In an online paper in JAMA Network Open, Dr. Kenneth L. Kehl of Harvard Medical School, in Boston, and colleagues note that pembrolizumab was the first checkpoint inhibitor approved for first-line treatment of advanced NSCLC. Based on clinical trial results, practice guidelines now recommend up-front immunotherapy using such agents.
However, say the researchers, "treatment patterns and outcomes among older patients who may not have met inclusion criteria for key clinical trials remain unclear."
To investigate, the team examined data on Medicare patients aged 66 to 89 years who had first palliative-intent systemic therapy for lung cancer between 2016 and 2020. More than 19,000 patients were followed for a mean of 18 months.
Regimens included pembrolizumab monotherapy, combined cisplatin/carboplatin (platinum) and pemetrexed disodium, combined platinum and a taxane and combined platinum, pemetrexed, and pembrolizumab.
The uptake of pembrolizumab-containing regimens increased from 0.7% of first-line treatments in 2016 to 42.4% by the third quarter of 2018. Those who were older and had higher Risk Stratification Index scores were among patients more likely to receive single-agent pembrolizumab than chemotherapy.
After propensity-score adjustment, survival associated with pembrolizumab was similar to that with platinum/pemetrexed or platinum/taxane. In addition, patients receiving platinum/pemetrexed/pembrolizumab chemoimmunotherapy had adjusted survival similar to those receiving platinum/pemetrexed chemotherapy.
The unadjusted median survival was 11.4 months in patients receiving pembrolizumab monotherapy, which was "approximately 15 months shorter than observed among pembrolizumab treated participants in the KEYNOTE-024 trial."
Similarly, the unadjusted median survival was 12.9 months in patients receiving platinum/pemetrexed/pembrolizumab chemoimmunotherapy, which was "approximately 10 months shorter than observed among platinum/pemetrexed/pembrolizumab-treated participants in the KEYNOTE-189 trial."
The researchers point out that "new anticancer drugs are approved after trials that include hundreds of patients - yet after approval, these drugs affect tens of thousands of patients each year, including many with frailty and multiple comorbidities who are underrepresented in clinical trials."
These results, they conclude, "may inform prognostic considerations in practice and reinforce the importance of understanding patient selection dynamics in assessing the value and clinical utility of transformative treatment strategies."
Dr. Kehl did not respond to requests for comments.
SOURCE: https://bit.ly/3uRFjJ0 JAMA Network Open, online May 21, 2021.
By Reuters Staff
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