TY - JOUR
T1 - Durvalumab plus tremelimumab alone or in combination with low-dose or hypofractionated radiotherapy in metastatic non-small-cell lung cancer refractory to previous PD(L)-1 therapy
T2 - an open-label, multicentre, randomised, phase 2 trial
AU - Schoenfeld, Jonathan D.
AU - Giobbie-Hurder, Anita
AU - Ranasinghe, Srinika
AU - Kao, Katrina Z.
AU - Lako, Ana
AU - Tsuji, Junko
AU - Liu, Yang
AU - Brennick, Ryan C.
AU - Gentzler, Ryan D.
AU - Lee, Carrie
AU - Hubbard, Joleen
AU - Arnold, Susanne M.
AU - Abbruzzese, James L.
AU - Jabbour, Salma K.
AU - Uboha, Nataliya V.
AU - Stephans, Kevin L.
AU - Johnson, Jennifer M.
AU - Park, Haeseong
AU - Villaruz, Liza C.
AU - Sharon, Elad
AU - Streicher, Howard
AU - Ahmed, Mansoor M.
AU - Lyon, Hayley
AU - Cibuskis, Carrie
AU - Lennon, Niall
AU - Jhaveri, Aashna
AU - Yang, Lin
AU - Altreuter, Jennifer
AU - Gunasti, Lauren
AU - Weirather, Jason L.
AU - Mak, Raymond H.
AU - Awad, Mark M.
AU - Rodig, Scott J.
AU - Chen, Helen X.
AU - Wu, Catherine J.
AU - Monjazeb, Arta M.
AU - Hodi, F. Stephen
N1 - Publisher Copyright:
© 2022 Elsevier Ltd
PY - 2022/2
Y1 - 2022/2
N2 - Background: Patients with non-small-cell lung cancer (NSCLC) that is resistant to PD-1 and PD-L1 (PD[L]-1)-targeted therapy have poor outcomes. Studies suggest that radiotherapy could enhance antitumour immunity. Therefore, we investigated the potential benefit of PD-L1 (durvalumab) and CTLA-4 (tremelimumab) inhibition alone or combined with radiotherapy. Methods: This open-label, multicentre, randomised, phase 2 trial was done by the National Cancer Institute Experimental Therapeutics Clinical Trials Network at 18 US sites. Patients aged 18 years or older with metastatic NSCLC, an Eastern Cooperative Oncology Group performance status of 0 or 1, and progression during previous PD(L)-1 therapy were eligible. They were randomly assigned (1:1:1) in a web-based system by the study statistician using a permuted block scheme (block sizes of three or six) without stratification to receive either durvalumab (1500 mg intravenously every 4 weeks for a maximum of 13 cycles) plus tremelimumab (75 mg intravenously every 4 weeks for a maximum of four cycles) alone or with low-dose (0·5 Gy delivered twice per day, repeated for 2 days during each of the first four cycles of therapy) or hypofractionated radiotherapy (24 Gy total delivered over three 8-Gy fractions during the first cycle only), 1 week after initial durvalumab–tremelimumab administration. Study treatment was continued until 1 year or until progression. The primary endpoint was overall response rate (best locally assessed confirmed response of a partial or complete response) and, along with safety, was analysed in patients who received at least one dose of study therapy. The trial is registered with ClinicalTrials.gov, NCT02888743, and is now complete. Findings: Between Aug 24, 2017, and March 29, 2019, 90 patients were enrolled and randomly assigned, of whom 78 (26 per group) were treated. This trial was stopped due to futility assessed in an interim analysis. At a median follow-up of 12·4 months (IQR 7·8–15·1), there were no differences in overall response rates between the durvalumab–tremelimumab alone group (three [11·5%, 90% CI 1·2–21·8] of 26 patients) and the low-dose radiotherapy group (two [7·7%, 0·0–16·3] of 26 patients; p=0·64) or the hypofractionated radiotherapy group (three [11·5%, 1·2–21·8] of 26 patients; p=0·99). The most common grade 3–4 adverse events were dyspnoea (two [8%] in the durvalumab–tremelimumab alone group; three [12%] in the low-dose radiotherapy group; and three [12%] in the hypofractionated radiotherapy group) and hyponatraemia (one [4%] in the durvalumab–tremelimumab alone group vs two [8%] in the low-dose radiotherapy group vs three [12%] in the hypofractionated radiotherapy group). Treatment-related serious adverse events occurred in one (4%) patient in the durvalumab–tremelimumab alone group (maculopapular rash), five (19%) patients in the low-dose radiotherapy group (abdominal pain, diarrhoea, dyspnoea, hypokalemia, and respiratory failure), and four (15%) patients in the hypofractionated group (adrenal insufficiency, colitis, diarrhoea, and hyponatremia). In the low-dose radiotherapy group, there was one death from respiratory failure potentially related to study therapy. Interpretation: Radiotherapy did not increase responses to combined PD-L1 plus CTLA-4 inhibition in patients with NSCLC resistant to PD(L)-1 therapy. However, PD-L1 plus CTLA-4 therapy could be a treatment option for some patients. Future studies should refine predictive biomarkers in this setting. Funding: The US National Institutes of Health and the Dana-Farber Cancer Institute.
AB - Background: Patients with non-small-cell lung cancer (NSCLC) that is resistant to PD-1 and PD-L1 (PD[L]-1)-targeted therapy have poor outcomes. Studies suggest that radiotherapy could enhance antitumour immunity. Therefore, we investigated the potential benefit of PD-L1 (durvalumab) and CTLA-4 (tremelimumab) inhibition alone or combined with radiotherapy. Methods: This open-label, multicentre, randomised, phase 2 trial was done by the National Cancer Institute Experimental Therapeutics Clinical Trials Network at 18 US sites. Patients aged 18 years or older with metastatic NSCLC, an Eastern Cooperative Oncology Group performance status of 0 or 1, and progression during previous PD(L)-1 therapy were eligible. They were randomly assigned (1:1:1) in a web-based system by the study statistician using a permuted block scheme (block sizes of three or six) without stratification to receive either durvalumab (1500 mg intravenously every 4 weeks for a maximum of 13 cycles) plus tremelimumab (75 mg intravenously every 4 weeks for a maximum of four cycles) alone or with low-dose (0·5 Gy delivered twice per day, repeated for 2 days during each of the first four cycles of therapy) or hypofractionated radiotherapy (24 Gy total delivered over three 8-Gy fractions during the first cycle only), 1 week after initial durvalumab–tremelimumab administration. Study treatment was continued until 1 year or until progression. The primary endpoint was overall response rate (best locally assessed confirmed response of a partial or complete response) and, along with safety, was analysed in patients who received at least one dose of study therapy. The trial is registered with ClinicalTrials.gov, NCT02888743, and is now complete. Findings: Between Aug 24, 2017, and March 29, 2019, 90 patients were enrolled and randomly assigned, of whom 78 (26 per group) were treated. This trial was stopped due to futility assessed in an interim analysis. At a median follow-up of 12·4 months (IQR 7·8–15·1), there were no differences in overall response rates between the durvalumab–tremelimumab alone group (three [11·5%, 90% CI 1·2–21·8] of 26 patients) and the low-dose radiotherapy group (two [7·7%, 0·0–16·3] of 26 patients; p=0·64) or the hypofractionated radiotherapy group (three [11·5%, 1·2–21·8] of 26 patients; p=0·99). The most common grade 3–4 adverse events were dyspnoea (two [8%] in the durvalumab–tremelimumab alone group; three [12%] in the low-dose radiotherapy group; and three [12%] in the hypofractionated radiotherapy group) and hyponatraemia (one [4%] in the durvalumab–tremelimumab alone group vs two [8%] in the low-dose radiotherapy group vs three [12%] in the hypofractionated radiotherapy group). Treatment-related serious adverse events occurred in one (4%) patient in the durvalumab–tremelimumab alone group (maculopapular rash), five (19%) patients in the low-dose radiotherapy group (abdominal pain, diarrhoea, dyspnoea, hypokalemia, and respiratory failure), and four (15%) patients in the hypofractionated group (adrenal insufficiency, colitis, diarrhoea, and hyponatremia). In the low-dose radiotherapy group, there was one death from respiratory failure potentially related to study therapy. Interpretation: Radiotherapy did not increase responses to combined PD-L1 plus CTLA-4 inhibition in patients with NSCLC resistant to PD(L)-1 therapy. However, PD-L1 plus CTLA-4 therapy could be a treatment option for some patients. Future studies should refine predictive biomarkers in this setting. Funding: The US National Institutes of Health and the Dana-Farber Cancer Institute.
UR - http://www.scopus.com/inward/record.url?scp=85123700428&partnerID=8YFLogxK
U2 - 10.1016/S1470-2045(21)00658-6
DO - 10.1016/S1470-2045(21)00658-6
M3 - Article
C2 - 35033226
AN - SCOPUS:85123700428
SN - 1470-2045
VL - 23
SP - 279
EP - 291
JO - The Lancet Oncology
JF - The Lancet Oncology
IS - 2
ER -