Ming-Hei Tai, PharmD, BCOP’s Post

More data from the NICHE-2 and NICHE-3 studies was presented at ESMO 2024.  Both these studies looked at giving neoadjuvant immunotherapy prior to surgery in MMR-deficient (dMMR) colon cancer.  Patients on NICHE-2 received 1 dose of ipilimumab and 2 doses of nivolumab, while patients on NICHE-3 received 2 doses of nivolumab/relatlimab. Patients on NICHE-2 had a 95% major pathologic response (MPR) and 68% pathologic complete response (pCR).  3-year disease-free survival (DFS) was reported at ESMO, and there was 100% DFS, even in the patients without a pCR.  Baseline ctDNA was detected in 92% of patients, but after treatment with immunotherapy, only 15% were still ctDNA positive. All patients were ctDNA negative 3 weeks post-surgery. Patients on NICHE-3 had a 91% MPR and 68% pCR, similar to the results of NICHE-2.  Data on ctDNA and DFS was not presented at ESMO 2024.  Rates of adverse events appeared similar to those in NICHE-2. What does this mean for dMMR colon cancer?  It's important to understand that many of these patients - especially those who are node negative - already have very good 3-year DFS simply from surgery.  The stage II patients, which comprise about 1/3 of the NICHE-2 population, are recommended observation under our current clinical guidelines.  So, the problem here is, is the improvement in DFS worth the potential toxicities from immunotherapy, given that all patients still get resected?  The evidence is unclear as we have no long-term overall survival data. The more interesting question is whether some of the NICHE-2 patients could have skipped surgery.  The majority of patients were ctDNA negative after only 1 dose of ipilimumab and 2 doses of nivolumab. Could a combination of ctDNA testing and imaging help determine whether some patients could skip surgery entirely?  Given that the 16 patients who were ctDNA positive were ctDNA negative after surgery, there appears to be some benefit to surgery - although the question remains whether another cycle of ipilumumab and nivolumab could have converted them to be ctDNA negative.  The investigators mention organ-sparing strategies in their abstract, and this would probably be the more interesting, and practice-changing, question.   Hopefully phase III trials are run answering this question.  #opdivo #opdualag #yervoy #coloncancer #colorectalcancer https://lnkd.in/ecHp3a4X

Does adjuvant durvalumab provide a benefit in resected non-small cell lung cancer (NSCLC)?  According to this abstract presented at ESMO 2024, the answer is no.  Patients with an R0 resection were randomized to either durvalumab for 12 months or placebo.  1219 patients who were EGFR/ALK negative were randomized, and there was no significant difference in disease-free survival between the two groups, with a HR of 0.89 (0.75–1.07).  This trial calls into question the AEGEAN trial, which looked at perioperative durvalumab in NSCLC.  Is there a benefit to adjuvant durvalumab after neoadjuvant durvalumab?  We don't know, because the AEGEAN trial gave everyone adjuvant durvalumab.  Is there any evidence for adjuvant immunotherapy after neoadjuvant chemoimmunotherapy in lung cancer?  Recently, there was an inverse probability of treatment weighting (IPTW) analysis presented at IASLC (https://lnkd.in/eSp3MXRQ).  In that analysis, which compared two phase III nivolumab trials, one neoadjuvant and one perioperative, adjuvant nivolumab did appear to provide a benefit.  IPTW analyses are slightly better than eyeballing across trials, but the best evidence would be a phase III trial on this subject.  Several other adjuvant trials, including an adjuvant nivolumab trial (https://lnkd.in/eS6AW8Zz), should read out soon, but there do not appear to be any perioperative vs neoadjuvant trials reading out in the near future.  #imfinzi #keytruda #opdivo #lungcancer https://lnkd.in/enK5iNFY

Is ivonescimab better than pembrolizumab? Looking at the top-line data from IASLC, it appears to be better. However, it is somewhat of an unfair comparison. First, we generally would add chemotherapy for patients with low expression of PD-L1. Second, ivonescimab is a dual VEGF/PD-1 inhibitor. There haven't been any immunotherapy/VEGF inhibitor trials without chemotherapy in lung cancer. I think it's an open question as to whether this "bispecific" is better than giving both pembrolizumab and bevacizumab. We really need a randomized phase III clinical trial to see if a bispecific provides any additional benefit, considering that this would be likely more expensive than giving the two agents separately. #keytruda #lungcancer #avastin https://lnkd.in/eSp3MXRQ

Some studies just sit there waiting to be closed.  For example, NRG-GI004 is technically open for enrollment at Karmanos, and looks at giving atezolizumab in dMMR colorectal cancer.  However, nobody has enrolled on this trial recently, and it is probably similar for the other 444 locations where NRG-GI004 is open.  According to clinicaltrials.gov, which was last updated August 28th, the trial is still recruiting, with a target of 120 patients.  This trial has tough competition - several agents are commercially available, and the PD-1 inhibitor based trials are much more attractive.  The window for clinician willingness to enroll patients on this trial has probably passed.  One of the reasons why clinical trials in the oncology space are so expensive is because a lot of money is spent to avoid logistical concerns and speed up enrollment.  For example, some studies will send study drug to every site before any patient enrolls, just to simplify the ordering process.  Not every site will use all the drug that is sent to them, meaning a portion of the supply that is sent out is wasted.  It's more expensive to lose a trial due to low enrollment than it is to write off unused medications, but that adds to the cost of a clinical trial.  Every clinical site probably has a story about the biggest clinical trial write off they saw. #clinicaltrials #oncology #tecentriq https://lnkd.in/eNUAnMTQ

Did you know that 18 pathologists only had 26% concordance on whether a HER2 IHC stain was 0 or 1+?  This study, done back in 2022, collected 170 biopsies from Yale and sent the scanned slides to 18 different pathologists.  Of those 170 biopsies, 92 were read as IHC 0 by at least one of the 18 pathologists.  17 of 18 pathologists agreed on 24/92 of these cases (26%), meaning that you have a good chance of turning an IHC 0 patient into an IHC 1 patient simply by sending the biopsy slides to another pathologist.  That would qualify a breast cancer patient for fam-trastuzumab deruxtecan - no repeat biopsy needed! Differences in HER2 testing before and after fixation have also been noted in our national guidelines (https://lnkd.in/eA8qKshR).  This is why central HER2 testing is very important in studies that look at HER2-directed agents, especially in "low" and "ultralow" patients, because it eliminates variation between institutions. New HER2 testing methodologies are needed (and being studied), but then the question is, how would that impact fam-trastuzumab deruxtecan?  The current FDA approval may need to be re-validated for any new testing methodology, not to mention all the clinical trials that currently use HER2 IHC testing.  #breastcancer #enhertu https://lnkd.in/eJh5XeCA

Very interesting perioperative lung data from Neocoast-2, which was a 5-arm phase II trial.  Three of the arms were presented at IASLC.   The first arm was neoadjuvant durvalumab (D) + chemotherapy (CT) + oleclumab (O), a novel anti-CD73 checkpoint inhibitor, followed by adjuvant D + O. The second arm was neoadjuvant D + CT + monalizumab (M), a novel anti-NKG2A checkpoint inhibitor, followed by adjuvant D + M.  The third arm was neoadjuvant D + CT + Dato-DXd, a TROP-2 directed antibody-drug conjugate (ADC), followed by adjuvant D.  Patients on the third arm received a single platinum agent, as opposed to doublet platinum chemotherapy. According to the abstract, pCR rates were 20%, 26.7%, and 34.1% respectively in the three arms presented.  Assuming that neoadjuvant chemoimmunotherapy has around a 20-25% pCR rate, the two double checkpoint inhibitions arms appear to show no improvement over currently available options.  These are small sample sizes, so double checkpoint inhibition with novel agents could still have a benefit, but that would need to be examined in a phase III trial.  In addition, the apparent benefit from the D + CT + Dato-DXd arm is from a higher pCR rate in the PD-L1 TPS <50% and the PD-L1 negative subgroups,  However, there are also weird subgroup analyses - for example, in the D + CT + O arm, 5.6% of patients with a PD-L1 TPS of <50% had a pCR, but 17.6% of PD-L1 negative patients had a pCR. It's hard to make any conclusions from these subgroups. The side effect profile appeared to be manageable.  Grade 3 or higher treatment-related adverse events were 33.8%, 38.0% and 18.5% respectively.  8.1%, 12.7%, and 7.4% of patients discontinued neoadjuvant therapy, so most patients appear to have finished all planned courses of treatment.  Overall, what can we conclude from this?  D + CT + Dato-DXd showed promising efficacy, but it's important to remember that this arm only had 44 patients.  One of the issues with reading efficacy from any 5-arm study like this is that they have wide confidence intervals, so the actual pCR rate could be much lower or higher than what was reported.  Dato-DXd could be a preoperative agent, but that will need to be compared against a standard-of-care chemoimmunotherapy regimen in a phase III trial.  #imfinzi #opdivo #keytruda #lungcancer https://lnkd.in/eSp3MXRQ

This phase II trial of atezolizumab before and after chemoradiation, published in JAMA oncology, is an interesting take on the idea of combining immunotherapy with radiation.  In this trial, patients received atezolizumab, then radiation, then consolidation chemotherapy, then atezolizumab maintenance. The disease control rate at 12 weeks was 74.2%. Median progression-free survival was 30.0 months and median overall survival was not reached. How does this trial relate to current trials? Recently, combination immunotherapy plus radiation was found to not be better than radiation followed by immunotherapy in the PACIFIC-2 trial (https://lnkd.in/eGSsw5hQ). However, that trial did not look at immunotherapy before chemoradiation, only in combination. In terms of trials that looked at immunotherapy before radiation, the trials I found were related to ipilimumab in melanoma (https://lnkd.in/eJw7Rzke and https://lnkd.in/eCTPvUYW). There could be other trials out there, but at the very least, there are no large trials that have tested this hypothesis. One concern is delaying treatment, but we are already using neoadjuvant therapy and delaying treatment for surgically resectable lung cancer patients. At some point, hopefully we have a large trial that at least tests this hypothesis of immunotherapy before radiation. #tecentriq #lungcancer https://lnkd.in/e5YQcZbQ

We don't often see phase III trials in leiomyosarcomas, due to its rarity.  The NIH doesn't even have an estimate of the incidence (https://lnkd.in/ey2rrWCf), although other sources estimate that this occurs in about 1 in 100,000 people. This phase III trial, published in the NEJM, enrolled 150 patients with metastatic or unresectable leiomyosarcoma who had not received prior chemotherapy.  Patients were randomized to either doxorubicin or doxorubicin plus trabectedin followed by maintenance trabectedin.  The study previously only reported progression-free survival (PFS), but now can report overall survival (OS) as well.  For overall survival, doxorubicin/trabectedin had an adjusted hazard ratio of 0.65 [0.44-0.95], 33 months vs 24 months.  37% of patients on the doxorubicin arm received second line trabectedin, and an additional 22% received trabectedin third line or later, so crossover seems to be appropriate.  100 patients received some sort of subsequent therapy, and for these patients, time to second progression was significantly longer in the doxorubicin/trabectedin group (HR 0.46 [0.32 to 0.65]), but this does include patients who did not get second line trabectedin.  Overall, either in terms of first or second progression or overall survival, patients on the experimental arm appear to have done better. What does this mean for sarcomas?  It's good because we finally have a new chemotherapy regimen with an overall survival benefit in leiomyosarcoma.  However, the time it took to enroll 150 patients (enrollment started Jan 2017) highlights the challenges in this space.  Sarcomas are both rare and heterogenous, so most trials have to be run in specific subtypes.  This is one of those tumors where the initial referral should absolutely be to an expert at an academic medical center.  Patients need to get enrolled onto clinical trials, and there's isn't an app you can click on which tells you what clinical trials are available, and which ones the patient qualifies for.  Otherwise, we are mostly relying on treatments which may not have changed for decades.  #yondelis #sarcoma https://lnkd.in/e_vz5kFh

This data on minimal residual disease (MRD) in first line treatment of chronic lymphocytic leukemia, published in JCO, shows that minimal residual disease (MRD) probably shouldn't be a surrogate endpoint in CLL.  End-of-treatment MRD had a weak correlation with overall survival, and this makes sense, considering that many CLL patients do well even if they are MRD positive.   Furthermore, looking at the supplemental data, peripheral blood MRD had a much poorer correlation with OS, meaning that if this was adopted as a surrogate endpoint, patients would need to undergo bone marrow biopsies to determine their MRD, which isn't common in clinical practice.   And ultimately, the problem here is that MRD is mostly used in time-limited therapy.  We still don't know how a time-limited MRD guided therapy would compare to an indefinite duration therapy. #cll https://lnkd.in/gGm4yshB