Search

Background Immune checkpoint inhibitors (ICIs) targeting the PD‐1/PD‐L1 axis have changed the first‐line treatment of people with advanced non‐small cell lung cancer (NSCLC). Single‐agent pembrolizumab (a PD‐1 inhibitor) is currently the standard of care as monotherapy in patients with PD‐L1 expression ≥ 50%, either alone or in combination with chemotherapy when PD‐L1 expression is less than 50%. Atezolizumab (PD‐L1 inhibitor) has also been approved in combination with chemotherapy and bevacizumab (an anti‐angiogenic antibody) in first‐line NSCLC regardless of PD‐L1 expression. The combination of first‐line PD‐1/PD‐L1 inhibitors with anti‐CTLA‐4 antibodies has also been shown to improve survival compared to platinum‐based chemotherapy in advanced NSCLC, particularly in people with high tumour mutational burden (TMB). The association of ipilimumab (an anti CTLA4) and nivolumab (PD‐1 inhibitor) has been approved by the US Food and Drug Administration (FDA) in all patients with PD‐L1 expression ≥1%. Although these antibodies are currently used in clinical practice, some questions remain unanswered, such as the best‐treatment strategy, the role of different biomarkers for treatment selection and the effectiveness of immunotherapy according to specific clinical characteristics. Objectives To determine the effectiveness and safety of first‐line immune checkpoint inhibitors (ICIs), as monotherapy or in combination, compared to platinum‐based chemotherapy, with or without bevacizumab for people with advanced NSCLC, according to the level of PD‐L1 expression. Search methods We performed an electronic search of the main databases (Cochrane Central Register of Controlled Trials, MEDLINE, Embase) from inception until 31 December 2020 and conferences meetings from 2015 onwards. Selection criteria We included randomised controlled trials (RCTs) reporting on the efficacy or safety of first‐line ICI treatment for adults with advanced NSCLC who had not previously received any anticancer treatment. We included trials comparing single‐ or double‐ICI treatment to standard first‐line therapy (platinum‐based chemotherapy +/‐ bevacizumab). All data come from ‘international multicentre studies involving adults, age 18 or over, with histologically‐confirmed stage IV NSCLC. Data collection and analysis Three review authors independently assessed the search results and a fourth review author resolved any disagreements. Primary outcomes were overall survival (OS) and progression‐free survival (PFS); secondary outcomes were overall objective response rate (ORR) by RECIST v 1.1, grade 3 to 5 treatment‐related adverse events (AEs) (CTCAE v 5.0) and health‐related quality of life (HRQoL). We performed meta‐analyses where appropriate using the random‐effects model for hazard ratios (HRs) or risk ratios (RRs), with 95% confidence intervals (95% CIs), and used the I² statistic to investigate heterogeneity. Main results Main results We identified 15 trials for inclusion, seven completed and eight ongoing trials. We obtained data for 5893 participants from seven trials comparing first‐line single‐ (six trials) or double‐ (two trials) agent ICI with platinum‐based chemotherapy, one trial comparing both first‐line single‐ and double‐agent ICsI with platinum‐based chemotherapy. All trials were at low risk of selection and detection bias, some were classified at high risk of performance, attrition or other source of bias. The overall certainty of evidence according to GRADE ranged from moderate‐to‐low because of risk of bias, inconsistency, or imprecision. The majority of the included trials reported their outcomes by PD‐L1 expressions, with PD‐L1 ≥ 50 being considered the most clinically useful cut‐off level for decision makers. Also, iIn order to avoid overlaps between various PDL‐1 expressions we prioritised the review outcomes according to PD‐L1 ≥ 50. Single‐agent ICI In the PD‐L1 expression ≥ 50% group single‐agent ICI probably improved OS compared to platinum‐based chemotherapy (hazard ratio (HR) 0.68, 95% confidence interval (CI) 0.60 to 0.76, 6 RCTs, 2111 participants, moderate‐certainty evidence). In this group, single‐agent ICI also may improve PFS (HR: 0.68, 95% CI 0.52 to 0.88, 5 RCTs, 1886 participants, low‐certainty evidence) and ORR (risk ratio (RR):1.40, 95% CI 1.12 to 1.75, 4 RCTs, 1672 participants, low‐certainty evidence). HRQoL data were available for only one study including only people with PD‐L1 expression ≥ 50%, which suggested that single‐agent ICI may improve HRQoL at 15 weeks compared to platinum‐based chemotherapy (RR: 1.51, 95% CI 1.08 to 2.10, 1 RCT, 297 participants, low‐certainty evidence). In the included studies, treatment‐related AEs were not reported according to PD‐L1 expression levels. Grade 3‐4 AEs may be less frequent with single‐agent ICI compared to platinum‐based chemotherapy (RR: 0.41, 95% CI 0.33 to 0.50, I² = 62%, 5 RCTs, 3346 participants, low‐certainty evidence). More information about efficacy of single‐agent ICI compared to platinum‐based chemotherapy according to the level of PD‐L1 expression and to TMB status or specific clinical characteristics is available in the full text. Double‐agent ICI Double‐ICI treatment probably prolonged OS compared to platinum‐based chemotherapy in people with PD‐L1 expression ≥50% (HR: 0.72, 95% CI 0.59 to 0.89 2 RCTs, 612 participants, moderate‐certainty evidence). Trials did not report data on HRQoL, PFS and ORR according to PD‐L1 groups. Treatment related AEs were not reported according to PD‐L1 expression levels. The frequency of grade 3‐4 AEs may not differ between double‐ICI treatment and platinum‐based chemotherapy (RR: 0.78, 95% CI 0.55 to 1.09, I² = 81%, 2 RCTs, 1869 participants, low‐certainty evidence). More information about efficacy of double‐agent ICI according to the level of PD‐L1 expression and to TMB status is available in the full text. Authors' conclusions Authors' conclusions The evidence in this review suggests that single‐agent ICI in people with NSCLC and PD‐L1 ≥50% probably leads to a higher overall survival rate and may lead to a higher progression‐free survival and overall response rate when compared to platinum‐based chemotherapy and may also lead to a lower rate of adverse events and higher HRQoL. Combined ICI in people with NSCLC and PD‐L1 ≥50% also probably leads to a higher overall survival rate when compared to platinum‐based chemotherapy, but its effect on progression‐free survival, overall response rate and HRQoL is unknown due to a lack of data. The rate of adverse events may not differ between groups. This review used to be a living review. It is transitioned out of living mode because current research is exploring ICI in association with chemotherapy or other immunotherapeutic drugs versus ICI as single agent rather than platinum based chemotherapy.

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: Primary To determine the efficacy and safety of first‐line immune checkpoint inhibitors, or immuno‐oncology therapy (IO), as monotherapy or in combination for patients with advanced non‐small cell lung cancer (NSCLC). Secondary To maintain the currency of evidence by taking a living systematic review approach.

International audience; Objectives: The economic evaluation (EE) of healthcare interventions has become a necessity. However, high quality needs to be ensured in order to achieve validated results and help making informed decisions. Thus, the objective of the present study was to systematically identify and review published pancreatic ductal adenocarcinoma-related EEs and to assess their quality. Methods: Systematic literature research was conducted in PubMed and Cochrane to identify published EEs between 2000 and 2015. The quality of each selected EE was assessed by two independent reviewers, using the Drummond's checklist. Results: Our systematic review was based on 32 EEs and showed a wide variety of methodo-logical approaches, including different perspectives, time horizon, and cost effectiveness analyses. Nearly two-thirds of EEs are full EEs (n Z 21), and about one-third of EEs had a Drummond score 7, synonymous with 'high quality'. Close to 50% of full EEs had a Drum-mond score 7, whereas all of partial EEs had a Drummond score

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: In patients with advanced NSCLC: to establish clinical effectiveness, in terms of overall survival (OS) and progression free survival and (PFS), of maintenance therapy compared with placebo or observation, which is considered as standard of care; to compare clinical effectiveness, in terms of OS and PFS, of different agents or combinations in the maintenance setting (i.e. chemotherapy vs targeted agent, chemotherapy plus targeted agent vs chemotherapy or targeted agent), and to assess the toxicity of maintenance therapy.

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: In patients with advanced (Stage IIIB and IV) NSCLC with EGFR wild‐type, unknown status of EGFR, or with EGFR activating mutations (Mountain 1997), to assess in terms of OS and PFS the clinical efficacy of third‐line chemotherapy compared to placebo or best supportive care, third‐line targeted therapy compared to placebo or best supportive care, the third‐line combination of chemotherapy and targeted therapy compared to placebo or best supportive care; and to assess the relative efficacy of third‐line chemotherapy compared to targeted therapy.