Non-small Cell Lung Cancer Cancer Patients Research Articles

Importance of driver gene mutation assessment and targeted therapy for patients with early‑stage non‑small cell lung cancer and non‑R0 resection.

Patients with non-small cell lung cancer (NSCLC) and incomplete resection have poor clinical outcomes. The present study aimed to identify risk factors for disease progression and mortality. A total of 65 patients with early-stage NSCLC that underwent operation but had a non-R0 resection between August 2011 and December 2020 were included in the present study, and the clinicopathological features and driver gene mutation status were analyzed. The median follow-up time was 36.2 months; 39 patients (60.0%) experienced disease progression and 3 patients (4.6%) died. In total, 22 patients (33.8%) harbored mutations in driver genes. Multivariate analysis demonstrated that the presence of driver gene mutations was associated with an increased risk of disease progression [adjusted odds ratio, 24.08; 95% confidence interval (CI), 2.77-209.01; P=0.004]. Tumors classed as Eastern Cooperative Oncology Group performance status 2 [adjusted hazard ratio (HR), 3.49; 95% CI, 1.10-11.03; P=0.033], stage II-IIIB tumors (adjusted HR, 2.55; 95% CI, 1.06-6.17; P=0.037) and the presence of a driver gene mutation (adjusted HR, 3.28; 95% CI, 1.55-6.94; P=0.002) were associated with a significantly reduced progression-free survival (PFS). Driver gene-targeted therapy was associated with an increased post-progression survival for patients that were reported to have disease progression (adjusted HR, 0.38; 95% CI, 0.16-0.91; P=0.030). There was no significant impact of driver gene mutation status on the overall survival (OS) of patients. Although the presence of a driver gene mutation was associated with an increased risk of disease progression and a reduced PFS, it was demonstrated that patients with disease progression may benefit from driver gene-targeted therapy, as patients with driver gene-targeted therapy had a similar OS compared with that of patients with a driver gene-negative or unknown status. Therefore, early comprehensive analysis of driver gene mutation status may be recommended for early-stage NSCLC cancer patients experiencing non-R0 resection.

Real-world use of a CSF circulating tumor cell assay in the diagnosis and management of leptomeningeal metastasis.

2029 Background: The diagnosis of leptomeningeal metastasis (LM) can be challenging due to variability in clinical symptoms, radiographic, and cerebrospinal fluid (CSF) findings. The National Comprehensive Cancer Network (NCCN) guidelines recommend assessment of circulating tumor DNA (ctDNA) to increase sensitivity of tumor cell detection and assess the response to treatment. We hypothesize that the real-world use of an assay for the direct detection and enumeration of circulating tumor cells (CTCs) in the CSF is clinically useful for accurate diagnosis of LM, particularly in an early stage of disease. Methods: We report a series of 55 patients treated at our institution with a cancer diagnosis and either neurological symptoms or radiographic findings that suggested LM. All patients underwent a lumbar puncture, assessment for CSF CTCs, and conventional hospital-based cytology testing between 6/1/2020 and 8/1/2023. Survival data cutoff was 12/31/2023. Patient outcomes are reported. Results: 55 patients were tested, and 30 patients were found to be positive for CTCs and diagnosed with LM. Only 10 patients were concurrently positive for CTCs and cytology at our institution, whereas 20 patients with positive CTCs had a negative or ambiguous cytology. No patients with a negative CTC result (25 patients) were subsequently diagnosed with LM, whereas 4 patients with a positive CTC result remained without progressive neurological symptoms. 5 patients diagnosed with LM were alive at the time of data cutoff. The histologic breakdown for LM was: breast (11), non-small cell lung cancer (NSCLC) (16), gastrointestinal (GI) (3). Median overall survival (OS) was longer in patients with a positive CTC and negative cytology result compared to patients with concurrent positive CTC and cytology (172 vs. 63 days, p = 0.06). Median OS was also longer in breast cancer LM compared to NSCLC LM (235 vs. 63 days, p = 0.008). Most patients diagnosed with LM received therapies including Ommaya reservoir placement, intrathecal chemotherapy, and/or radiation. Conclusions: The use of a CSF circulating tumor cell assay aided the diagnosis of LM and led to timely initiation of treatment. A negative result of the CTC assay was associated with ruling out LM. Diagnosis of LM with the CTC assay and negative cytology was associated with longer survival, possibly due to earlier treatment initiation, and not solely a lead time bias. Breast cancer LM patients had improved survival compared to NSCLC and GI cancer patients, possibly due to more effective treatment options.

Simultaneous detection of tumor-derived mutations in DNA and RNA extracted from a single circulating tumor cell based on droplet digital polymerase chain reaction.

e15053 Background: Androgen receptor splice variant 7 (AR-V7) is a constitutively activated isoform of AR and has been associated with resistance to AR-targeted therapies and development of metastatic castration-resistant prostate cancer. Confirmation of AR-V7 expression is important step in prostate cancer diagnosis and determining the appropriate drug, however, the detection of AR-V7 with tissues has limitations, such as the clinical challenge to poorly accessible tumor tissues before and after therapy. In addition, KRAS mutations serve as a prognostic biomarker for the administration of appropriate anti-cancer drugs in patients with various cancers, including non-small cell lung cancer (NSCLC). Here, we developed the process for the simultaneous detection of AR-V7 and KRAS mutation in CTCs using isolation with CytoGen’s Smart Biopsy™ System with droplet digital polymerase chain reaction (ddPCR) with high sensitivity and specificity, overcoming the limitations of tissue biopsy. Methods: ddPCR assays were performed to detect the KRAS G12C mutation using CTC gDNA and to evaluate the absolute levels of AR-V7 using CTC mRNA. Analytical validation was performed using NSCLC NCI-H358 and prostate cancer 22Rv1 cells (10 and 5 cells each), which harbor KRAS G12C and AR-V7, respectively, spiked into 5 mL of healthy blood to mimic CTC. CTCs were isolated using CytoGen's Smart Biopsy™ System. Oligo-dT magnetic beads were used to isolate mRNA from CTCs, and gDNA was isolated from the mRNA-depleted CTC lysates using the AllPrep DNA/mRNA Nano Kit. PCR and droplet reading for each assay were performed on the QX200 AutoDG Droplet Digital PCR System. Results: As a result of CTC KRAS G12C detection using the ddPCR™ KRAS G12/G13 Screening Kit, the mutated KRAS gene was successfully detected in as few as 5 NCI-H358 cells. In the results of CTC AR-V7 detection using the custom TaqMan ddPCR assay, transcripts (AR-V7 and HPRT1) were successfully detected even with only 5 22Rv1 cells. These results suggest that CytoGen's Smart Biopsy™ System could be applied to the simultaneous detection of DNA/RNA mutated genes in clinical NSCLC and prostate cancer patients with detection technology requiring high sensitivity and specificity. Conclusions: Accurately detecting multiple genetic mutations in CTCs is a challenging because CTCs are very rare in the blood. In this study, we developed the process to simultaneously extract and detect DNA mutations and RNA splicing variants in CTCs using CytoGen's Smart Biopsy™ System. This process, along with the results from our ongoing clinical trials, could provide information for the diagnosis and appropriate treatment of patients with various cancers, including NSCLC and prostate cancer.

Abstract CT056: Development of a novel next-generation RET inhibitor

Abstract Oncogenic RET alterations confer constitutive activation in multiple types of human cancers. Two first-generation selective RET inhibitors selpercatinib and pralsetinib have been approved for patients with RET-driven solid tumors including non-small cell lung cancer (NSCLC) and thyroid cancer. However, critical unmet medical needs remain due to drug resistance caused by RET mutations in patients treated with the first-generation RET inhibitors. To address this emerging clinical issue, we discovered a highly potent and selective RET inhibitor with novel chemical scaffold through structure-based drug design, APS03118. Preclinical studies showed APS03118 had stronger in vitro and in vivo biological activity than the first-generation RET inhibitors targeting a broad range of RET fusions and mutations. Importantly, APS03118 was highly potent against a series of resistant RET mutations including the solvent front mutations RET G810C/R/S (IC50 0.04-5.72 nM) and gatekeeper mutations RET V804E/L/M (IC50 0.04-1.36 nM). Off-target screen analysis using the 468-kinase panel demonstrated APS03118 was highly selective for RET. APS03118 was orally bioavailable with good ADME and PK properties and markedly suppressed tumor growth in various RET-driven mouse xenograft tumor models (tumor growth inhibition 87-108% at 10-30 mg/kg BID). In addition, APS03118 exhibited excellent brain penetrating properties with strong efficacy in the in vivo orthotopic brain tumor model. GLP toxicity studies showed acceptable safety profiles. APS03118 received IND approval from both US FDA and China NMPA, and was granted the fast-track designation by FDA. We recently achieved First-in-Human milestone for APS03118 and the Ph 1 clinical trial is ongoing. As of January 5, 2024, three dose levels have been tested. Plasma exposure of APS03118 increased proportionally following single and repeated administration of APS03118 at different doses. APS03118 was well tolerated in NSCLC and thyroid cancer patients harboring RET fusions or mutations relapsed on the chemotherapy, multi-kinase inhibitor and first-generation RET inhibitor therapy. In addition to the favorable safety profiles, we observed sign of efficacy in the RET altered cancer patients in response to APS03118 treatment even in the early clinical trial testing. Partial response and stable disease were observed in patients 2-4 months after administration of APS03118 and dose limiting toxicity (DLT) dose has not been reached. Dose escalation for APS03118 is continuing. Taken together, APS03118 is a novel highly potent and selective next-generation RET inhibitor overcoming resistance following treatment with the first-generation RET inhibitors. APS03118 warrants further clinical development. Citation Format: Jun Zhong, Ruxue Xiao, Wenya Xie, Minchun Chen, Xiaohu Chen, Hao Wang, Yongbo Liu, Qin Gao, Xiupeng Wang, Zongbao Wang, Qian Chen, Jing Yang, Yizhe Ji, Yuxun Wang. Development of a novel next-generation RET inhibitor [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 2 (Late-Breaking, Clinical Trial, and Invited Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(7_Suppl):Abstract nr CT056.

Abstract 7165: Clinical population pharmacokinetic (popPK) analysis of NBF-006, a novel siRNA inhibitor of glutathione-S-transferase P (GSTP) encapsulated in a lipid nano particle (LNP), for treatment of advanced non-small cell lung cancer (NSCLC)

Abstract GSTP has an important role in detoxification and antioxidative damage response. Additionally, GSTP has a chaperone function that regulates multiple oncogenic pathways such as KRAS and JNK. Since alternative pathways could compensate for the inhibition of a single kinase, targeting multiple pathways could lead to more effective therapy. NBF-006 is a drug product comprised of GSTP siRNA encapsulated within a novel LNP. It is designed to deliver siRNA to localized and metastatic lung tumors. Unlike other well-established drug modalities, there is a general need for increased understanding of the PK of RNA therapeutics. For NBF-006, we present popPK analysis of patients who have undergone treatment in a Phase I (a/b) clinical study. A primary goal of popPK modeling is to identify PK parameters and sources of variability in a population. Other goals include correlating drug exposures with administered doses through identification of predictive covariates in a target population and establishing whether fixed dosing as opposed to weight-based dosing can be utilized in future clinical studies. Ultimately this analysis will help to inform decision-making for dosing regimens in future clinical trial designs and to better predict PK variability across populations. A total of 48 advanced NSCLC (N=38), pancreatic (N=5), or colorectal cancer (N=5) patients received 4 doses (QW) of NBF-006 by infusion at 0.15, 0.3, 0.6, 1.2 or 1.6 mg/kg followed by a 2-week rest period. In all studies, serial blood samples were collected at weeks 1 and 4. Plasma concentrations of siRNA were determined by hybridization ELISA. PopPK analysis was performed to characterize NBF-006 PK and to explore intrinsic and extrinsic covariate effects that could affect NBF-006 exposure. The analysis included 695 quantifiable PK observations. A popPK model with two-compartment disposition and linear elimination adequately described the PK profile of NBF-006. Exploratory data analysis of dose-normalized PK profiles suggested that exposure increased proportionally with increasing dose from 0.15 to 1.6 mg/kg. Little to no apparent accumulation nor exposure reduction was observed between weeks 1 and 4. The impact of individual patient covariates, including body weight, baseline ALT, sex, KRAS mutation, cancer type and race, was assessed on PK parameters. None of the covariates evaluated had a significant effect on NBF-006 clearance or central distribution volume (Vc) in the model. Vc showed a slight positive trend with higher body weight, but was not statistically significant. A popPK model was successfully developed for NBF-006. No covariates were identified that impact NBF-006 exposure. The lack of a relationship of exposure with body weight suggests the potential to use fixed dosing in future clinical studies. Citation Format: Michael P. Hall, Zhihong O'Brien, Xi Chen, Angelean Hendrix, Stacy Brenes-Coto, Sonya Zabludoff. Clinical population pharmacokinetic (popPK) analysis of NBF-006, a novel siRNA inhibitor of glutathione-S-transferase P (GSTP) encapsulated in a lipid nano particle (LNP), for treatment of advanced non-small cell lung cancer (NSCLC) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 7165.

Abstract C101: Preclinical and clinical pharmacokinetics (PK) of NBF-006, a novel siRNA inhibitor of glutathione-s-transferase P (GSTP) encapsulated in a lipid nanoparticle (LNP), for treatment of advanced non-small cell lung cancer (NSCLC)

Abstract Background: GSTP has an important role in detoxification and anti-oxidative damage response. Additionally, GSTP has a chaperone function that regulates multiple key oncogenic pathways such as KRAS and JNK. Since alternative or redundant pathways could compensate for the inhibition of a single kinase, targeting multiple pathways could lead to more effective therapy. NBF-006 is a drug product comprised of GSTP siRNA encapsulated within a novel LNP. It is designed to deliver siRNA to localized and metastatic lung tumors. Unlike other well-established drug modalities, there is a general need for increased understanding of the PK of RNA therapeutics. For NBF-006, we present preclinical PK data in healthy mice and monkeys, prediction of human doses, and phase 1 clinical PK data. Methods: Preclinical PK studies were performed by intravenous bolus injection of NBF-006 once weekly for 1 month at 5, 20, and 40 mg/kg in mice and 6, 12, and 18 mg/kg in cynomolgus monkeys. Human drug exposures were predicted based upon simple allometry. For the phase 1 clinical study, a total of 48 advanced NSCLC, pancreatic, or colorectal cancer patients received 4 weekly doses of NBF-006 by infusion at 0.15, 0.3, 0.6, 1.2 or 1.6 mg/kg followed by a 2-week rest period. In all studies, serial blood samples were collected at weeks 1 and 4. Plasma concentrations of siRNA were determined by a hybridization ELISA. Non-compartmental PK analysis (NCA) was performed with the resulting concentration-time data. Results: In mice, terminal elimination half-life (t1/2) of plasma siRNA ranged between 3.69 to 9.04 hr, clearance (CL) ranged between 3.61 and 5.81 mL/hr/kg, and volume of distribution (Vd) ranged between 23.5 and 57.4 mL/kg. In cynomolgus monkeys, t1/2 ranged between 8.22 and 28.2 hr, CL ranged between 1.38 and 3.97 mL/hr/kg, and Vd ranged between 31.7 to 83.3 mL/kg. Exposure (maximal plasma concentration, Cmax, and area under the curve, AUC) increased with increasing dose in both species and was generally dose proportional. Following weekly administration of NBF-006, no apparent accumulation or reduction of siRNA exposure was observed. Human PK exposures were well-predicted within 2-fold accuracy at clinically studied doses. Clinically, NCA demonstrated consistent slow CL and low Vd with a mean t1/2 of 41 (± 13) hours. Exposure showed dose proportionality from 0.15 to 1.2 mg/kg. At 1.6 mg/kg, exposure was not statistically different than that of 1.2 mg/kg. No accumulation risk potential was identified following the current dosing regimen. Moreover, exposure was not reduced after repeat dosing in any dose group. Conclusions: Preclinical PK profiling enabled initial characterization of the in vivo disposition of NBF-006 and prediction of human PK and doses. In patients, repeated administration of NBF-006 was well-tolerated up to 1.6 mg/kg. Exposure appeared to be dose proportional through 1.2 mg/kg. Neither exposure reduction nor accumulation was observed. Citation Format: Michael Hall, Zhihong O'Brien, Sonya Zabludoff. Preclinical and clinical pharmacokinetics (PK) of NBF-006, a novel siRNA inhibitor of glutathione-s-transferase P (GSTP) encapsulated in a lipid nanoparticle (LNP), for treatment of advanced non-small cell lung cancer (NSCLC) [abstract]. In: Proceedings of the AACR-NCI-EORTC Virtual International Conference on Molecular Targets and Cancer Therapeutics; 2023 Oct 11-15; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2023;22(12 Suppl):Abstract nr C101.

TIGIT expression and outcomes in pembrolizumab treated patients with NSCLC.

e21110 Background: Immune checkpoint inhibitors (ICIs) have emerged as effective treatments for multiple cancers. TIGIT is an emerging ICI target that impairs T cell activation by dendritic cells, enhances the immune suppressive activity of regulatory T cells, and inhibits tumor killing by natural killer and cytotoxic T cells. In this study, we describe the mRNA expression landscape of TIGIT across 35 solid tumor types, its co-expression with additional checkpoint targets, and correlation with survival of patients with Non-Small Cell Lung Cancer (NSCLC) treated with pembrolizumab. Methods: A discovery cohort (DC) of 15,630 tumors across 35 types were evaluated by comprehensive immune profiling. TIGIT expression was ranked across a population of 735 samples to yield rank values [0-100]. TIGIT rank was grouped as high (rank ≥75) and low (rank < 25). We assessed the distribution of TIGIT expression across cancer types, cellular proliferation, and significant co-expression with other checkpoint targets. Co-expression was assessed using Spearman correlation(rs). Additionally, in a retrospective cohort (RC) of 72 pembrolizumab treated patients with NSCLC, Kaplan-Meier analysis was used to test for differences in overall survival (OS) and progression free survival (PFS). Differences in objective response rate (ORR) were determined using chi squared test. Results: The DC demonstrated a dynamic range of TIGIT expression with highest median expression observed in lung cancer (median rank = 60) where 36% of lung cancers were TIGIT high. Tumors with high expression of proliferation markers including Ki67 were predominantly TIGIT high (87.5%; p < 0.001), whereas tumors with poor proliferation were TIGIT low (73.5%, p < 0.001). TIGIT was found to be significantly co-expressed (p < 0.001) with other immunotherapy targets including PD-1 (rs= 0.5), PD-L1 (rs= 0.5), and TIM3 (rs= 0.6) by RNA-Seq. For dual expression, we identified subgroups that are both PD-1 high and TIGIT high (2766/15,630; 17%). Similar results were observed for TIGIT and PD-L1 dual expression (PD-L1 high and TIGIT high 2167/15,630; 14%). TIGIT high patients from the NSCLC RC demonstrated significantly higher OS (median OS = 44 months; p = 0.01) and PFS (median PFS = 35 months; p = 0.006) compared the TIGIT low patients (median OS = 23 months; median PFS = 18 months). TIGIT high cases had significantly (ORR = 60%, p = 0.001) improved response to pembrolizumab compared to TIGIT low cases (ORR = 39%). Conclusions: Comprehensive immune profiling of a clinically tested pan-cancer cohort showed that TIGIT is a potential immune target with dynamic expression across multiple solid tumors. TIGIT expression is strongly associated with proliferation and suggests improved outcomes for NSCLC cancer patients treated with an ICI therapy. Furthermore, significant TIGIT co-expression with other checkpoint targets such as PD-1/PD-L1 highlights its potential use in combination therapy strategies.

Laboratory blood test profiling reveals distinct biochemical and hemocyte features of KRAS mutated non-small cell lung cancer.

The testing for capability of some routine blood test parameters to reflect the biology of non-small cell lung carcinoma with different driver mutations is of great interest and practice significance. We aim to screen these variables and, if allowed, develop a novel predictive model based on results of these routine blood tests commonly performed in clinical practice to inform which can help doctors assess the patient's genetic mutation status as early as possible before surgery. For the exploration cohort, we included 1,595 patients who were diagnosed with non-small cell lung cancer (NSCLC) and genetically profiled by a next-generation sequencing panel in the First Affiliated Hospital of Guangzhou Medical University. The external validation cohort, which consists of 197 NSCLC cancer patients from Sun Yat-sen University Cancer Hospital, was subsequently established. We analyzed the association between 46 frequently tested laboratory variables and different genetic mutation types. KRAS mutation was found to be a unique subtype that exclusively correlated with several blood parameters in our study. Least absolute shrinkage and selection operator (LASSO) regression was performed, and the following parameters were found to be significantly associated with KRAS mutation: triglycerides [odds ratio (OR) =1.63], arterial oxygen partial pressure (OR =0.97), uric acid (OR =1.01), basophil count (OR =1.41), eosinophil count (OR =1.146), fibrinogen (OR =1.42), standard bicarbonate (OR =0.85), high-density lipoprotein cholesterol (OR =0.18), alpha-L-fucosidase (OR =1.07). The areas under the receiver-operator characteristic curve in the training set and the external validation set were 0.85 [95% confidence interval (CI): 0.81-0.88] and 0.81 (95% CI: 0.71-0.91), respectively. We developed a non-invasive, more cost-effective predictive model of NSCLC based on routinely available variables, with practical predictive power. This model can be used as a practical screening tool to guide the use of more specialized and expensive molecular assays for KRAS mutation in NSCLC. However, further studies are warranted to investigate the mechanism underlying such association between KRAS mutations and the related parameters of blood tests.

55P Comparison of BiomeOne and PD-L1 expression tests as a predictor for response to immune checkpoint inhibitors (ICI) in patients with non-small cell lung cancer (NSCLC)

55P Comparison of BiomeOne and PD-L1 expression tests as a predictor for response to immune checkpoint inhibitors (ICI) in patients with non-small cell lung cancer (NSCLC)

Four-Phase, Definitive Chemoradiation for a Real-World (Poor Risk and/or Elderly) Patient Population With Locally Advanced Non-small Cell Lung Cancer.

IntroductionWith the incorporation of modernized radiotherapy, chemotherapy, and immunotherapy, treatment outcomes have improved for patients with locally advanced, unresectable diseases. Elderly or poor performance status patients comprise more than half of non-small cell lung cancer (NSCLC) patients, but they are often underrepresented or excluded in clinical trials. Split-course concurrent chemoradiotherapy can be an effective treatment, showing good adherence and a favorable toxicity profile for unresectable, locally advanced NSCLC.MethodWe identified locally advanced NSCLC cancer patients via a single institution retrospective study. Patients were treated using a four-phase, split-course external beam radiotherapy approach with concurrent chemotherapy. The primary endpoints analyzed were completion rate, incidence, and severity of treatment-related toxicities, progression-free survival (PFS), and median overall survival (OS).ResultsThirty-nine locally advanced lung cancer patients were treated with split-course chemoradiation (CRT). The median age at diagnosis was 73 years old. Seventeen patients had an Eastern Cooperative Oncology Group (ECOG) performance score of 2. Twenty-three patients had a clinical diagnosis of chronic obstructive pulmonary disease (COPD), and 10 patients were on home oxygen at the time of diagnosis. All patients completed 6000 centigrays (cGy) of radiation, and 95% of the patients completed at least three cycles of concurrent chemotherapy. No patients experienced grade 3 to 5 acute thoracic toxicities. Overall median survival was 12.7 months, and PFS was 7.5 months.ConclusionOur retrospective analysis of 39 poor risk and/or elderly patients with locoregional NSCLC treated with concurrent CRT via a split-course regimen suggests favorable oncologic outcomes and superb treatment completion rates and toleration.

Regulation and Therapeutic Targeting of MTHFD2 and EZH2 in KRAS-Mutated Human Pulmonary Adenocarcinoma.

Activating KRAS mutations occur in about 30% of pulmonary adenocarcinoma (AC) cases and the discovery of specific inhibitors of G12C-mutated KRAS has considerably improved the prognosis for a subgroup of about 14% of non-small cell lung cancer (NSCLC) patients. However, even in patients with a KRAS G12C mutation, the overall response rate only reaches about 40% and mutations other than G12C still cannot be targeted. Despite the fact that one-carbon metabolism (1CM) and epigenetic regulation are known to be dysregulated by aberrant KRAS activity, we still lack evidence that co-treatment with drugs that regulate these factors might ameliorate response rates and patient prognosis. In this study, we show a direct dependency of Methylenetetrahydrofolate dehydrogenase 2 (MTHFD2) and Enhancer of Zeste Homolog 2 (EZH2) expression on mutationally activated KRAS and their prognostic relevance in KRAS-mutated AC. We show that aberrant KRAS activity generates a vulnerability of AC cancer cell lines to both MTHFD2 and EZH2 inhibitors. Importantly, co-inhibition of both factors was synergistically effective and comparable to KRASG12C inhibition alone, paving the way for their use in a therapeutic approach for NSCLC cancer patients.

The use of medical cannabis concomitantly with immune-check point inhibitors (ICI) in non-small cell lung cancer (NSCLC): A sigh of relief?

e21097 Background: In recent years, the use of medical cannabis rapidly increased among cancer patients in Israel. Yet, cannabinoid receptors are abundantly expressed on immune cells and modulate their activity. It is abundantly being use by metastatic NSCLC patients, shortly following diagnosis and is taken in parallel to first line treatment with ICI. Recent studies suggested that the use of cannabis may reduce the efficacy of ICI. However, these studies were biased by the heterogeneity of patients and the increased use of cannabis specifically in highly symptomatic patients with high disease burden. Methods: We first tested the interaction anti-PD-1 antibody and Δ−9-tetrahydrocannabinol (THC) in a preclinical model consisting of CT26 tumor-bearing mice, and examined the effects on tumor size, T-cell infiltrates, and mice survival. Mice were euthanized when tumor volume reached above 700 mm3. Next, we conducted a retrospective study of NSCLC patients, treated at a tertiary center, and included all consecutive patients treated with a single agent pembrolizumab as a first line treatment for advanced disease and evaluated clinical outcome and response to treatment. Results: Studies using the CT26 mice cancer model, indicated a potential beneficial effect for the combination an anti-PD-1 antibody and THC with a median overall survival (OS) of the mice receiving no treatment, THC, anti-PD-1 antibody or their combination being 21 days, 24, 31 days and 54 days, respectively (p < 0.05). Data of 201 NSCLC cancer patients who received first-line single agent pembrolizumab for metastatic disease, 102 (50.7%) patients received cannabis and 99 (49.3%) were cannabis naïve was analyzed. Their median age was 68 for the cannabis treated group and 74 for the cannabis naïve (p = 0.003), 34 (34.3%) in the cannabis treated group and 62 (60.8%) for the cannabis naïve were women (p = 0.002). Similar distribution of histology, smoking status and PDL1 expression was noted between the groups. The efficacy of pembrolizumab, as determined by time to progression (TTP) was similar for cannabis-naïve and cannabis-treated patients (6.1 vs. 4.8 months, respectively, p = 0.386), while OS was higher, though not statistically significant, in the cannabis-naïve group (54 vs. 23.3 months, respectively p = 0.08). Conclusions: Both preclinical and clinical data suggest no deleterious effect of cannabis on the activity of pembrolizumab as first line monotherapy for advanced NSCLC. The differences in OS can be most likely by attributed to higher disease burden and more symptomatic disease in the cannabis-treated group. While additional validation is required, these data provide somewhat reassuring data regarding the absence of a deleterious effect of cannabis in this clinical setting.

The budget impact of adding pralsetinib to a US health plan formulary for treatment of non-small cell lung cancer and thyroid cancer with RET alterations.

BACKGROUND: Lung cancer is the leading cause of cancer death in the United States. Non-small cell lung cancer (NSCLC) accounts for 80% to 85% of all lung cancers. Thyroid cancer, while generally not as lethal as lung cancer, has a large prevalent population and a rapidly increasing incidence in the United States. Pralsetinib is a highly potent, selective rearranged during transfection (RET) inhibitor indicated for the treatment of RET-positive NSCLC and thyroid cancer tumors. OBJECTIVE: To estimate the budget impact of adding pralsetinib to a 1 million-member US health plan formulary for the treatment of patients with metastatic RET fusion-positive NSCLC, advanced or metastatic RET-mutant medullary thyroid cancer (MTC), or advanced or metastatic RET fusion-positive thyroid cancer (non-MTC). METHODS: A budget impact model with a 3-year time horizon was developed in Microsoft Excel to estimate the number of eligible RET-positive NSCLC and thyroid cancer patients in a plan and quantify associated treatment costs (2020 USD). Comparators in the analyses included pralsetinib, selpercatinib, and cabozantinib, as well as indication-specific use of pembrolizumab, pemetrexed/carboplatin combination, vandetanib, lenvatinib, and sorafenib. Drug acquisition, molecular testing, treatment monitoring, and adverse event management costs were included to estimate total annual costs and per-member per-month (PMPM) costs in current (without pralsetinib) and potential future market scenarios, where pralsetinib is assumed to split the projected RET inhibitor market share with selpercatinib. The number of treated patients was based on age- and sex-adjusted incidence of disease, the proportion of patients diagnosed with advanced or metastatic disease, and projected RET testing rates. Treatment duration was based on progression-free survival or duration of response data from clinical trials. Medical resources were monetized using standardized sources such as Medicare reimbursement and wholesale acquisition cost (WAC). RESULTS: The model estimated that there would be approximately 6 new treatment-eligible patients in a 1 million-member plan annually. Monthly WAC is $19,243 for pralsetinib and $20,600 for selpercatinib at the recommended starting dose. Adoption of pralsetinib, with corresponding increases in pralsetinib market share, would be slightly cost saving to a payer, decreasing the overall budget impact to the health plan by $49,985 in year 3 (-$0.0042 PMPM; -$0.0030, -$0.0006, and -$0.0005 for NSCLC, MTC, and thyroid cancer [non-MTC], respectively). In year 3, drug costs were the key driver of total costs (~80%-98%) and cost savings. All other medical resource categories were cost-neutral or nominally cost saving or additive in the budget impact analysis. CONCLUSIONS: Quantifying the budget impact associated with the adoption of new targeted precision therapies is an important consideration for payers. For eligible NSCLC and thyroid cancer patients, our analysis suggests that adoption of pralsetinib is expected to result in modest cost savings for US payers. DISCLOSURES: Support for this study was provided by Blueprint Medicines Corporation. This study was conducted by Veritas Health Economics Consulting, Inc., in collaboration with Blueprint Medicines, which was involved in the design of the study; collection, analysis, and interpretation of the data; writing of the report; and the decision to submit the report for publication. Duff is an employee of Veritas Health Economics Consulting, which received research funding from Blueprint Medicines to develop the budget impact model. Norregaard and Sullivan are employees of Blueprint Medicines. Bargiacchi and Brener were employees of Blueprint Medicines at the time of the research study. This study was presented as a poster at the AMCP Virtual Learning Event, April 2021.

Utilization of palliative care services in patients who died from stage IV non-small cell lung cancer (NSCLC): A retrospective study from a tertiary care center in rural Maine.

95 Background: It is known that palliative care involvement in metastatic NSCLC cancer patients has been shown to improve quality of life in previous studies. The aim of our study was to analyze the utilization of palliative care services among patients who died from NSCLC and the setting in which these patients first received palliative care. Methods: This is a retrospective chart review analysis of patients with stage IV NSCLC who were diagnosed at Eastern Maine Medical center and the affiliated cancer center who died between January 2016 and December 2018. We collected demographic data, date and stage of diagnosis, location of palliative referral, location of first palliative care contact with the patient, time between diagnosis and death, utilization of hospice services and time between the initial palliative care consult and death. Results: 255 patients with stage IV NSCLC died between 2016 and 2018. Mean age was 65.5 years. Women were 49% and men were 51%. Majority (60%) of patients had good performance status with ECOG score between 0-1 at presentation. All 255 patients were referred to palliative care. The location of initial palliative care referral following diagnosis was 40% from the hospital, 32% from the oncology clinic and 28% from the outpatient specialist or PCP office. Overall, 174 patients (68%) were seen by palliative care and 81 (32%) were not seen. Of the patients seen 119 (68%) had their initial palliative evaluation in the hospital, and 55 (32%) in the clinic. Majority (55%) had more than one follow-up visit. Consults initiated in the inpatient setting were more likely to be seen by palliative care than in the outpatient setting (p 0.0009). Time between diagnosis to palliative care consult was less than one month in 39%, 1-2 months in 25%, 2-6 months in 21%, and more than 6 months in 14% patients. Patients seen by palliative care had a more likelihood to end up on hospice (p 0.09). The majority of patients seen by palliative care (53%) died within a month of initial consultation. Conclusions: All patients in our study population were referred to palliative care with 100% provider compliance. Among these, 68% were seen by palliative care. Interestingly, inpatient referrals were more likely to be seen by palliative care than the outpatient referrals. We think this is likely related to ease of access to palliative care team in the hospital as well as some of the patients being at terminal stages of their disease. About 33% of patients died within a month of their initial diagnosis, likely giving palliative care team a shorter window of opportunity to be seen in the outpatient setting. Prioritizing referrals of stage IV NSCLC patients might decrease the wait time after initial referral and increase the availability of palliative care services to these patients.

Interferon-γ-Inducible Chemokines as Prognostic Markers for Lung Cancer.

Interferon (IFN)-γ-inducible chemokines in the CXCR3/ligand axis are involved in cell-mediated immunity and play a significant role in the progression of cancer. We enrolled patients with lung cancer (n = 144) and healthy volunteers as the controls (n = 140). Initial blood samples were collected and concentrations of IFN-γ and IFN-γ-inducible chemokines CXCL9, CXCL10, and CXCL11 were measured using enzyme-linked immunosorbent assay. Of patients with lung cancer, 125 had non-small cell lung cancer (NSCLC) and 19 had small cell lung cancer. The area under the curve (AUC) (95% CI) of CXCL9 was 0.83 (0.80–0.89) for differentiating lung cancer patients from controls. The levels of all the markers were significantly higher in NSCLC patients with stage IV than in those with stages I–III. A Kaplan-Meier survival analysis showed that NSCLC cancer patients with higher levels of all markers showed poorer survival than those with lower levels. In Cox multivariate analysis of patients with NSCLC, independent prognostic factors for overall survival were CXCL9 and CXCL11. CXCL9 was the only independent prognostic factor for cancer-specific survival. Serum IFN-γ-inducible chemokines may be useful as clinical markers of metastasis and prognosis in NSCLC, and CXCL9 levels showed the most significant results.

Multiomic, plasma-only ctDNA NGS assay for minimal residual disease (MRD) detection in solid tumors.

3045 Background: Detection of minimal residual disease (MRD) by circulating tumor DNA (ctDNA) post-curative intent treatment is predictive of recurrence in many solid tumors. Due to biological challenges with low ctDNA shed in early-stage disease and potential to detect non-tumor derived alterations in plasma (e.g. CHIP), most ctDNA MRD assays are dependent on a priori knowledge of genomic alterations from tumor tissue to achieve high sensitivity and specificity. Tissue-dependent methods limit the clinical application of a MRD assay, especially in cancer types where tissue biopsy is challenging, neoadjuvant therapy (NAT) is standard of care, and/or rapid turnaround times are needed for clinical decision making. We previously validated an assay (Guardant Reveal) that combines somatic and epigenomic analysis to detect ctDNA from early-stage colorectal tumors without tumor tissue or peripheral blood cells. Here we describe the expansion of this assay to detect MRD across multiple tumor types. Methods: Cell-free DNA (cfDNA) fragments are extracted from patient plasma, partitioned based on methylation fraction, enriched using a panel to target informative genomic and epigenomic regions, barcoded, and pooled for sequencing. Methylation status is determined non-destructively and with minimal loss of molecules, allowing sensitive genomic and epigenomic analysis of the same cfDNA fragments. A single assay with a total panel size of 5.3 Mb was developed for MRD analysis in multiple cancer types, including CRC, Lung and Bladder. A “ctDNA detected” result is defined by the de novo identification of tumor-derived somatic variants and/or the observation of a tumor-specific methylation profile exceeding predefined thresholds. Results: The assay performance was tested using 163 pre-treatment clinical samples from patients with early-stage non small cell lung cancer (NSCLC) and bladder cancer and 133 self-declared healthy donors. Sensitivity for pre-treatment detection in NSCLC was 68.9% at 95% specificity (20/42 Stage I: 47.6%, 25/30 Stage II: 83.3%, 19/21 Stage III: 90.5%). Sensitivity for bladder cancer was 44.2% at 95% specificity (13/43 NMIBC: 30.2%, 18/27 MIBC: 66.7%). Additional development from larger cohorts and other tumor types is ongoing and data will be presented as available. Conclusions: Using cancer-specific genomic and epigenomic signals combined with learning-based classifiers, we developed a highly specific method for detecting the presence of ctDNA in early-stage NSCLC and bladder cancer patients from plasma without the need for tumor tissue but with comparable sensitivities to tissue-dependent approaches. A plasma-only MRD assay will allow for greater clinical impact by overcoming the challenges of tissue procurement, particularly following NAT, and enabling faster time to results.

Prospective evaluation of EBUS-TBNA specimens for programmed death-ligand 1 expression in non-small cell lung cancer patients: a pilot study.

ABSTRACTObjective:EBUS-TBNA cytological sampling is routinely performed for pathological diagnosis, mediastinal staging, and molecular testing in lung cancer patients. EBUS-TBNA samples are not formally accepted for testing programmed death-ligand 1 (PD-L1) expression. The objective of the study was to compare the feasibility, reproducibility, and accuracy of PD-L1 expression assessment in cytological specimens and histological samples. Methods:We prospectively collected histological (transbronchial forceps biopsy) and cytological (EBUS-TBNA) samples from peribronchial neoplastic lesions during an endoscopic procedure at the same target lesion for the pathological diagnosis and molecular assessment of stage IV non-small cell lung cancer (NSCLC). Results:Fifteen patients underwent the procedure. Adequate cytological samples (at least 100 neoplastic cells) were obtained in 12 cases (92.3%). Assessment of PD-L1 expression was similar between histological and cytological samples (agreement rate = 92%). Sensitivity and diagnostic accuracy of EBUS-TBNA cytological specimens were 88.9% and 100%, respectively. Conclusions:The evaluation of PD-L1 expression in EBUS-TBNA cytological specimens is feasible and presents good reproducibility when compared with routine histological samples. EBUS-TBNA cytological samples could be used for the assessment of PD-L1 expression in patients with NSCLC as a minimally invasive approach in stage IV NSCLC cancer patients.

How selecting best upfront therapy for metastatic disease?-Focus on ROS1-rearranged disease.

ROS proto-oncogene 1 (ROS1) rearrangements defines a distinct group of non-small cell lung cancer (NSCLC), mainly represented by younger subjects, never smokers and with adenocarcinoma histology. Fusions involving ROS1 gene are present in 1-2% of lung adenocarcinomas and other solid tumors. Identification of patients harboring ROS1 rearrangements is a critical issue and current guidelines recommend screening of all advanced non-squamous NSCLC and certain squamous lung cancer patients. A number of trials have supported crizotinib as the best option for NSCLC patients with ROS1 translocations, irrespective of line of therapy. Unfortunately, the majority of patients become insensitive to crizotinib, due to the occurrence of secondary ROS1 mutations or failure within the central nervous system (CNS). Several highly potent and CNS penetrant ROS1 inhibitors have been developed and recent data highlight their potential role in the front-line treatment of this disease. Among them entrectinib, also known as RXDX-101, is a potent second-generation, multitarget oral inhibitor against the neurotrophin receptors TRKA, TRKB, TRKC ALK, and ROS1 with the ability to cross the blood-brain barrier. In the next few years, results of ongoing trials with novel ROS1 inhibitors and dedicated translational research studies might help to define the optimal sequence of treatment for ROS1-positive NSCLC patients.

Evodiamine suppresses non-small cell lung cancer by elevating CD8+ T cells and downregulating the MUC1-C/PD-L1 axis

BackgroundAccumulating evidence showed that regulating tumor microenvironment plays a vital role in improving antitumor efficiency. Programmed Death Ligand 1 (PD-L1) is expressed in many cancer cell types, while its binding partner Programmed Death 1 (PD1) is expressed in activated T cells and antigen-presenting cells. Whereas, its dysregulation in the microenvironment is poorly understood. In the present study, we confirmed that evodiamine downregulates MUC1-C, resulting in modulating PD-L1 expression in non-small cell lung cancer (NSCLC).MethodsCell viability was measured by MTT assays. Apoptosis, cell cycle and surface PD-L1 expression on NSCLC cells were analyzed by flow cytometry. The expression of MUC1-C and PD-L1 mRNA was measured by real time RT-PCR methods. Protein expression was examined in evodiamine-treated NSCLC cells using immunoblotting or immunofluorescence assays. The effects of evodiamine treatment on NSCLC sensitivity towards T cells were investigated using human peripheral blood mononuclear cells and Jurkat, apoptosis and IL-2 secretion assays. Female H1975 xenograft nude mice were used to assess the effect of evodiamine on tumorigenesis in vivo. Lewis lung carcinoma model was used to investigate the therapeutic effects of combination evodiamine and anti-PD-1 treatment.ResultsWe showed that evodiamine significantly inhibited growth, induced apoptosis and cell cycle arrest at G2 phase of NSCLC cells. Evodiamine suppressed IFN-γ-induced PD-L1 expression in H1975 and H1650. MUC1-C mRNA and protein expression were decreased by evodiamine in NSCLC cells as well. Evodiamine could downregulate the PD-L1 expression and diminish the apoptosis of T cells. It inhibited MUC1-C expression and potentiated CD8+ T cell effector function. Meanwhile, evodiamine showed good anti-tumor activity in H1975 tumor xenograft, which reduced tumor size. Evodiamine exhibited anti-tumor activity by elevation of CD8+ T cells in vivo in Lewis lung carcinoma model. Combination evodiamine and anti-PD-1 mAb treatment enhanced tumor growth control and survival of mice.ConclusionsEvodiamine can suppress NSCLC by elevating of CD8+ T cells and downregulating of the MUC1-C/PD-L1 axis. Our findings uncover a novel mechanism of action of evodiamine and indicate that evodiamine represents a potential targeted agent suitable to be combined with immunotherapeutic approaches to treat NSCLC cancer patients. MUC1-C overexpression is common in female, non-smoker, patients with advanced-stage adenocarcinoma.

Abstract 3953: Serum type XIX collagen is significantly elevated in non-small cell lung cancer and is a biomarker with clinical potential

Abstract Introduction: Type XIX collagen is a poorly characterized collagen associated with the basement membrane zone along with type XVIII and XV collagen. Type XIX collagen has shown altered regulation during tumor progression of melanoma and breast cancer. In this study, we developed and validated an ELISA targeting the natural C-terminus of type XIX collagen and quantified it in serum of cancer patients, demonstrating the biomarker potential of type XIX collagen. Methods: A monoclonal antibody was raised against the C-terminus of type XIX collagen and utilized in a competitive ELISA named PRO-C19. PRO-C19 was quantified in serum from patients with breast (n=12), colon (n=7), gastric (n=9), melanoma (n=6), non-small cell lung cancer (NSCLC) (n=11), small cell lung cancer (SCLC) (n=7), ovarian (n=8), pancreas (n=2), prostate cancer (n=13) and healthy controls (n=38). PRO-C19 was further assessed in another cohort comprising stage III (n=20) and stage IV (n=20) NSCLC patients and healthy controls (n=24). Lastly, PRO-C19 was assessed in the conditioned media of a cell model mimicking the fibroblast activation found in fibrotic lung diseases using lung fibroblasts stimulated with TGF-β. Results: The PRO-C19 assay was technically robust and specific for the C-terminus of type XIX collagen. PRO-C19 was significantly elevated in serum from breast (p=0.0201), NSCLC (p<0.0001) and ovarian cancer patients (p=0.0108) compared to healthy controls. PRO-C19 was also elevated in colon, pancreatic and SCLC cancers, although this was not statistically significant. The separation between NSCLC and healthy controls was excellent as demonstrated by an AUROC of 0.995 (p<0.0001). Consequently, PRO-C19 was also assessed in a separate cohort of NSCLC patients. Here PRO-C19 was also significantly elevated in NSCLC patients compared to healthy controls (p<0.0001) and the AUROC was 0.980 (p<0.0001). Lastly, because PRO-C19 performed well in lung cancer, we assessed it in a lung fibrosis cell model. PRO-C19 was found in the conditioned media of the lung fibroblasts, but levels were independent of TGF-β stimulation. Conclusion: This study demonstrates that type XIX collagen is elevated in several types of cancer and proved excellent at separating NSCLC and healthy controls. The elevated levels seen in NSCLC patients do not seem to be induced by lung fibrosis. This all provide novel clues to the function of type XIX collagen - an otherwise poorly characterized collagen. Further investigations are ongoing to explore diagnostic or prognostic uses of PRO-C19 and the function of type XIX collagen. Citation Format: Jeppe Thorlacius-Ussing, Samuel Daniels, Morten Karsdal, Nicholas Willumsen. Serum type XIX collagen is significantly elevated in non-small cell lung cancer and is a biomarker with clinical potential [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 3953.