Trials In Non-small Cell Lung Cancer Research Articles

Programmed Cell Death Ligand 1 Expression in Resected Non–Small Cell Lung Cancer

BackgroundRecently, anti–programmed cell death 1 (PD-1) and anti–programmed cell death ligand 1 (PD-L1) immunotherapies have yielded promising outcomes for patients with advanced non–small cell lung cancer (NSCLC) and led to great interest in applying these agents to treat resectable early-stage NSCLC. The objective of our study was to evaluate PD-L1 protein expression in resectable early-stage NSCLC specimens from a large Northern European cohort, examine the relationship to clinical characteristics, and demonstrate the prognostic role in resected NSCLC. Materials and MethodsA large cohort of 875 NSCLC tumors consisted of 337 patients from Sweden and 538 patients from Norway was studied. All the patients had undergone pulmonary resection, and most patients had had early-stage NSCLC. PD-L1 protein expression was assessed by immunohistochemistry using the Dako PD-L1 22C3 pharmDx kit. The tumor proportion score for PD-L1 protein expression was compared with comprehensive demographic and clinicopathologic data. ResultsThe overall prevalence of PD-L1 protein expression in the resectable NSCLC cohort was 9.5% at a tumor proportion score cutoff of ≥ 50%. Stage I NSCLC had lower PD-L1 expression compared with that of the other stages (P = .0012). PD-L1 expression correlated with wild-type EGFR gene expression (P = .0156) and mutated KRAS gene expression (P = .0004). No significant association was found between PD-L1 expression and mortality after multivariable adjustment for clinical characteristics, although the survival curves showed PD-L1 expression significantly correlated with a poor prognosis in the total NSCLC cohort and in the adenocarcinoma subgroup. ConclusionPD-L1 expression in the present large cohort of resectable NSCLC was relatively low compared with data from clinical trials of advanced NSCLC. PD-L1 expression correlated positively with tumor stage, wild-type EGFR, and KRAS mutation. PD-L1 expression was not found as an independent prognostic factor in the present study. These findings could be important in the future when evaluating the role of anti–PD-1/PD-L1 immunotherapy in the setting of neoadjuvant or adjuvant trials for early-stage resectable NSCLC.

Incidence and Risk of Colitis With Programmed Death 1 Versus Programmed Death Ligand 1 Inhibitors for the Treatment of Cancer

Colitis is a major immune-related adverse event associated with programmed death 1 (PD-1) and programmed death-ligand 1 (PD-L1) inhibitors, but the risk of colitis with PD-1 versus PD-L1 inhibitors is not well characterized. We performed a meta-analysis for the incidence of all grade and grade 3-4 colitis with PD-1 inhibitor (nivolumab, pembrolizumab, and cemiplimab) or PD-L1 inhibitor (atezolizumab, avelumab, and durvalumab) monotherapy using a fixed effects model. We also conducted subgroup meta-analyses of non-small cell lung cancer (NSCLC) or urothelial carcinoma (UC) trials, and a network meta-analysis of randomized trials comparing PD-1 or PD-L1 inhibitors with docetaxel for NSCLC. We also analyzed the Food and Drug Administration Adverse Event Reporting System database to estimate the reporting odds ratio of each medication. PD-1 inhibitors were associated with a higher incidence of all grade and grade 3-4 colitis compared with PD-L1 inhibitors in the analysis of all cancer types [1.49% vs. 0.83%, relative risk; 1.80, 95% confidence interval (CI); 1.22-2.67 for all grade colitis, and 0.85% vs. 0.34%, relative risk; 2.52, 95% CI; 1.46-4.37 for grade 3-4 colitis]. The meta-analyses of NSCLC and UC trials, and the network meta-analysis of NSCLC trials were also suggestive of a higher risk of colitis with PD-1 versus PD-L1 inhibitors. The reporting odds ratio of colitis with PD-1 versus PD-L1 inhibitors was 1.80 (95% CI; 1.53-2.14). In this meta-analysis of clinical trials exploring PD-1 and PD-L1 inhibitors in solid tumors, PD-1 inhibitors were associated with a higher risk of colitis.

Multiorgan Immune-Related Adverse Events During Treatment With Atezolizumab.

Immune-related adverse events (irAEs) are known to occur in patients with cancer who are treated with immune checkpoint inhibitors. However, limited literature exists on the incidence, time of onset, and risk factors for irAEs, particularly those affecting multiple organs, associated with anti-PD-L1 inhibitors. A post hoc pooled analysis was conducted using individual patient data from atezolizumab monotherapy arms of 4 non-small cell lung cancer clinical trials. Incidence, clinical patterns, outcomes, and risk factors were investigated of selected organ-specific and multiorgan irAEs during treatment using the anti-PD-L1 inhibitor atezolizumab. From a total of 1,548 patients, 730 irAE episodes were reported in 424 patients (27%). Skin irAEs were the most common (42%), followed by laboratory abnormalities (27%) and endocrine (11.6%), neurologic (7.6%), and pulmonary (6.2%) irAEs. A total of 84 patients (5.4%) had multiorgan irAEs, 70 had 2, 13 had 3, and 1 had 4 different organs affected. "Skin plus" or "laboratory plus" were the most common irAE multiorgan clusters. Patients with multiorgan irAEs were more likely to be white and have a good performance status, a lower baseline neutrophil-lymphocyte ratio, and a good or intermediate lung immune prognostic index score. Multiorgan irAEs were also associated with improved overall survival (hazard ratio, 0.47; 95% CI, 0.28-0.78; P<.0001) but not with progression-free survival (hazard ratio, 0.92; 95% CI, 0.62-1.35; P=.74) compared with the cohort with no irAEs. Multiorgan irAEs occurred in 5.4% of patients treated with atezolizumab in non-small cell lung cancer trials. Future trials should consider routine reporting of data on multiorgan toxicities in addition to organ-specific toxicities.

Adverse events reporting in stage III NSCLC trials investigating surgery and radiotherapy.

BackgroundCurrent treatment options for stage III non-small cell lung cancer (NSCLC) consist of different combinations of chemotherapy, surgery, radiotherapy and immunotherapy. Treatment choices are highly individual decisions, in which adverse events (AEs) are relevant for decision-making. This study aims to analyse reporting of AEs in prospective stage III NSCLC trials, focussing on trials including radiotherapy and/or surgery.MethodsPubMed was searched for prospective studies dealing with stage III NSCLC from January 1987 to April 2019. Meta-analyses were screened as a positive control. Pearson's Chi-squared test and smooth kernel distribution were used to estimate distributions. Data was resampled using bootstrapping.ResultsOut of 1193 initially identified studies, 119 met the inclusion criteria. Of these, 31 had a surgical procedure in any study arm. Grade 3 and 4 AEs were reported in 94.12% and 92.44% of the included studies, respectively. Reporting of grade 5 AEs was provided in 87.39% of cases. Grade 1 and 2 AEs were less commonly reported at 53.78% and 63.03%, respectively. One study did not mention any AEs. Of the 31 treatment arms including any form of surgery, AEs were not reported in 10. Overall, 231 different AE items were reported, only 18 of them were included in at least 20% of the analysed studies.ConclusionOverall, AE reporting in stage III NSCLC was inconsistent and inhomogeneous. Studies including surgical study arms often reported only treatment-related deaths in regards of surgical AEs. Underreporting of AEs prohibits the extraction of patient-relevant information for decision-making and represents a suboptimal use of invested resources.

Characteristics of Drug Intervention Clinical Trials and Scientific Impact of the Trial Outcome: A Bibliometric Analysis Using the Relative Citation Ratio in Non-small Cell Lung Cancer from 2007 to 2016.

Although a large number of clinical trials have been conducted, the types of clinical trials that are scientifically influential, frequently utilized by society, and contribute to the progress of evidence-based medicine (EBM) have not been studied. Thus, we aimed to investigate the relationship between the characteristics of clinical trials and the scientific impact of the outcome in non-small cell lung cancer (NSCLC) by performing a bibliometric analysis using relative citation ratio (RCR), a newly developed bibliometric index by the National Institutes of Health (NIH). Primary publications of drug intervention clinical trials for NSCLC between 2007 and 2016 were included in the study. The characteristics of clinical trials were compared among four RCR categories with 50 trials in each [LOW50, 50 NIH percentile (50NIH%ile), 95 NIH percentile (95NIH%ile), and TOP50], totaling to 200 trials. Median RCRs of LOW50, 50NIH%ile, 95NIH%ile, and TOP50 were 0.03, 1.00, 5.76, and 26.89, respectively. Publications of Phase 3, randomized, blinded, for-profit-company supported/sponsored, multi-center trials, and trials with a larger number of subjects were shown to have a higher scientific impact. Publications of clinical trials of newly developed molecular target drugs, including epidermal growth factor receptor-tyrosine kinase inhibitors, anaplastic lymphoma kinase inhibitors, and immune checkpoint inhibitors demonstrated a higher scientific impact than those of traditional chemotherapies. Clinical trials designed to have a high evidence level would improve the scientific impact of the outcome, and novel interventions would be another factor to improve the clinical trials' influence.

Phenotyping clinical trial treatment regimens in cancer: An integrative ontology, artificial intelligence and knowledge engineering approach.

e14054 Background: Matching clinical attributes (i.e. indications, lab tests, treatment regimens) of clinical trial eligibility criteria with real world patient data is extremely challenging. Attribute phenotyping is one of the key components of Trial2Patient, a customized system developed by Sema4 to find patients for clinical trials. Transforming treatment regimens to a standard ontology and encoding drugs with standard nomenclatures will facilitate the semantic retrieval of treatments mentioned in clinical trial criteria. This will also enable the interoperation between different data sources that is often required for fast-learning and scalable healthcare information system. Methods: Free text containing treatment regimen/medication terms were extracted and preprocessed from three sources: 1) clinical trials listed in a commercial database citeline.com, 2) clinical trials listed in clinicaltrials.gov, and 3) National Comprehensive Cancer Network (NCCN) Guidelines. The regimen terms such as neoadjuvant therapy for non-small cell lung cancer, checkpoint inhibitor, EGFR inhibitor, androgen deprivation therapy (ADT), among many others, were profiled by AI methods (i.e. pattern reorganization and rule-based) and knowledge engineering via Sema4’s in-house knowledge base (CAV), Pharmaprojects in citline.com and NCCN Guidelines. The drugs related to each regimen were identified and mapped to RxCUI via RxNorm ontology. Results: We identified 76 regimen terms for non-small cell lung cancer (NSCLC), small cell lung cancer (SCLC) and prostate cancer (e.g. PD-L1 ≥1% nonsquamous NSCLC, bone antiresorptive therapy for M1 castration resistant prostate cancer), and 14,476 drug-category pair (e.g. pembrolizumab is a PD-1 inhibitor, pembrolizumab is used as the third line and beyond systemic therapy for M1 CRPC). All drugs identified were mapped to RxCUI for real world patient matching. Conclusions: This approach systematically extracted and normalized regimens and medications mentioned in clinical trials in NSCLC, SCLC and prostate cancer to standard codes. These standardized data can be used in mapping treatment histories of a patient to the eligibility criteria for clinical studies or for identifying studies relevant to a patient. The outcome of profiling cancer treatment regimens through standard ontology RxNorm may be particularly valuable in cancer studies based on real-world evidence.

Evolving risk of therapy-related myelodysplastic syndromes and acute myeloid leukemia (tMDS/AML) following modern cancer therapies.

7516 Background: Data describing risks of tMDS/AML after targeted and immunotherapy (IO) agents are lacking. Melanoma (Mel) and renal cell carcinoma (RCC) are considered chemotherapy insensitive and have been treated with IO (interferon and interleukin) since the 1990s. In 2004, use of tyrosine kinase inhibitors (TKIs) began in non-small cell lung cancer (NSCLC) and expanded to RCC in 2005 and Mel trials in 2011. Checkpoint inhibitor (CPI) use began in 2011 for Mel, 2012 for NSCLC in trials and later for RCC. For multiple myeloma (MM), use of lenalidomide has been increasing since 2007. All these modern therapies have well described immunomodulatory functions. Methods: Using 17 population-based SEER cancer registries, we studied 565,149 patients diagnosed from 2000-2015 with Mel, RCC, NSCLC, or MM who survived ≥1 year and assessed risk of tMDS/AML across periods P1 (2000-2005), P2 (2006-2010) and P3 (2011-2015). Censoring occurred at 5 years of follow up to limit bias and assess risk alteration across approval and utilization periods of these modern therapies. Results: tMDS/AML risk was significantly elevated after RCC in P1 [standardized incidence ratio (SIR): 1.61, possibly from chemo exposure that was still prevalent to some extent in P1 period] and a downtrend noted in P2 (SIR: 1.11) and P3 (SIR: 0.60). tMDS/AML risk after Mel showed similar downtrend, not statistically significant. In contrast, risk for tMDS/AML after MM increased across all periods ( SIRs 4.51 &gt; 5.05 &gt; 5.23), and risk after NSCLC increased from P1 to P2 but decreased thereafter, pattern most pronounced in stage I-III NSCLC ( 1.64 &gt; 3.15 &gt; 1.92). Conclusions: Periods when TKI and CPI use became standard in Mel and RCC, we observed a decrease in tMDS/AML risk. Similar decrease in the most recent period for stage I-III NSCLC was observed, possibly due to progression of these earlier staged cancers resulting in receipt of TKIs and CPI for stage IV disease. tMDS/AML risk after MM increased contradicting the decline in risk previously reported in the literature. Discordance may be due to survival bias as MM patients are now living longer (SEER 5-yr survival in ‘00 was 35% and 53% in ‘15) with more time to develop tMDS/AML. Overall, aside from better efficacy and/or tolerability of modern therapies, another observed benefit was lower tMDS/AML risk. This risk was lower than general population in Mel/RCC, suggesting a possible protective effect of these therapies. SIR tables/graphs with updated SEER data (available 04/2020) with follow up through 2018 will be presented.

Detection of residual disease and recurrence in early-stage non-small cell lung cancer (NSCLC) patients using sensitive personalized ctDNA sequencing assays.

e15560 Background: Detection of residual circulating tumour DNA (ctDNA) in patient plasma following curative intervention for localized non-small cell lung cancer (NSCLC) could identify patients who are at higher risk of relapse. These patients may benefit from adjuvant treatment, even if they have no macroscopic disease identified by radiographic imaging, which is the current standard of care. Here we evaluate the performance of the Inivata personalized sequencing assays to detect ctDNA in a cohort of 90 patients with early-stage NSCLC undergoing treatment with curative intent. Methods: The Inivata assay uses a highly sensitive next-generation sequencing platform, to identify tumor-specific variants from exome sequencing of tumor tissue and to track up to 48 patient-specific mutations in plasma specimens by multiplex PCR and ultra-high-depth next-generation sequencing. Samples from 90 patients with Stage I-III NSCLC who underwent radical treatment with curative intent, either surgery or radiotherapy ± chemotherapy, were collected as part of the LUng cancer - CIrculating tumor DNA (LUCID) study. Results: 350 plasma samples from 90 patients were analyzed using the Inivata assay, including samples collected before and after treatment and at subsequent follow-up visits. ctDNA was detected in pre-treatment samples in 38% of 32 patients (12/32) with Stage I NSCLC and in 90% of 21 patients (19/21) with Stage II/III disease, at allele fractions ranging from 6 parts per million (ppm, equivalent to 0.0006%) to over 20,000 ppm (equivalent to 2%). In plasma samples collected post-treatment, ctDNA was detected in close to 50% of cases. Conclusions: These findings highlight the Inivata assay is a sensitive method for detection of residual ctDNA and recurrence in early stage NSCLC. Initial detection rates ranged from 38% in Stage I disease to 90% for patients with Stage II/III disease prior to treatment, including detection of ctDNA to levels as low as a few parts per million. ctDNA was detected in at least one post-treatment timepoint in close to 50% patients. Together with additional data to be presented from the full 90 patient cohort, this suggests a possible route to improving treatment and designs of adjuvant trials for early stage NSCLC by detection of residual disease post-treatment and monitoring for early detection of relapse.

Effectivity and safety of PD-1/PD-L1 inhibitors for different level of PD-L1-positive, advanced NSCLC: A meta-analysis of 4939 patients from randomized controlled trials

BackgroundEffective improvement for the programmed death 1 (PD-1)/programmed death ligand 1 (PD-L1) inhibitors had been shown in advanced non-small cell lung cancer (NSCLC) patients compared with traditional therapy. However, we do not have ample evidences to demonstrate the safety and effectivity in the treatment of PD-L1-positive, advanced NSCLC. The relation was controversial about the expression of PD-L1 and survival outcomes of PD-1/PD-L1 inhibitors. Materials and methodsElectronic databases (PubMed, EMBASE, and the Cochrane library) and major conference proceedings were systematically searched for all clinical trials in NSCLC using PD-1/PD-L1 inhibitors. Randomized controlled trials (RCTs) were included to compare PD-1/PD-L1 inhibitors with chemotherapy in advanced NSCLC patients reporting adverse events (AEs) and immune-related AEs (irAEs). The incidence, Hazard Ratio (HR), Odds Ratio (OR), and corresponding 95% confidence interval (CI) of outcomes were calculated. ResultsA total of 4939 patients from 10RCTs were included. In the group of PD-L1 ≥ 1%, PD-L1 ≥ 5%, PD-L1 ≥ 10%, PD-L1 ≥ 50%, the HR of OS is 0.31(95%CI 0.38–0.23; p < 0.0001), 0.47(95%CI 0.82–0.12; p = 0.008), 0.85(95%CI 1.17–0.53; p < 0.0001), 0.47(95%CI 0.59–0.36; p < 0.0001) respectively. The HR of PFS is 0.13(95%CI 0.01–0.24; p = 0.027), 0.31(95%CI 0.00–0.62; p < 0.0001), 0.62(95%CI 0.30–0.93; p < 0.0001), 0.40(95% CI 0.20–0.59; p < 0.0001) respectively. In terms of summary adverse events, PD-1/PD-L1 inhibitors groups had a significant lower risks in any treat-realated AEs than chemotherapy. About irAEs, PD-1/PD-L1 inhibitors groups had a significant higher risks in irAEs than chemotherapy. ConclusionPD-1/PD-L1 inhibitors are generally effected and safer than chemotherapy for patients with PD-L1-positive, advanced NSCLC. However, PD-1/PD-L1 inhibitors can generate a unique spectrum of irAEs, and even life-threatening.

Abstract B55: Exploratory biomarker analyses of tumor and peripheral blood samples from the phase I durvalumab plus gefitinib trial in EGFR-mutated NSCLC

Abstract There has been significant interest in combining anti-PD-1/PD-L1 agents with other clinically active anticancer agents. Gefitinib, a first-generation inhibitor of the epidermal growth factor receptor (EGFR) tyrosine kinase, is approved for non-small cell lung cancer (NSCLC) patients with sensitizing EGFR mutations. Durvalumab has demonstrated clinical activity in NSCLC and is approved for Stage III, unresectable NSCLC that has not progressed following platinum-based chemotherapy and radiotherapy. A phase I trial (NCT02088112) combining gefitinib and durvalumab was initiated to establish the safety profile of this combination in tyrosine-kinase inhibitor (TKI)-naive patients with NSCLC containing EGFR-positive sensitizing mutations. As part of this trial, paired tumor biopsies and multiple blood samples were collected for biomarker evaluation. Peripheral blood samples were analyzed for gene expression, cytokine production, immunophenotyping, and circulating DNA (ctDNA). Paired tumor biopsies were evaluated for expression of multiple proteins by immunohistochemistry, including phosphorylated EGFR (pEGFR), PD-L1, CD73, and CD8. We saw ≥50% inhibition of pEGFR in 8 of 17 paired biopsies but no consistent directional changes with PD-L1. We observed known durvalumab-mediated effects such as increases in tumor CD8+ cells (3.7 fold, p=0.011), proliferating CD8+ cells in circulation (2.4 fold, p=0.074), and increased interferon gamma (10.3 fold, p=0.01). A cohort of patients (n=10) was treated with a 28-day gefitinib run-in prior to addition of durvalumab. Sample collection during this period allowed us to evaluate the effects of gefitinib alone on immunologic readouts. While treatment with gefitinib alone resulted in ≥50% reduction of pEGFR in 5 of 8 paired tumor biopsies, its effect on expression of immune-related genes, interferon-related cytokines, and immune subpopulations was minimal. Interestingly, we saw an association between higher baseline tumor PD-L1, pEGFR or CD73 expression and a numerical trend for longer progression-free survival. Finally, analysis of ctDNA showed robust decreases in mutant EGFR could be observed as early as Day 5 of gefitinib treatment, either alone or in combination with durvalumab. Altogether, these results demonstrate that each agent had its expected downstream biologic effects and there was no antagonism between the two agents. We did not observe any novel biologic effects nor any striking synergy for known readouts. New hypotheses (i.e., high PD-L1/pEGFR/CD73) for patient selection biomarkers were identified, although more follow-up is required to determine whether they reflect combination or single-agent treatment. These studies highlight the utility of collecting biomarker samples to confirm target engagement, understand downstream effects, identify patient selection biomarkers, and explore ctDNA biomarkers. Citation Format: Tammie C. Yeh, Helen K. Angell, Vicky Rowlands, Emma V. Jones, Vidalba Rocher Ros, Alison Pritchard, Martine P. Roudier, Nathan Standifer, Mike Kuziora, Philip Martin, Kirill Peskov, Rosie Taylor, J. Carl Barrett, Ben Sidders. Exploratory biomarker analyses of tumor and peripheral blood samples from the phase I durvalumab plus gefitinib trial in EGFR-mutated NSCLC [abstract]. In: Proceedings of the AACR Special Conference on Tumor Immunology and Immunotherapy; 2019 Nov 17-20; Boston, MA. Philadelphia (PA): AACR; Cancer Immunol Res 2020;8(3 Suppl):Abstract nr B55.

Targeting the PI3K/Akt/mTOR pathway in non-small cell lung cancer (NSCLC).

The traditional classification of lung cancer into small cell lung cancer and non‐small cell lung cancer (NSCLC) has been transformed with the increased understanding of the molecular alterations and genomic biomarkers that drive the development of lung cancer. Increased activation of the phosphatidylinositol 3‐kinase (PI3K)/Akt/mechanistic target of rapamycin (mTOR) pathway leads to numerous hallmarks of cancer and this pathway represents an attractive target for novel anticancer therapies. In NSCLC, the PI3K/Akt/mTOR pathway has been heavily implicated in both tumorigenesis and the progression of disease. A number of specific inhibitors of PI3K, Akt and mTOR are currently under development and in various stages of preclinical investigation and in early phase clinical trials for NSCLC. Early evidence has yielded disappointing results. Clinical trials, however, have been performed on predominantly molecularly unselected populations, and patient enrichment strategies using high‐precision predictive biomarkers in future trials will increase the likelihood of success. A greater understanding of the underlying molecular biology including epigenetic alterations is also crucial to allow for the detection of appropriate biomarkers and guide combination approaches.

The efficacy and safety of immune checkpoint inhibitors in non-small cell lung cancer patients of different age groups: a meta-analysis

BackgroundAge is closely related to the efficacy of treatment for non-small cell lung cancer (NSCLC) patients. Latest clinical trials have proved the better overall survival (OS) for the use of immune checkpoint inhibitors verse chemotherapy in NSCLC patients. However, we had no clear idea of the efficacy of them in elderly patients. So we conducted a meta-analysis to compare the efficacy of immune checkpoint inhibitors for NSCLC patients of different age groups and summarized overall treatment-related adverse events.Materials and methodsPubMed, EMBASE, Web of Science and the Cochrane Library were searched for all clinical trials in NSCLC until 30th of April 2019. Eligible studies included randomized controlled trials (RCTs) comparing immune checkpoint inhibitors with chemotherapy in NSCLC patients. The hazard ratio (HRs) and 95% confidence intervals (CIs) of OS, progression-free survival or adverse events (AEs) were used.ResultsA total of 4994 patients from 8 RCTs were included. Immune checkpoint inhibitors significantly prolonged the OS (HR, 0.73; 95% CI, 0.61–0.89) versus chemotherapy in NSCLC patients who were less than 65 years old. Also, they prolonged the OS (HR, 0.74; 95% CI, 0.59–0.93) in NSCLC patients who were more than 65 years old. However, there was no statistical significance of OS (HR, 0.87; 95% CI, 0.57–1.30) among NSCLC patients who were more than 75 years old. It also showed that the single use of immune checkpoint inhibitors had fewer all-grade AEs.ConclusionRegardless of the NSCLC patients who were less or more than 65 years, immune checkpoint inhibitors could achieve better OS than chemotherapy. But there was no significant difference when NSCLC patients who were more than 75 years old. Older patient should be offered immune therapies if it is possible and the mechanism in old age treatment should be further studied.

Enapotamab vedotin, an AXL-specific antibody-drug conjugate, shows preclinical antitumor activity in non-small cell lung cancer.

Targeted therapies and immunotherapy have shown promise in patients with non-small cell lung cancer (NSCLC). However, the majority of patients fail or become resistant to treatment, emphasizing the need for novel treatments. In this study, we confirm the prognostic value of levels of AXL, a member of the TAM receptor tyrosine kinase family, in NSCLC and demonstrate potent antitumor activity of the AXL-targeting antibody-drug conjugate enapotamab vedotin across different NSCLC subtypes in a mouse clinical trial of human NSCLC. Tumor regression or stasis was observed in 17/61 (28%) of the patient-derived xenograft (PDX) models and was associated with AXL mRNA expression levels. Significant single-agent activity of enapotamab vedotin was validated in vivo in 9 of 10 AXL-expressing NSCLC xenograft models. In a panel of EGFR-mutant NSCLC cell lines rendered resistant to EGFR inhibitors in vitro, we observed de novo or increased AXL protein expression concomitant with enapotamab vedotin-mediated cytotoxicity. Enapotamab vedotin also showed antitumor activity in vivo in 3 EGFR-mutant, EGFR inhibitor-resistant PDX models, including an osimertinib-resistant NSCLC PDX model. In summary, enapotamab vedotin has promising therapeutic potential in NSCLC. The safety and preliminary efficacy of enapotamab vedotin are currently being evaluated in the clinic across multiple solid tumor types, including NSCLC.

Benchmarking single-arm studies against historical controls from non-small cell lung cancer trials – an empirical analysis of bias

Background: Recent trials of novel agents in ‘rare’ molecular subtypes of non-small cell lung cancer (NSCLC) have used single-arm trial designs and benchmarked outcomes against historical controls. We assessed the consistency of historical control outcomes using docetaxel data from published NSCLC randomized controlled trials (RCTs).Material and methods: Advanced NSCLC RCTs including a docetaxel monotherapy arm were included. Heterogeneity in tumor objective response rates (ORRs), progression-free survival (PFS) and overall survival (OS), and correlations between outcomes and year of trial commencement were assessed.Results: Among 63 trials (N = 10,633) conducted between 2000 and 2017, ORR ranged from 0% to 26% (I2 = 76.1%, pheterogeneity < .0001). Mean of the median PFS was 3.0 months (range: 1.4–6.4), 3-month PFS ranged from 25% to 85% (I2 = 86.0%, pheterogeneity < .0001). Mean of the median OS was 9.1 months (range: 4.7–22.9), 9-month OS ranged from 23% to 79% (I2 = 83.0%, pheterogeneity < .0001). Each later year of trial commencement was associated with 0.3% (p = .046), 0.5% (p = .11) and 0.9% (p = .001) improvement in ORR, 3-month PFS and 9-month OS rates, respectively.Conclusions: There was significant heterogeneity and an improving trend in docetaxel outcomes across trials conducted over 20 years. Benchmarking biomarker-targeted agents against historical controls may not be a valid approach to replace RCTs. Innovative study designs involving a concurrent control arm should be considered.

1245P - Eosinophilia during treatment of immune checkpoint inhibitors (ICIs) predicts succeeding onset of immune-related adverse events (irAEs)

BackgroundPatients with sensitive gene mutations could achieve better overall survival by taking targeted drugs. Many trials have shown that non-small cell lung cancer (NSCLC) patients with epidermal growth factor receptor (EFGR) mutation responded to PD-1/PD-L1 inhibitors worse than EGFR wild-type. And subgroups of trials have also reported the efficacy of PD-1/PD-L1 inhibitors in the treatment of NSCLC patients with other sensitive gene mutations. So, we conducted a complementary systematic review and meta-analysis to compare efficacy of PD-1/PD-L1 inhibitors for NSCLC patients with sensitive gene mutations. MethodsPubMed, EMBASE, Web of Science and the Cochrane Central Register of Controlled Trials (Central) databases were searched for all clinical trials in NSCLC until 5th of January 2019. Eligible studies included randomized controlled trials (RCTs) comparing PD-1/PD-L1 inhibitors with chemotherapy in NSCLC patients with sensitive gene mutations. The hazard ratio (HR) and 95% confidence intervals (CIs) of overall survival (OS) or progression-free survival (PFS) were used. ResultsWe analyzed 193 patients in this study. Among cumulative total of 210 patients, 197 were treated with PD-1 or PD-L1 inhibitors. Another 8 and 5 patients were treated with CTLA-4 inhibitor alone and combination with PD-1 inhibitor, respectively. This study included non-small cell lung cancer (n=106; 50.5%), kidney (n=23; 10.9%), melanoma (n=30; 14.3%), gastric (n=19; 9.0%), Hodgkin lymphoma (n=11; 5.2%), urothelial carcinoma (n=10; 4.8%) and others (n=10; 4.8%). Any grade of irAEs occurred in 73 (34.8%) cumulative patients, and among them, 28 (13.3%) were classified as grade 3-5. The most common irAEs in any grade were skin disorders (n=29) and endocrine disorders including thyroid dysfunction and adrenal insufficiency (n=28). Eosinophilia occurred in 57 cumulative patients (27.1%), and 21 patients out of them had eosinophilia from baseline. Among the clinical and laboratory factors, only eosinophilia was significantly associated with the occurrence of any grade of irAEs in both univariate (p=0.010) and multivariate (p=0.0463) analyses. Notably, endocrine irAEs were significantly related to eosinophilia (p=0.0287). ConclusionsEosinophilia after the initiation of treatment with ICIs predicts succeeding onset of irAEs. Legal entity responsible for the studyThe authors. FundingHas not received any funding. DisclosureY. Miura: Honoraria (self): Ono; Honoraria (self): Bristol-Myers Squibb Japan; Honoraria (self): Chugai. T. Takano: Honoraria (self): Daiichi Sankyo; Honoraria (self): Kyowa Hakko Kirin; Honoraria (self): Eisai; Research grant / Funding (self): MSD; Research grant / Funding (self): Ono; Research grant / Funding (self): Merck Serono; Research grant / Funding (self): Taiho; Research grant / Funding (self): Novartis; Research grant / Funding (self): Chugai. All other authors have declared no conflicts of interest.

1254P - Efficacy of PD-1/PD-L1 inhibitors in the treatment of non-small cell lung cancer patients with sensitive genes mutation

BackgroundAs we all know, patients with sensitive genes mutation could achieve better overall survival by taking targeted drugs. Many trials showed that non-small cell lung cancer (NSCLC) patients with epidermal growth factor receptor (EFGR) mutation responded to PD-1/PD-L1 inhibitors worse than EGFR wild-type. And subgroups of trials also reported the efficacy of PD-1/PD-L1 inhibitors in the treatment of NSCLC patients with other sensitive genes mutation. So we conducted a complementary systematic review and meta-analysis to compare efficacy of PD-1/PD-L1 inhibitors for NSCLC patients with sensitive genes mutation. MethodsPubMed, EMBASE, Web of Science and the Cochrane Central Register of Controlled Trials (Central) databases were searched for all clinical trials in NSCLC until 5th of January 2019. Eligible studies included randomized controlled trials (RCTs) comparing PD-1/PD-L1 inhibitors with chemotherapy in NSCLC patients with sensitive genes mutation. The hazard ratio (HR) and 95% confidence intervals (CIs) of overall survival (OS) or progression-free survival (PFS) were used. ResultsA total of 2419 patients from 4 RCTs (2 with PD-1 inhibitors; 2 with PD-L1 inhibitors) were included. PD-1/PD-L1 inhibitors significantly prolonged the OS (HR, 0.67; 95% CI, 0.60–0.67) and PFS (HR, 0.46; 95% CI, 0.36–0.60) in NSCLC patients with EGFR wild-type versus chemotherapy. Meanwhile, PD-1/PD-L1 inhibitors prolonged the OS (HR, 0.61; 95% CI, 0.39–0.94) in NSCLC patients with KRAS mutation versus chemotherapy. However, for NSCLC patients with EGFR mutation (the OS of HR, 1.11; 95% CI, 0.80–1.55; the PFS of HR, 0.76; 95% CI, 0.35–1.64) and KRAS wild-type (the OS of HR, 0.89; 95% CI, 0.68–1.17), there were no significant differences between PD-1/PD-L1 inhibitors and chemotherapy. ConclusionsPD-1/PD-L1 inhibitors are more efficacious in NSCLC patients with EGFR wild-type and KRAS mutation compared with chemotherapy. There was no significant difference between PD-1/PD-L1 inhibitors and chemotherapy in NSCLC patients with EGFR mutation and KRAS wild-type. Legal entity responsible for the studyThe authors. FundingNational Natural Science Foundation of China (No. 81873396). DisclosureAll authors have declared no conflicts of interest.

Study protocols of three parallel phase 1 trials combining radical radiotherapy with the PARP inhibitor olaparib

BackgroundPoly (ADP-ribose) Polymerase (PARP) inhibitors are promising novel radiosensitisers. Pre-clinical models have demonstrated potent and tumour-specific radiosensitisation by PARP inhibitors. Olaparib is a PARP inhibitor with a favourable safety profile in comparison to clinically used radiosensitisers including cisplatin when used as single agent. However, data on safety, tolerability and efficacy of olaparib in combination with radiotherapy are limited.MethodsOlaparib is dose escalated in combination with radical (chemo-)radiotherapy regimens for non-small cell lung cancer (NSCLC), breast cancer and head and neck squamous cell carcinoma (HNSCC) in three parallel single institution phase 1 trials. All trials investigate a combination treatment of olaparib and radiotherapy, the NSCLC trial also investigates a triple combination of olaparib, radiotherapy and concurrent low dose cisplatin. The primary objective is to identify the maximum tolerated dose of olaparib in these combination treatments, defined as the dose closest to but not exceeding a 15% probability of dose limiting toxicity. Each trial has a separate dose limiting toxicity definition, taking into account incidence, duration and severity of expected toxicities without olaparib. Dose escalation is performed using a time-to-event continual reassessment method (TITE-CRM). TITE-CRM enables the incorporation of late onset toxicity until one year after treatment in the dose limiting toxicity definition while maintaining an acceptable trial duration. Olaparib treatment starts two days before radiotherapy and continues during weekends until two days after radiotherapy. Olaparib will also be given two weeks and one week before radiotherapy in the breast cancer trial and HNSCC trial respectively to allow for translational research. Toxicity is scored using common terminology criteria for adverse events (CTCAE) version 4.03. Blood samples, and tumour biopsies in the breast cancer trial, are collected for pharmacokinetic and pharmacodynamic analyses.DiscussionWe designed three parallel phase 1 trials to assess the safety and tolerability of the PARP inhibitor olaparib in combination with radical (chemo-)radiotherapy treatment regimens. PARP inhibitors have the potential to improve outcomes in patients treated with radical (chemo-)radiotherapy, by achieving higher locoregional control rates and/or less treatment associated toxicity.Trial registrationClinicalTrials.gov Identifiers: NCT01562210 (registered March 23, 2012), NCT02227082 (retrospectively registered August 27, 2014), NCT02229656 (registered September 1, 2014).

Abstract LB-217: The cancer subtype ontology: Predicting response to therapy in clinical and translational research using 840 cancer subtypes

Abstract Background: Detailed understanding of cancer subtypes is key to precision oncology and instrumental for effective patient-to-therapy assignment and development of combination therapy regimens. While many molecular and pathologic cancer subtypes have been developed over the last decade, key challenges remain. Paramount among them is the ability to effectively track and compare cancer subtypes across studies, identify meaningful associations with clinical outcomes, and robustly assign new patients into subtypes in a clinical setting. Approach: Here we report on the development of the Cancer Subtype Ontology (CSO) - a global resource for cancer subtype interrogation and patient-to-subtype assignment, constituting, to our knowledge, the largest collection of cancer subtypes to date. The foundational CSO resource currently catalogues 840 cancer subtypes which subcategorize ~40 histologies based on a diverse range of evidence types ranging from cancer genomics and transcriptomics, to epigenetics, proteomics and immune infiltration. CSO includes a wide collection of previously-published subtypes as well as a new model-based subtype collection reported here for the first time. CSO provides tools to compare across subtypes as well as characterize subtype enrichment for molecular, pathologic and clinical features, including response to therapy and patient survival. As an integrative part of the CSO, we develop a novel machine learning framework for robust assignment of new clinical and pre-clinical samples into the CSO subtypes. We first evaluate the CSO subtype collection using TCGA, measuring the ability to predict overall, progression-free, disease-specific, and disease-free survival. Next, using a novel curated collection of recent immune checkpoint inhibitor (ICI) trials, we demonstrate the power of the subtypes to predict ICI treatment responses and clinical outcomes. Results: First using TCGA, we found that the CSO significantly expands the ability to uncover subtypes predictive of clinical outcomes. Notably, new model-based subtypes in CSO, while constituting less than 1/3 of the ontology, accounted for ~60% of the most significant outcome associations across genomic and molecular subtypings. Next, we applied the CSO patient assignment system to systematically assign patients from 10 ICI trials across 4 histologies into 103 CSO subtypes. We found that half of the trials had CSO assignments predictive of patient survival and/or response and most of them were novel. Specifically, assignment of IMvigor 210 urinary bladder cancer patients revealed two subtypes enriched for partial (P=0.0002, OR=3.87) and complete response (P =0.002, OR=6.86), respectively, only one of which was previously characterized (Mariathasan et al. 2018). For the Snyder et al. 2014 cohort we observed that while stratification using the cohort data alone did not yield predictive subtypes, CSO patient assignment revealed subtypes that were predictive of long term clinical benefit (P=0.003). Furthermore, across non-small cell lung cancer trials analyzed, CSO assignment was predictive of progression-free survival (P=0.048) in the Rizvi et al. 2018 cohort and showed suggestive associations with both progression-free survival (P=0.055) and response (durable clinical benefit, P=0.08) for the Rizvi et al. 2016 cohort. Citation Format: Roy Ronen, Christopher DeBoever, Boguslaw Kluge, Janusz Dutkowski. The cancer subtype ontology: Predicting response to therapy in clinical and translational research using 840 cancer subtypes [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr LB-217.

Abstract 523: Implications of the A2a receptor (A2aR) on tumor microenvironment in non-small cell lung cancer (NSCLC)

Abstract Hypoxia-driven adenosine accumulation in tumor microenvironment is believed to play an important role in tumor evasion of immune response. Adenosine via interaction with its A2a receptor, expressed on immune cells, acts as a negative regulator of cytotoxic T-cell immune activity. Increased A2aR expression was observed in tumor infiltrating lymphocytes in freshly resected NSCLC specimens. Higher expression of A2aR was associated with worse prognostic findings in head and neck squamous cell carcinoma. Conversely, it correlated with favorable clinical outcome in non-metastatic lung adenocarcinoma. It has been hypothesized that A2aR antagonism could lead to enhanced efficacy for immune checkpoint blockade. A2aR antagonists have demonstrated favorable in vitro and ex vivo response in NSCLC and ongoing clinical trials are testing these drugs in conjunction with established immunotherapy. However, little is known about the role of A2aR in NSCLC patients. We investigated how A2aR expression affected tumor immune landscape, PD-L1 expression and clinical outcomes in a large pool of NSCLC patients. Methods: We obtained A2aR expression for NSCLC patients from TCGA; adenocarcinoma (ADC), n=586; squamous cell carcinoma (SCC), n=517. The data was arranged into 4 quartiles according to A2aR expression mRNA-seq z-scores, defining the highest quartile as A2aR-high and the lowest quartile as A2aR-low. We evaluated how A2aR expression correlated with a) immune landscape, b) PD-L1 expression, c) tumor mutational burden (TMB) and neoantigen burden, and d) clinical outcome. Results: In ADC, A2aR-high was significantly associated with lower infiltration of activated CD4 and CD8 T cells when compared with A2aR-low patients (12% vs 48% ; 9% vs 47%, all p&amp;lt;0.001). In SCC, similar results were observed (12% vs 61%; 9% vs 52%, all p&amp;lt;0.001). In addition, higher PD-L1 (CD274) expression was observed in A2aR-high ADC (p&amp;lt;0.05). There was no difference on TMB or neoantigen burden between groups. In ADC, A2aR-high was associated with more favorable overall survival (OS) and progression free survival when compared with A2aR-low (median 71 vs 41 months and 84 vs 27 months, respectively, all p&amp;lt;0.05). An inverse trend was noted in SCC, with A2aR-high patients having significantly shorter OS (median 39 vs 71 months, p&amp;lt;0.05). Conclusion: Higher A2aR expression was associated with lower activated CD4 and CD8 T-cells in NSCLC and higher PD-L1 expression in lung ADC, suggesting a potential target for developing new strategies for immunotherapy in NSCLC. Citation Format: Pedro Viveiros, Bhoomika Sukhadia, Pratyusha Nunna, Keon Woo Park, Jeffrey Chuang, Lihua Zou, Young Kwang Chae. Implications of the A2a receptor (A2aR) on tumor microenvironment in non-small cell lung cancer (NSCLC) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 523.

Reporting of patient reported outcome (PRO) in clinical trials: A systematic review of clinical trials.

6590 Background: Clinically relevant outcomes as improvements in overall survival (OS) or quality of life (QOL) should guide decision-making. The FDA encourages the implementation of patient-centric measures in clinical trials. Over the past decade a growing number of protocols have included PROs in their outcome measures. We aimed to evaluate the frequency at which PRO measures, incorporated into clinical trials, are made publicly available, when trial results are published. Methods: We searched Citeline Trialtrove database, a registry of clinical trials, for randomized phase 3 trials of patients with non-small cell lung cancer (NSCLC), recruiting during 2006-2016, with PRO listed. We excluded trials evaluating supportive treatment, and those unpublished. We identified publications associated with the trial, and extracted various parameters, including whether or not PRO outcome was published. Results: Of 158 NSCLC trials identified, 99 listed at least 1 PRO. 24 trials were excluded (supportive care, unpublished). The commonly used scales were EORTC-QLQ C30, QLQ-LC13, LCSS, FACT-L, and EQ-5D. Study sponsor was industry in 45 trials, and industry-academic in 12 trials. Of 75 trials analyzed, 41 (55%) published the results of the PRO endpoint. Only 37% of the 75 included a comprehensive report of PRO, and many publications referenced the PRO briefly. Of 41 trials that reported PRO, only 21 (51%) provided information about missing PRO data. 59 trials were published as full-text, of which 40 (68%) reported the PRO, and 53% reported the PRO more than 6 months after the initial full publication. Of the trials that showed PFS benefit, with no OS benefit, 22/34 (65%) published the results of the PRO endpoints. Conclusions: Despite a growing emphasis on QOL and the inclusion of PROs in oncology clinical trials, and despite patient and healthcare provider efforts to record PRO data, a significant number of NSCLC randomized trials do not report the PRO. The collection of PRO data should result in routine, timely and appropriate reporting as part of the trial outcome publication, to allow for a thorough assessment of investigational clinically relevant treatment effect.