Pts with unresectable HCC have few treatment (tx) options. Checkpoint inhibitors and combination approaches with anti-VEGFs are emerging as potential new tx options. Here we report the first randomised dataset evaluating atezo (anti-PD-L1) as monotherapy vs the combination of atezo + bev (anti-VEGF; Arm F) as well as updated single-arm atezo + bev data (Arm A) from a Ph 1b study.
Arms F and A of the Ph 1b study GO30140 enrolled systemic tx-naïve pts with unresectable HCC. Arm F pts were randomised 1:1 to atezo + bev or atezo monotherapy and received atezo 1200 mg IV q3w +/- bev 15 mg/kg IV q3w until unacceptable toxicity or loss of clinical benefit. Arm A pts received atezo + bev. Primary endpoints were progression free survival (PFS; Arm F) and objective response rate (ORR, Arm A) by independent review facility (IRF)-assessed RECIST 1.1, and safety (Arms F and A).
In Arm F, 60 pts were randomised to atezo + bev (Group F1) and 59 pts to atezo (Group F2). Arm F showed a statistically significant improvement in the primary endpoint median PFS for atezo + bev vs atezo (5.6 vs 3.4 mo, HR 0.55, 80% CI, 0.40 – 0.74, P = 0.0108). Any-Gr TRAEs occurred in 41 (68%) F1 pts and 24 (41%) F2 pts; Gr 3-4 TRAEs occurred in 12 (20%) F1 pts and 3 (5%) F2 pts. There were no Gr 5 TRAEs in Arm F. For the 104 pts in Arm A, primary endpoint ORR was 36% (37 pts) with 76% of responses ongoing. Any-Grade (Gr) tx-related adverse events (TRAEs) occurred in 91 (88%) pts; Gr 3-4 TRAEs occurred in 41 (39%) pts. Gr 5 TRAEs were seen in 3 (3%) pts.
By meeting its primary endpoint of improved PFS for atezo + bev vs atezo alone, Arm F showed the single-agent contribution of atezo and bev to the overall tx effect. With longer follow up, Arm A highlights the clinically meaningful and durable responses of atezo + bev. Coupled with a tolerable safety profile, these data suggest that atezo + bev is a promising first-line tx option for unresectable HCC. Table: LBA7 0.55 0.40 – 0.74 P = 0.0108 0.54 0.40 – 0.74 Data cut off: 14 Jun 2019. 1 randomised pt did not receive atezo. Primary endpoint.Arm F IRF RECIST 1.1 IRF HCC mRECIST F1 Atezo + Bev n = 60 F2 Atezo n = 59 F1 Atezo + Bev n = 60 F2 Atezo n = 59 Median follow up, mo 6.6 6.7 6.6 6.7 Median PFS, mo 5.6 3.4 5.6 3.4 95% CI 3.6 – 7.4 1.9 – 5.2 3.6 – 7.4 1.9 – 5.2 HR 80% CI Arm A: Atezo + Bev n = 104 IRF RECIST 1.1 IRF HCC mRECIST Median follow up, mo 12.4 Confirmed ORR, n (%) 37 (36) 41 (39) 95% CI 26 – 46 30 – 50 CR 12 (12) 16 (15) PR 25 (24) 25 (24) On-going response 28 (76) 28 (68) DCR (CR + PR + SD), n (%) 74 (71) 74 (71) Median DOR, mo NE NE 95% CI 11.8 – NE 11.8 – NE Median PFS, mo 7.3 7.3 95% CI 5.4 – 9.9 5.4 – 9.9
NCT02715531.
Jonathan Lee, PhD, of Health Interactions and funded by F. Hoffmann-La Roche, Ltd.
F. Hoffmann-La Roche, Ltd.
F. Hoffmann-La Roche, Ltd.
C. Hsu: Honoraria (self), Advisory / Consultancy: BMS; Honoraria (self), Advisory / Consultancy: Ono Pharmaceutical; Honoraria (self), Research grant / Funding (institution): MSD; Advisory / Consultancy: Eli Lilly; Advisory / Consultancy: AstraZeneca; Advisory / Consultancy: Roche. M.S. Lee: Research grant / Funding (self): Amgen; Research grant / Funding (self): BMS; Research grant / Funding (self): Pfizer; Research grant / Funding (self): EMD Serono; Research grant / Funding (self): Genentech/Roche. K. Lee: Honoraria (self), Advisory / Consultancy: Roche; Honoraria (self), Advisory / Consultancy: AZ; Advisory / Consultancy: Bayer; Advisory / Consultancy: Ono Pharmaceutical; Advisory / Consultancy: Samsung Bioepis; Advisory / Consultancy: Eisai. S. Stein: Advisory / Consultancy: Genentech; Advisory / Consultancy: BMS; Advisory / Consultancy: Eisai; Advisory / Consultancy: Bayer; Advisory / Consultancy: Exelixis. W. Verret: Full / Part-time employment: Genentech. S. Hack: Shareholder / Stockholder / Stock options, Full / Part-time employment: Roche/Genentech. J. Spahn: Shareholder / Stockholder / Stock options, Full / Part-time employment: Roche/Genentech. B. Liu: Full / Part-time employment: Genentech. C. Huang: Full / Part-time employment: Roche. R. He: Speaker Bureau / Expert testimony: Bayer; Speaker Bureau / Expert testimony: BMS; Speaker Bureau / Expert testimony: Eisai Inc; Speaker Bureau / Expert testimony: Exelixis Inc; Advisory / Consultancy, Research grant / Funding (institution): Merck & Co; Advisory / Consultancy: AZ.
KEYNOTE-048 (NCT02358031) is a randomized, open-label, phase 3 trial of pembrolizumab (pembro) or pembro + chemotherapy (chemo) vs EXTREME (E) as first-line therapy for recurrent and/or metastatic (R/M) head and neck squamous cell carcinoma (HNSCC). At the second interim analysis, overall survival (OS) was significantly longer with pembro than E in patients with PD-L1 combined positive score (CPS) ≥20 (P = 0.0007) and CPS ≥1 (P = 0.0086) and was noninferior in the total population (pop). Pembro + chemo significantly improved OS vs E in the total pop (P = 0.0034). Safety was favorable or similar to that of E.
Patients with R/M HNSCC not curable by local therapy and with no prior systemic therapy were randomized (1:1:1) to pembro 200 mg Q3W, pembro + chemo (cisplatin 100 mg/m2 or carboplatin AUC 5 Q3W + 5-FU 1000 mg/m2/day for 4 days Q3W), or E (cetuximab 400 mg/m2 loading dose with 250 mg/m2 subsequent infusion QW + chemo) until progressive disease, unacceptable toxicity, 6 cycles of chemo, or 24 months of pembro. Primary end points were progression-free survival and OS. Data cutoff date was June 13, 2018.
Efficacy is reported in the table. Gr 3-5 drug-related AE rates with pembro vs E were 28.6% vs 76.9% in the Asia subgroup and 13.9% vs 67.2% in the non-Asia subgroup; rates with pembro + chemo vs E were 71.9% vs 76.9% in the Asia subgroup and 70.8% vs 67.2% in the non-Asia subgroup.
Pembro vs E showed favorable OS in Asia and non-Asia subgroups, regardless of PD-L1 status; responses were durable, particularly among all non-Asia subgroups; safety was favorable. Pembro + chemo vs E showed favorable OS in patients with CPS ≥20 in Asia and non-Asia subgroup regardless of PD-L1 status, durable responses, and similar safety. Table: 286O HRs, Kaplan-Meier method; 95% CIs, Cox regression model.Asia CPS ≥20 Asia CPS ≥1 Asia Tot Pop Non-Asia CPS ≥20 Non-Asia CPS ≥1 Non-Asia Tot Pop HR; 95% CI P vs E 22 v 23 P+C v E 22 v 21 P v E 48 v 46 P+C v E 45 v 43 P v E 56 v 53 P+C v E 57 v 49 P v E 111 v 99 P+C v E 104 v 89 P v E 209 v 209 P+C v E 197 v 192 P v E 245 v 247 P+C v E 224 v 229 OS 0.39; 0.19-0.80 0.80; 0.41-1.58 0.80; 0.51-1.27 1.13; 0.71-1.79 0.74; 0.48-1.13 1.03; 0.68-1.58 0.75; 0.54-1.04 0.68; 0.48-0.96 0.76; 0.61-0.95 0.65; 0.51-0.82 0.87; 0.71-1.06 0.71; 0.57-0.88 PFS 1.16; 0.63-2.11 1.07; 0.58-1.99 1.25; 0.82-1.91 1.14; 0.74-1.76 1.39; 0.94-2.05 1.12; 0.75-1.66 0.95; 0.70-1.28 0.65; 0.47-0.89 1.10; 0.89-1.35 0.74; 0.60-0.92 1.27; 1.05-1.54 0.82; 0.67-1.00
NCT02358031.
Medical writing and/or editorial assistance was provided by Doyel Mitra, PhD, CMPP, and Holly Cappelli, PhD, CMPP, of the ApotheCom pembrolizumab team (Yardley, PA, USA). This assistance was funded by Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA.
Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA.
Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA.
N. Ngamphaiboon: Honoraria (self): Roche, AstraZeneca, Eisai, Amgen, MSD, Novartis; Advisory / Consultancy: MSD, Amgen, Novartis, Boehringer Ingelheim, AstraZeneca; Speaker Bureau / Expert testimony: Roche, AstraZeneca, Eisai, Amgen, MSD, Novartis; Travel / Accommodation / Expenses: Roche, MSD, Amgen, Novartis, Merck, Eisai, Taiho; Research grant / Funding (institution): MSD, Pfizer, Roche, AstraZeneca. K. Tanaka: Honoraria (self): Merck Serono, Bristol-Myers Squibb, Eisai, Ono Pharmaceutical, MSD, AstraZeneca; Advisory / Consultancy: Merck Serono, Bristol-Myers Squibb, Ono Pharmaceutical, MSD, Pfizer, Rakuten Medical, Celgene, Amgen; Research grant / Funding (institution): Bristol-Myers Squibb, Ono Pharmaceutical, MSD, Pfizer, Rakuten Medical, Novartis, Loxo, AstraZeneca, Rakuten Medical. R-L. Hong: Research grant / Funding (institution): MSD. W.Z. Wan Ishak: Honoraria (self): Eli Lilly Malaysia, Roche Malaysia, Pfizer Malaysia, MSD Ltd, Eisai Korea, Eisai Malaysia, Mundipharma, Merck Serono, Roche Myanmar; Advisory / Consultancy: Boehringer Ingelheim (M), Merck Serono (M), Roche (M), Eli Lilly (M), Amgen (M); Speaker Bureau / Expert testimony: Eli Lilly Inc; Research grant / Funding (self): Amgen Inc, MSD, Roche & Genetech, AstraZeneca; Travel / Accommodation / Expenses: Eisai (M), Eli Lilly (M), AstraZeneca (M), MSD Inc, Roche (M), Merck Serono (M), Mundipharma (M), Novartis (M), Pfizer (M), Amgen (M), Menarini (M). V. Sriuranpong: Honoraria (self): MSD; Advisory / Consultancy: MSD. S. Takahashi: Honoraria (self): Novartis, MDS, Eisai, Taiho, Chugai, Daiichi-Sankyo, Bayer, AstraZeneca; Research grant / Funding (self): MSD, Eisai, Taiho, Chugai, Daiichi-Sankyo, Bayer, AstraZeneca, Quintiles. N. Nohata: Shareholder / Stockholder / Stock options: Merck; Full / Part-time employment: MSD KK. A. Roy: Shareholder / Stockholder / Stock options, Full / Part-time employment: Merck & Co., Inc. B. Gumuscu: Shareholder / Stockholder / Stock options, Full / Part-time employment: Merck. R. Swaby: Shareholder / Stockholder / Stock options, Full / Part-time employment: Merck. M. Tahara: Honoraria (self): Merck Serono, Bristol-Myers Squibb, Eisai, Ono Pharmaceutical, MSD, AstraZeneca; Advisory / Consultancy: Merck Serono, Bristol-Myers Squibb, Ono Pharmaceutical, MSD, Pfizer, Rakuten Medical, Celgene, Amgen; Research grant / Funding (institution): Bristol-Myers Squibb, Ono Pharmaceutical, MSD, Pfizer, Rakuten Medical, Novartis, Loxo, AstraZeneca, Rakuten Medical. All other authors have declared no conflicts of interest.
Clinical guidelines for treatment decision in NPC are mainly based on the anatomical classification by UICC TNM staging. The concentration of plasma EBV DNA measured after radiotherapy (RT) or chemoradiation (CRT) is highly prognostic and independent of UICC stage, which may be useful in risk stratification of NPC patients to adjuvant therapy.
For model development, we used the prospective multi-center 0502 EBV DNA screening cohort (recruitment period 2006 - 2015; n = 745). Eligible patients had histologically confirmed NPC of stage II-IVB (UICC 7th Edition) and post-RT EBV DNA measured in plasma, no loco-regional disease or distant metastasis after RT/CRT and received no adjuvant therapy. Primary endpoint was overall survival (OS). We used recursive-partitioning analysis (RPA) to classify patients into groups of low-, intermediate- and high-risk of death. For internal validation, we pooled independent patient cohorts from previous published biomarker studies (1997-2006; n = 340). For external validation, we used external cohort of NPC patients treated at Sun Yat-sen University Cancer Center (2009 - 2012; n = 837) using SYSU EBV DNA test.
RPA classified NPC patients based on the post-RT plasma EBV DNA level and UICC stage into three distinct prognostic groups (Table). RPA low risk group shared similar 5-yr OS (89.4%; 95% CI = 86.4-92.5%) as UICC stage II (88.5%; 84.0-93.1%) but included 2.3x number of patients that could be potentially spared of adjuvant therapy toxicity. The overall C-index of OS was 0.7118 for RPA risk group, compared to 0.6042 for TNM stage and 0.6747 for EBV DNA (both p < 0.01). RPA risk group has improved hazard discrimination and calibration than either TNM stage or plasma EBV DNA level. The result was validated in both internal and external cohorts. Table: 287OPatient No. (%) 5-yr OS HR (95% C.I.) P UICC TNM stage (7th Ed) 1) Stage II 209 (28.1) 88.5 - 2) Stage III 368 (49.4) 81.0 1.50 (0.99-2.25) 0.054 3) Stage IVAB 168 (22.6) 69.4 3.01 (1.97-4.59) <0.0001 Post-RT plasma EBV DNA (copies/ml) 1) 0 573 (76.9) 87.3 - 2) 1-49 74 (9.9) 83.2 1.32 (0.76-2.27) 0.3259 3) 50-499 59 (7.9) 50.5 3.85 (2.55-5.81) <0.0001 4) > =500 39 (5.2) 28.3 11.59 (7.60-17.67) <0.0001 RPA risk group 1) Low risk EBV DNA 0 and stage II/III 1-49 and stage II 483 (64.8) 89.4 - 2) Intermediate risk EBV DNA 0 and stage IVAB 1-49 and stage III/IVAB 50-499 and stage II 176 (23.6) 78.5 2.40 (1.65-3.50) <0.0001 3) High risk EBV DNA 50-499 and stage III/IVAB >500 and any stage 86 (11.5) 37.2 8.54 (5.93-12.29) <0.0001
Incorporation of post-RT plasma EBV DNA level into UICC TNM stage improved risk stratification of NPC patients to adjuvant therapy.
Identifier: NCT00370890.
Comprehensive Cancer Trials Unit, Department of Clinical Oncology, The Chinese University of Hong Kong.
Has not received any funding.
E.P. Hui: Advisory / Consultancy, Research grant / Funding (institution): Merck Sharp & Dohme; Speaker Bureau / Expert testimony: Merck Serono; Research grant / Funding (institution): Pfizer. W.K.J. Lam: Shareholder / Stockholder / Stock options: Grail. K.C.A. Chan: Advisory / Consultancy, Shareholder / Stockholder / Stock options: Grail; Leadership role, Shareholder / Stockholder / Stock options: Take2; Leadership role, Shareholder / Stockholder / Stock options: DRA. Y.M.D. Lo: Advisory / Consultancy, Leadership role, Shareholder / Stockholder / Stock options: Grail; Leadership role, Shareholder / Stockholder / Stock options: Take2 Health; Leadership role, Shareholder / Stockholder / Stock options: DRA. A.T.C. Chan: Research grant / Funding (institution): Pfizer; Research grant / Funding (institution): Boehringer Ingelheim; Research grant / Funding (institution): Bristol-Myers Squibb; Research grant / Funding (institution): Merck Sharp & Dohme. All other authors have declared no conflicts of interest.