Real-world outcomes versus clinical trial results of immunotherapy in stage IV non-small cell lung cancer (NSCLC) in the Netherlands

Christine M Cramer-van der Welle, Marjon V Verschueren, Merel Tonn, Bas J M Peters, Franz M N H Schramel, Olaf H Klungel, Harry J M Groen, Ewoudt M W van de Garde, Santeon NSCLC Study Group, E A Kastelijn, L C Vermeer, B E E M van den Borne, J W G van Putten, J H Schouwink, A A J Smit, Christine M Cramer-van der Welle, Marjon V Verschueren, Merel Tonn, Bas J M Peters, Franz M N H Schramel, Olaf H Klungel, Harry J M Groen, Ewoudt M W van de Garde, Santeon NSCLC Study Group, E A Kastelijn, L C Vermeer, B E E M van den Borne, J W G van Putten, J H Schouwink, A A J Smit

Abstract

This study aims to assess how clinical outcomes of immunotherapy in real-world (effectiveness) correspond to outcomes in clinical trials (efficacy) and to look into factors that might explain an efficacy-effectiveness (EE) gap. All patients diagnosed with stage IV non-small cell lung cancer (NSCLC) in 2015-2018 in six Dutch large teaching hospitals (Santeon network) were identified and followed-up from date of diagnosis until death or end of data collection. Progression-free survival (PFS) and overall survival (OS) from first-line (1L) pembrolizumab and second-line (2L) nivolumab were compared with clinical trial data by calculating hazard ratios (HRs). From 1950 diagnosed patients, 1005 (52%) started with any 1L treatment, of which 83 received pembrolizumab. Nivolumab was started as 2L treatment in 141 patients. For both settings, PFS times were comparable between real-world and trials (HR 1.08 (95% CI 0.75-1.55), and HR 0.91 (95% CI 0.74-1.14), respectively). OS was significantly shorter in real-world for 1L pembrolizumab (HR 1.55; 95% CI 1.07-2.25). Receiving subsequent lines of treatment was less frequent in real-world compared to trials. There is no EE gap for PFS from immunotherapy in patients with stage IV NSCLC. However, there is a gap in OS for 1L pembrolizumab. Fewer patients proceeding to a subsequent line of treatment in real-world could partly explain this.

Conflict of interest statement

EvdG reports research grants from the Dutch Cancer Society during the conduct of the study, and from AbbVie NL outside the submitted work. HG reports a grant from Boehringer-Ingelheim and other from BMS, Roche, Novartis, Merck and Pfizer, outside the submitted work. All remaining authors have declared no conflicts of interest.

Figures

Figure 1
Figure 1
Treatment patterns of patients diagnosed with stage IV NSCLC between 2015 and 2018 in six Dutch hospitals. BSC, best supportive care; TKI, Tyrosine Kinase Inhibitors. *1L immunotherapy: pembrolizumab: n = 83 (90%), nivolumab: n = 3 (3%), other n = 6 (7%). **2L immunotherapy: nivolumab: n = 164 (82%, of which n = 141 with non-squamous histology), pembrolizumab: n = 20 (10%), atezolizumab: n = 13 (6.5%), other: n = 3 (1.5%).
Figure 2
Figure 2
Kaplan–Meier curves of PFS and OS in patients receiving 1L pembrolizumab in real-world and clinical trial.
Figure 3
Figure 3
Kaplan–Meier curves of PFS and OS in patients receiving 2L nivolumab in real-world and clinical trial.

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