# Comparative Efficacy and Safety of First-Line Immune Checkpoint Inhibitors Plus Chemotherapy with or Without Bevacizumab in Advanced Non-Squamous Non-Small Cell Lung Carcinoma

## TL;DR

Adding bevacizumab to immunotherapy and chemotherapy improves progression-free survival in lung cancer but increases toxicity without improving overall survival.

## Contribution

This study clarifies the role of bevacizumab in modern chemoimmunotherapy for non-squamous lung cancer through real-world data and network meta-analysis.

## Key findings

- Bevacizumab added to chemoimmunotherapy improved progression-free survival but not overall survival.
- Higher toxicity was observed with the addition of bevacizumab, including more severe adverse events and treatment discontinuations.
- No patient subgroup clearly benefited from bevacizumab without increased risks.

## Abstract

For patients with advanced non-squamous non-small cell lung cancer lacking EGFR or ALK mutations, initial treatment typically involves a combination of chemotherapy and immunotherapy. While adding the anti-angiogenic drug bevacizumab to chemotherapy has previously shown benefit, its role when combined with modern chemoimmunotherapy was uncertain. This study found that incorporating bevacizumab into first-line chemoimmunotherapy significantly improved progression-free survival, especially for patients with high-risk features. However, this was accompanied by significantly increased treatment-related toxicities and no overall survival benefit. Consequently, our data identified no clinical subgroup where the benefit clearly outweighs these risks, necessitating extreme caution in its clinical application.

Background: First-line chemoimmunotherapy (I + C) is the standard of care for advanced non-squamous non-small cell lung cancer (NSCLC) without oncogenic mutation. Bevacizumab has been shown to enhance the efficacy of chemotherapy in non-squamous NSCLC, yet its added value when combined with I + C (I + C + B) remains unclear. To address this gap, we conducted a real-world comparative study and a network meta-analysis to evaluate I + C + B versus I + C in this setting. Methods: This retrospective study included patients with advanced EGFR/ALK-negative non-squamous NSCLC treated with first-line I + C + B or I + C. Propensity score matching (PSM) was employed to balance baseline characteristics between groups. Efficacy endpoints were progression-free survival (PFS) and overall survival (OS). Subgroup analyses examined outcomes by PD-L1 expression, age, metastases, and chemotherapy, among other factors. In parallel, a network meta-analysis of four randomized trials (n = 2026) indirectly compared I + C + B against I + C for PFS, OS, and safety outcomes. Results: A total of 277 patients were included, with 167 (60.3%) receiving I + C + B and 110 (39.7%) receiving I + C. Before PSM, the I + C + B regimen significantly prolonged PFS versus I + C (hazard ratio [HR] = 0.69, 95% CI 0.52–0.92, p = 0.010), with this benefit maintaining post-matching (HR = 0.70, 95% CI 0.49–0.99, p = 0.045). However, OS did not differ significantly between groups in either the pre-PSM (HR = 0.93, 95% CI: 0.67–1.30; p = 0.665) or matched analyses (HR = 0.84, 95% CI: 0.54–1.29; p = 0.421). Subgroup analyses suggested greater PFS benefit from I + C + B among PD-L1-negative, older patients, those with brain metastases or multiple metastatic sites, and in patients receiving specific chemotherapy doublets. The network meta-analysis confirmed a PFS advantage for I + C + B over I + C (HR = 0.84, 95% CI: 0.71–0.98) without an OS benefit (HR = 0.95, 95% CI: 0.79–1.14). Toxicity was higher with I + C + B; rates of grade 3–5 adverse events, serious adverse events, and treatment discontinuation were all significantly increased compared to I + C. Conclusions: In the first-line treatment of advanced EGFR/ALK-negative non-squamous NSCLC, adding bevacizumab to I + C improved PFS but did not translate into an OS gain. Although PFS benefits were observed in certain subgroups, these were accompanied by significantly increased treatment-related toxicities. Our findings suggest that no clear subgroup has been identified where the benefit outweighs the risks, necessitating extreme clinical caution.