Advanced gastroesophageal junction and gastric carcinoma: front-line Pembrolizumab is promising alternative to chemotherapy
The KEYNOTE-062 phase III randomized clinical trial has achieved its primary endpoint, showing that for patients with PD-L1-positive, HER2-negative, advanced gastric or gastroesophageal junction ( G/GEJ ) cancer, initial therapy with Pembrolizumab ( Keytruda ) resulted in comparable ( non-inferior ) overall survival as standard chemotherapy.
Additionally, Pembrolizumab showed clinically meaningful improvement in overall survival among patients with tumors that had high levels of PD-L1 expression.
At two years, 39% of patients ( all of whom had high PD-L1 levels ) that received Pembrolizumab alone were alive, compared with 22% of people who received standard chemotherapy.
The trial also evaluated combined treatment with Pembrolizumab and standard chemotherapy but found this regimen did not improve survival relative to chemotherapy alone.
Approximately 27,510 new gastric cancers and 11,140 deaths from the disease are expected to occur in the United States in 2019. It is the fifth most frequently diagnosed cancer worldwide.
Gastroesophageal junction carcinoma, a less common cancer, has seen increasing incidence rates during this decade, particularly in Western nations but the reasons for this increase are not entirely clear.
The trial enrolled 763 patients with a median age of 62 and 26% had previous gastric surgery to remove a tumor.
In total, 69% had gastric cancer and 30% had gastroesophageal junction cancer, which are typically very similar types of tumors despite their adjacent locations.
Investigators focused only on HER2-negative cancers, which studies have shown have a higher chance of recurrence after treatment, to limit factors that could affect outcomes.
PD-L1 expression was assessed via CPS ( Combined Positive Score ). Previous studies of gastric or gastroesophageal junction cancers have demonstrated that patients with a PD-L1 CPS of one or more may benefit from Pembrolizumab, while a PD-L1 CPS of 10 or more indicates a higher likelihood of benefit.
In the current trial, all patients had a PD-L1 CPS of one or greater, and 281 ( 37% of the enrollees ) had a score of 10 or more.
Patients were randomly assigned, in equal numbers, to receive one of three treatment options as initial therapy: intravenous Pembrolizumab, Pembrolizumab and chemotherapy, or chemotherapy plus placebo.
The patients were followed for a median of 11.3 months.
Treatment with Pembrolizumab Alone: The trial reached its primary endpoint, demonstrating that overall survival for Pembrolizumab was non-inferior ( comparable ) to standard chemotherapy. A favorable survival outcome was seen among enrolled patients with PD-L1 CPS of 10 or more.
Specific findings include: A) Patients with PD-L1 CPS of one or more: Survival was non-inferior to chemotherapy [ hazard ratio, HR = 0.91] -- median overall survival was 10.6 months for those receiving Pembrolizumab compared with 11.1 months for those who received chemotherapy; B) Patients with PD-L1 CPS 10 or more: Survival with Pembrolizumab was superior to chemotherapy [ HR= 0.69 ] -- median overall survival was 17.4 months for those receiving Pembrolizumab compared with 10.8 months for those receiving chemotherapy. After 2 years, 39% of people taking pembrolizumab were alive compared with 22% of those taking chemotherapy.
Treatment with Pembrolizumab and Chemotherapy : Overall survival and progression-free survival ( time until disease progression ), regardless of CPS score, for the combination treatment of Pembrolizumab and chemotherapy was comparable to that of chemotherapy alone.
The rates of serious side effects were lowest among patients treated with Pembrolizumab alone. Grade 3 or higher toxic treatment-related adverse events were found in 17% of people receiving Pembrolizumab, 73% of people receiving Pembrolizumab and chemotherapy, and 69% receiving only chemotherapy.
The most common adverse events were nausea and fatigue.
The safety profile of Pembrolizumab was consistent with prior experiences of patients who have been treated with it.
The trial enrolled 58% of patients from North America, Europe, and Australia; 25% from Asia; and 17% from other regions of the world.
Prior population-based studies have shown that people from Asia usually have better survival rates for gastric and gastroesophageal junction cancers, have lower amounts of tumor, and slower disease progression. ( Xagena )
Source: American Society of Clinical Oncology ( ASCO ) Annual Meeting, 2019