How Low Can You Go? Impact of Baseline Corticosteroid Use on Immunotherapy Outcomes in Patients With Advanced Non-Small-Cell Lung Cancer

This JCO Podcast provides observations and commentary on the JCO article, "Impact of Baseline Steroids on Efficacy of PD-(L)1 Blockade in Patients With NSCLC" by Arbour et al. My name is Deepa Rangachari, and I am an Assistant Professor of Medicine at the Beth Israel Deaconess Medical Center and Harvard Medical School in Boston, Massachusetts, USA. My oncologic specialty is thoracic cancers.

For decades, the management of advanced non-small-cell lung cancer has relied on use of cytotoxic chemotherapies with a median overall survival not exceeding one year. As this longstanding therapeutic approach has been limited by modest efficacy, finite durability, and significant treatment-associated toxicity, evolving better tailored, more effective, and less toxic care strategies has long been an unmet need. Beginning in the mid-2000s with the identification of actionable oncogenic driver mutations in the epidermal growth factor receptor, the landscape for personalized care in advanced non-small-cell lung cancer has been permanently transformed. Today, the evidence-based standard of care for upfront therapeutic stratification in all patients with advanced stage disease relies on mandatory genomic and immunologic profiling, with emphasis on identifying subsets of patients who will experience better outcomes and less toxicity through the use of disease-specific therapies.

It is in this landscape that the use of immune checkpoint inhibitors has flourished for patients with lung cancer. Since 2015, 3 different immune checkpoint inhibitors—Nivolumab, Pembrolizumab, and Atezolizumab—have all gained approval from regulatory agencies for management of patients with advanced stage non-small-cell lung cancer on the basis of phase III studies showing improved overall survival with more durable responses, less toxicity, and better quality of life with checkpoint inhibitors when compared with chemotherapy.[1-5] This benefit has been seen in both previously treated patients regardless of tumor programmed death ligand 1 (hereafter referred to simply as “PD-L1”) status and in upfront management of patients with high tumor PD-L1, defined by a tumor proportion score >/= 50%. Combined chemoimmunotherapy for patients with non-squamous disease regardless of tumor PD-L1 status is also now a vetted approach.[6]

With widespread use of immune checkpoint inhibitors now the standard of care for many patients with this disease, important pragmatic concerns regarding concurrent use of checkpoint inhibitors and corticosteroids have emerged. Specifically, as many patients will present with refractory anorexia, nausea, fatigue, pain, brain metastases, and/or dyspnea for which corticosteroids are often used as helpful adjuncts to cancer-directed therapy for symptomatic palliation, what if any are the consequences of concurrent use? How do we balance these symptomatic issues against the need for delivering effective cancer therapy?

Due to concerns for the immunomodulatory effects of corticosteroids on T-cell activity and function, nearly all clinical trials leading to approval of these agents have excluded patients requiring the equivalent of Prednisone 10-20mg daily or more prior to initiation of checkpoint inhibitor therapy. In contrast, there is now an emerging body of evidence suggesting the safety of subsequent corticosteroid use, once checkpoint inhibitors have been started, for management of immune-related adverse events , without jeopardizing any previously achieved therapeutic benefit.[7, 8]

But what about those patients being newly initiated on checkpoint inhibitors who have been previously maintained on palliative corticosteroids?

In the article that accompanies this podcast, Arbour and colleagues present important insights into this question. This is a retrospective analysis of 640 patients with advanced non-small-cell lung cancer with immunotherapy-naïve disease treated with checkpoint inhibitors at the Memorial Sloan Kettering and Goustave Roussy Cancer Centers from 2011-2017. Data regarding steroid dose, mode of administration, and indications for use were collected along with efficacy of checkpoint inhibitors as assessed by an independent team of radiologists using the Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1. At the time of checkpoint inhibitor initiation, 90/640 (14%) of patients were receiving the equivalent of Prednisone 10mg/day or more; an additional 17 patients (or 3% of the total study population) were receiving /= 10mg/day was associated with statistically significant reductions in objective response rates (6% vs. 19%), median progression free survival (1.9 vs. 2.6 months), and median overall survival (5.4 vs. 12.1 months) in the steroid vs. no steroid groups, respectively. Similar findings were seen in the Gustave Roussy cohort. Pooled data from both coh...