Pembrolizumab versus Pembrolizumab plus Chemotherapy in Non-small Cell Lung Cancer with High PD-L1 Expression - Multicenter Real-world Evidence Study

TL;DR

This study compares pembrolizumab alone versus pembrolizumab plus chemotherapy in non-small cell lung cancer patients with high PD-L1 expression, finding higher response rates but no overall survival benefit with the combination.

Contribution

Provides real-world evidence from Central Europe on pembrolizumab-based treatment outcomes in PD-L1 high NSCLC patients.

Findings

Combination pembrolizumab plus chemotherapy showed significantly higher response rates compared to pembrolizumab alone.

No significant improvement in progression-free survival or overall survival was observed with the combination treatment after patient matching.

Performance status was a key factor influencing survival outcomes in the Cox model.

Abstract

Background: Patients with non-small cell lung cancer (NSCLC) with PD-L1 expression ≥ 50% can be treated with immunotherapy alone or with a combination of immunotherapy and chemotherapy. One of these options is treatment with pembrolizumab (P) with/without chemotherapy (CHT). Meta-analyses from randomized trials suggest a beneficial effect on response rate (RR) or progression free survival (PFS) when using the combination treatment P + CHT compared to P alone, but not on improving overall survival (OS). However, data from real-world clinical practice are insufficient especially in European patients. Regional differences, e.g. in the representation of KRAS mutations between Asian and European patients, could theoretically influence potential differences between P + CHT and P. Therefore, the aim of this study was to compare P + CHT versus P alone in real clinical practice in patients from Central Europe.

Methods: Retrospective data from 8 comprehensive oncology centres in Central Europe were used. All patients with PD-L1 expression ≥ 50% with stage IV NSCLC treated with pembrolizumab in daily practice to June 2024 were included and their data statistically analysed.

Results: In the whole group 793 patients was included in the study - 706 treated with P and 87 with P+ CHT. In this unadjusted sample, we observed significantly higher RR (p <0.0001) and OS (p = 0.044) for the P + CHT group vs. P. For significant differences in both groups, where performance status in particular played a role in survival in the Cox model, we subsequently performed patient matching 2 (P+CHT):1 (P) from the whole group of patients. After this patient matching, we continued to observe a significant difference in RR (p = 0.005), but no longer in OS (p = 0.103). The PFS was not significantly different in both cases (p= 0.174 for unadjusted patients resp. p = 0.342 for matching groups).

Conclusions: P+CHT leads to a significantly higher RR compared to P and can therefore be considered in patients with a more certain treatment response goal (e.g., bulky symptomatic tumor), however, this advantage does not translate into PFS and OS benefit.

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