥25% of tumor cells expressing PD-L1. Exploratory analyses identified a bTMB threshold of â‰¥20 mutations per megabase for optimal OS benefit with durvalumab plus tremelimumab. Trial Registration/UNASSIGNED:ClinicalT rials.gov Identifier: NCT02453282.
Third-Line Nivolumab Monotherapy in Recurrent SCLC: CheckMate 032
INTRODUCTION/BACKGROUND:For patients with recurrent SCLC, topotecan remains the only approved second-line treatment, and the outcomes are poor. CheckMate 032 is a phase 1/2, multicenter, open-label study of nivolumab or nivolumab plus ipilimumab in SCLC or other advanced/metastatic solid tumors previously treated with one or more platinum-based chemotherapies. We report results of third- or later-line nivolumab monotherapy treatment in SCLC. METHODS:In this analysis, patients with limited-stage or extensive-stage SCLC and disease progression after two or more chemotherapy regimens received nivolumab monotherapy, 3 mg/kg every 2 weeks, until disease progression or unacceptable toxicity. The primary end point was objective response rate. Secondary end points included duration of response, progression-free survival, overall survival, and safety. RESULTS:Between December 4, 2013, and November 30, 2016, 109 patients began receiving third- or later-line nivolumab monotherapy. At a median follow-up of 28.3 months (from first dose to database lock), the objective response rate was 11.9% (95% confidence interval: 6.5-19.5) with a median duration of response of 17.9 months (range 3.0-42.1). At 6 months, 17.2% of patients were progression-free. The 12-month and 18-month overall survival rates were 28.3% and 20.0%, respectively. Grade 3 to 4 treatment-related adverse events occurred in 11.9% of patients. Three patients (2.8%) discontinued because of treatment-related adverse events. CONCLUSIONS:Nivolumab monotherapy provided durable responses and was well tolerated as a third- or later-line treatment for recurrent SCLC. These results suggest that nivolumab monotherapy is an effective third- or later-line treatment for this patient population.
Creating a Comprehensive Lung Cancer Screening Program to Diagnose Early Stage Lung Cancers [Meeting Abstract]
Improving Annual Adherence in a Community Based Lung Cancer Screening Program [Meeting Abstract]
Assessment of nivolumab exposure and clinical safety of 480â€‰mg every 4 weeks flat-dosing schedule in patients with cancer
Background/UNASSIGNED:A nivolumab monotherapy flat-dosing regimen of 480â€‰mg every 4â€‰weeks (Q4W) has been approved in several markets, including the United States, Canada, and European Union, as an alternative dosing regimen for several indications. Approvals of this Q4W regimen were based on population pharmacokinetic (PK) analyses, established flat exposure-response relationships, and clinical safety. The objective of this study was to compare the PK exposure of 480â€‰mg Q4W with 3â€‰mg/kg every 2â€‰weeks (Q2W) and 240â€‰mg Q2W using modeling and simulation, and to evaluate clinical safety of the Q4W regimen. Patients and methods/UNASSIGNED:Nivolumab PK exposure for the 480â€‰mg Q4W schedule was simulated for 3817 patients across multiple tumor types and compared with those for the 3â€‰mg/kg Q2W and 240â€‰mg Q2W schedules. The safety profile of the Q4W schedule was assessed by analysis of clinical data from 61 patients who transitioned to nivolumab 480â€‰mg Q4W from 3â€‰mg/kg Q2W during four phase III clinical trials. Results/UNASSIGNED:Compared with 3â€‰mg/kg Q2W, nivolumab 480â€‰mg Q4W produced similar time-averaged concentration, approximately 16% lower trough concentration, and 45% higher peak concentration at steady state. The peak concentration for 480â€‰mg Q4W was significantly lower than that of 10â€‰mg/kg Q2W, a dose previously shown to have an acceptable tolerability and safety profile. Treatment-related adverse events (TRAEs) that started after transitioning from 3â€‰mg/kg Q2W to 480â€‰mg Q4W were reported in 14.8% of patients, with 1.6% of patients reporting grades 3-4 TRAEs. Pooled safety data for these patients are consistent with those for the 3â€‰mg/kg Q2W schedules, and no new safety signals were identified. Conclusions/UNASSIGNED:The time-averaged steady-state exposure and safety profile of nivolumab 480â€‰mg Q4W are consistent with that of 3â€‰mg/kg Q2W across multiple tumor types. Nivolumab 480â€‰mg Q4W represents a new dosing schedule option, and in addition to 240â€‰mg Q2W, provides convenience and flexibility for patient care. Clinical trial numbers/UNASSIGNED:NCT01721772, NCT01668784, NCT01673867, NCT01642004.
Painless Jaundice: A Rare Presentation of Uterine Leiomyosarcoma With Pancreatic Metastasis [Meeting Abstract]
A Retrospective Review of CyberKnife Stereotactic Body Radiotherapy for Adrenal Tumors (Primary and Metastatic): Winthrop University Hospital Experience
The adrenal gland is a common site of cancer metastasis. Surgery remains a mainstay of treatment for solitary adrenal metastasis. For patients who cannot undergo surgery, radiation is an alternative option. Stereotactic body radiotherapy (SBRT) is an ablative treatment option allowing larger doses to be delivered over a shorter period of time. In this study, we report on our experience with the use of SBRT to treat adrenal metastases using CyberKnife technology. We retrospectively reviewed the Winthrop University radiation oncology data base to identify 14 patients for whom SBRT was administered to treat malignant adrenal disease. Of the factors examined, the biological equivalent dose (BED) of radiation delivered was found to be the most important predictor of local adrenal tumor control. We conclude that CyberKnife-based SBRT is a safe, non-invasive modality that has broadened the therapeutic options for the treatment of isolated adrenal metastases.