Lv et al. Journal for ImmunoTherapy of Cancer (2019) 7:159 https://doi.org/10.1186/s40425-019-0636-7 COMMENTARY Open Access Comparative safety and efficacy of anti-PD- 1 monotherapy, chemotherapy alone, and their combination therapy in advanced nasopharyngeal carcinoma: findings from recent advances in landmark trials Jia-Wei Lv1†, Jun-Yan Li1†, Lin-Na Luo2†, Zi-Xian Wang2* and Yu-Pei Chen1* Abstract Recent phase 1–2 trials reported manageable safety profiles and promising antitumor activities of anti-PD-1 drugs (pembrolizumab, nivolumab, camrelizumab and JS001) with/without chemotherapy in recurrent/metastatic nasopharyngeal carcinoma (RM-NPC), however head-to-head comparison among these regimens is lacking. We aimed to comprehensively compare the efficacy and safety of different anti-PD-1 drugs, standard chemotherapy, and their combination therapy in RM-NPC. Adverse event (AE) and objective response rate (ORR) were assessed. The pooled incidence rates of grade 1–5/3–5 AEs were 74.1%/29.6, 54.2%/17.4, 92.3%/24.5, 96.8%/16.1, 91.2%/42.8, and 100%/87.9% for pembrolizumab, nivolumab, JS001, camrelizumab, chemotherapy and camrelizumab+chemotherapy, respectively, which suggested that nivolumab and pembrolizumab exhibited the optimal safety regarding grade 1–5 AEs whereas camrelizumab and nivolumab regarding grade 3–5 AEs. As second- or later-line therapy, ORR was higher with camrelizumab (34.1%), followed by pembrolizumab (26.3%), JS001 (23.3%), and nivolumab (19.0%); whereas ORR with first-line nivolumab reached 40%. Additionally, first-line camrelizumab+chemotherapy achieved a dramatically higher ORR than that with chemotherapy alone (90.9% vs. 64.1%). Pooled ORR was 28.4 and 17.4% for PD-L1–positive and PD-L1–negative patients, respectively (P = 0.11). Here, we represent preliminary evidence for the comparative safety and efficacy of existing anti-PD-1 agents with/ without chemotherapy in RM-NPC, which indicated that camrelizumab has the least toxicity profile and merits future investigation. Our findings might provide insights into the future design of immunotherapy trials in RM-NPC. Keywords: Nasopharyngeal carcinoma, Anti-PD-1, Chemotherapy, Combination therapy, Safety profiles, Efficacy, Predictive biomarker * Correspondence: [email protected]; [email protected] †Jia-Wei Lv, Jun-Yan Li and Lin-Na Luo contributed equally to this work. 2Department of Medical Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, People’s Republic of China 1Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, 651 Dongfeng Road East, Guangzhou 510060, People’s Republic of China © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Lv et al. Journal for ImmunoTherapy of Cancer (2019) 7:159 Page 2 of 9 Background different regimens were evaluated by the odds ratio (OR) Nasopharyngeal carcinoma (NPC) is one of the most and corresponding 95% confidence interval (CI) using common head and neck cancers in Southeast Asia and Fisher’s exact test. OR > 1 stands for fewer AEs. When AE North Africa. The age-standardized incidence ranges rate in any comparative arm equaled 100% or 0%, the from 20 to 50 per 100,000 males in southern China to Haldane-Anscombe correction was adopted to evaluate 0.5 per 100,000 in white populations [1]. Recently, the OR and its 95% CI [10]. Given that ORR of PD-1 blockade first phase 3 trial in recurrent or metastatic NPC (RM- may differ according to treatment lines (first-line vs. >1st NPC), the landmark GEM20110714 study, has estab- line), we also evaluated the anti-PD-1 drugs per treatment lished gemcitabine plus cisplatin (GP) regimen as the setting and considered them as independent comparative standard first-line treatment [2]. However, no consensus groups when data was available. Given the evidence that has been reached beyond the first-line setting, in which high PD-L1 expression tended to be associated with favor- the prognosis is extremely poor. able responses to PD-1 blockade in NPC [6], we further Endemic NPC is etiologically associated with Epstein- evaluated the pooled ORR of anti-PD-1 therapies stratified Barr virus infection. This virus-associated cancer by PD-L1 positivity. Statistical analyses were performed represents the archetypal “inflamed tumor,” which using R version 3.5.1 (http://www.r-project.org). A two- exhibits a dense lymphocytic infiltrate and increased tailed P < 0.05 was considered statistically significant. programmed death-ligand 1 (PD-L1) expression [3, 4]. These features make immunotherapy a promising treat- Results ment option for NPC patients. Recently in 2017, the Safety profile of different regimens landmark KEYNOTE-028 trial firstly reported promising Table 1 summarizes the characteristics of included trials. antitumor activities and safety profiles of pembrolizumab The median sample size for anti-PD-1 monotherapy was in previously treated RM-NPC [5]. Subsequently, five 45 (range, 24–143), sample sizes for combination ther- additional phase 1–2 trials evaluating anti-PD-1 anti- apy and GP chemotherapy were 23 and 181, respectively. bodies in RM-NPC were reported [6–9]. The NCI-9742 Four of the seven (57.1%) trials investigated anti-PD-1 [6] and CheckMate-385 [7] trials demonstrated a man- therapy in pretreated RM-NPC, 2/7(28.5%) trials investi- ageable safety profile and clinical activity of nivolumab gated treatment-naive RM-NPC, while one trial (Check- in multiply pretreated and/or treatment-naive RM-NPC Mate-385) investigated patients receiving ≤2 prior patients. Fang and colleagues [8] reported that camreli- systemic therapies. Figure 1 shows the comparison of zumab monotherapy was a well-tolerated and potentially safety profiles of anti-PD-1 monotherapy, chemotherapy effective treatment option for previously treated RM- alone, and their combination. The pooled incidence rates NPC. They further reported that the combination of cam- of grade 1–5/3–5 AEs were 74.1%/29.6, 54.2%/17.4, relizumab plus chemotherapy of GP regimen has a man- 92.3%/24.5, 96.8%/16.1, 91.2%/42.8, and 100%/87.9% for ageable toxicity profile and promising preliminary pembrolizumab, nivolumab, JS001, camrelizumab, antitumor activity in treatment-naive RM-NPC [8]. chemotherapy, and camrelizumab+chemotherapy, re- Another latest trial, the JS001 study, reported in the Euro- spectively (Fig. 1a). The incidence rate of grade 1–5 AEs pean Society for Medical Oncology (ESMO) 2018 confer- was lowest with nivolumab monotherapy, while grade ence demonstrated the clinical activity of JS001 in 3–5 AEs was lowest with single-agent camrelizumab. multiply pretreated RM-NPC [9]. However, to date there Treatment-related deaths were reported in patients re- is no head-to-head comparison of different anti-PD-1 ceiving pembrolizumab (sepsis, n = 1) and nivolumab drugs, standard first-line GP chemotherapy, and their (pulmonary tuberculosis, n = 1) (Fig. 1a). Treatment dis- combination therapy in RM-NPC. Therefore, we initiated continuation due to AEs was most commonly recorded this study to comprehensively compare the safety and effi- in pembrolizumab (18.5%), followed by camrelizumab+- cacy of the abovementioned trials, and explore the optimal chemotheray (13.0%) and JS001 (9.8%), while lowest in therapeutic regimens of anti-PD-1 approach in RM-NPC. camrelizumab (2.2%) (Fig. 1a). Fisher’s exact test indi- We hypothesized that the efficacy and safety profiles cated a noticeably lower risk of grade 1–5 AEs favoring differed across different anti-PD-1-based regimens. nivolumab and pembrolizumab over other regimens, while nivolumab and camrelizumab demonstrated super- Methods ior safety ranking to other regimens for grade 3–5 AEs The abovementioned anti-PD-1 trials were included in the (Fig. 1b). Generally, risks of grade 1–5 and 3–5 AEs of analysis with GP arm from GEM20110714 trial as chemo- anti-PD-1 agents were lower than those of chemother- therapy control [2]. The major assessed outcomes were apy alone, while their combination therapy shared the adverse event (AE) and objective response rate (ORR). AE highest incidence of grade 1–5 and 3–5 AEs (Fig. 1b). and ORR data were pooled up per regimen and described To profile the toxicity spectra of different regimens, in percentage. The comparative incidences of AE between we further evaluated the incidence of immune-related Lv Table 1 Summary of trial- and patient-level characteristics and clinical endpoints of included trials et al. Journal for ImmunoTherapy of Cancer Items KEYNOTE-028 NCI-9742 CheckMate-358 JS001 SHR-1210 (monotherapy) GEM20110714a SHR-1210 (combination) Trial-level characteristics Region Taiwan International- International- Mainland China Mainland China Mainland China Mainland China collaborated collaborated