Adding ICI to EP is a breakthrough strategy for treating ESCLC in the first-line setting. However, there is no head to head comparison between these agents to guide the clinical decisions. Thus, we performed a systematic review and network meta-analysis (NMA) to evaluate the effectiveness and safety of ICIs in combination with EP for this target population. According to PRISMA-NMA statement, a systematic search of literature was carried out in PUBMED, Cochrane Central Register of Controlled Trials, and Clinicaltrial.gov database up to Jun 31, 2020. Only randomized clinical trials (RCTs) comparing ICIs+EP vs. EP were considered. We performed an NMA using MetaInsight V 3.13 web-based tool, with a Bayesian framework to estimates risk ratios (RRs) and Odds ratios (OR) with their 95% credible intervals (CrIs). Ranking tables with the probability of best treatment choice for each outcomes, derivated from the model and network estimates were obtained. OS and PFS rate at 12 months, ORR, AEs G3-4 , and immune-related AEs were the selected outcomes. Five RCTs that involved more than 2000 pts and 7 interventions met the inclusion criteria. All selected trials had EP as a control arm. No significant differences in the risk of mortality, risk of progression, and risk of immune-related AEs were observed between Atezolizumab (A), Durvalumab+Tremelimumab (DT), Durvalumab (D), Pembrolizumab (P), or Ipilimumab (I) (4 RCTs, n 2615) in association with EP, neither between these interventions and Nivolumab (5 RCTs, n 2759) for ORR and EAs G3-4. In Bayesian ranking results, A and D were most likely to be ranked first for OS (cumulative probability 40%). Meanwhile, P and D were ranked first for ORR (36%) and PFS (30%). In the safety profile, D was ranked with the less probability of AEs G3-4 (30%), but P and I were first for immune-related AEs (15%). In the comparison of anti PD-1 vs. PD-L1 agents, therapy with anti PD-1 had the highest chance to provide better ORR (70%) and less immune-related AEs (66%), but anti PDL-1 were best regarding AEs G3-4 (42%) and PFS rate at 12 months (72%). Due to the comparisons between experimental treatments proceeded only from indirect evidence, inconsistency between direct and indirect estimates was not feasible. This indirect comparison did not find evidence suggesting survival differences between these agents. All treatments showed better efficacy results over EP, except A for ORR. For safety outcomes in PD-1 vs. PD-L1 comparison; even there was a not significant difference in producing AEs G 3-4 or immuno-related AEs, they did not rank similarly. Therefore this distinct pattern of AEs could to be considered for choosing an agent. Producing data related to the quality of life, economic burden, and patient´s preferences may help to define what would the best option for this population.
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