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Antibiotic treatment is an independent poor risk factor in NSCLC but not in melanoma patients who had received anti-PD-1/L1 monotherapy

Open AccessPublished:January 24, 2023DOI:https://doi.org/10.1016/j.cllc.2023.01.004

      Highlights

      • Recent antibiotic treatment may reduce the efficacy of cancer immunotherapy by disrupting gut microbiome
      • The association of antibiotic treatment and survival outcomes were retrospectively analyzed in melanoma and NSCLC patients who had received anti-PD-1/L1 antibodies
      • Antibiotic treatment was associated with inferior OS in melanoma and with inferior PFS and OS in NSCLC patients
      • Antibiotic treatment was an independent risk factor for inferior OS and PFS in NSCLC but not in melanoma when accounting for other relevant prognostic factors in multivariable analysis

      Abstract

      Background

      Antibiotic treatment may reduce the efficacy of cancer immunotherapy by disrupting gut microbiome. We aimed to study the association of antibiotics and survival outcomes in advanced cutaneous melanoma and NSCLC patients who had received anti-PD-1/L1 monotherapy.

      Patients and methods

      222 melanoma and 199 NSCLC patients had received anti-PD-1/L1 monotherapy in five Finnish hospitals between January 2014 and December 2020. Clinical characteristics, antibiotic and corticosteroid treatment, and survival outcomes were retrospectively collected from hospital and national medical records.

      Results

      32% of melanoma and 31% of NSCLC patients had received antibiotic treatment (ABT) three months before to one month after the first anti-PD-1/L1 antibody infusion. In survival analyses, early antibiotic treatment was associated with inferior OS (ABT 19.2 (17.6−43.7) vs no ABT 29.3 (35.6−NA) months, p=0.033) but not with inferior PFS (ABT 5.8 (3.0−12.6) vs no ABT 10.2 (7.7−15.3) months, p=0.3) in melanoma patients and with inferior OS (ABT 8.6 (6.4−12.3) vs no ABT 18.5 (15.1−21.6) months, p<0.001) and PFS (ABT 2.8 (2.1−4.5) vs no ABT 5.6 (4.4−8.0) months, p=0.0081) in NSCLC patients. In multivariable analyses, ABT was not an independent risk-factor for inferior OS and PFS in melanoma but was associated with inferior OS (HR 2.12 (1.37−3.28)) and PFS (HR 1.65 (1.10−2.47)) in NSCLC after adjusted for other risk factors.

      Conclusions

      Early ABT was an independent poor risk factor in NSCLC patients who had received anti-PD-1/L1 monotherapy but not in melanoma patients. The weight of ABT as a poor risk factor might depend on other prognostic factors in different cancers.

      Micro abstract

      • Recent antibiotic treatment may reduce the efficacy of cancer immunotherapy; •The association of antibiotic treatment and survival outcomes were retrospectively analyzed in melanoma and NSCLC patients who had received anti-PD-1/L1 antibodies; •Antibiotic treatment was an independent risk factor for inferior OS and PFS in NSCLC but not in melanoma when accounting for other relevant prognostic factors in multivariable analysis

      Key Words

      Introduction

      In Europe, anti-PD-1/L1 antibodies have been one of the mainstays of the treatment of advanced cutaneous melanoma and non-small cell lung cancer (NSCLC) since 2015. In melanoma, the median progression-free survival (mPFS) was 5.1 8.4 months, and the median overall survival (mOS) 33 37 months with anti-PD-1 monotherapy outweighing the results of chemotherapy and ipilimumab
      • Assertor PA
      • Long GV
      • Robert C
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      Survival Outcomes in Patients With Previously Untreated BRAF Wild-Type Advanced Melanoma Treated With Nivolumab Therapy: Three-Year Follow-up of a Randomized Phase 3 Trial.
      • Robert C
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      • et al.
      Pembrolizumab versus ipilimumab in advanced melanoma (KEYNOTE-006): post-hoc 5-year results from an open-label, multicentre, randomised, controlled, phase 3 study.
      • Larkin J
      • Chiarion-Sileni V
      • Gonzalez R
      • et al.
      Five-Year Survival with Combined Nivolumab and Ipilimumab in Advanced Melanoma.
      . In NSCLC, anti-PD-1/L1 antibodies were first shown to improve survival in patients previously treated with chemotherapy and later as the first-line treatment of tumors without EGFR mutations and ALK translocations
      • Planchard D
      • Popat S
      • Kerr K
      • et al.
      Metastatic non-small cell lung cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up.
      . The mPFS of 7.7 months, and the mOS of 26.3 months was observed in the first-line treatment of tumors with high PD-L1 expression (≥ 50%)
      • Reck M
      • Rodríguez-Abreu D
      • Robinson AG
      • et al.
      Five-Year Outcomes With Pembrolizumab Versus Chemotherapy for Metastatic Non–Small-Cell Lung Cancer With PD-L1 Tumor Proportion Score ≥ 50%.
      . Anti-PD-1/L1 antibodies have also been successfully combined with chemotherapy to treat tumors with low PD-L1 expression (<50%)
      • Gandhi L
      • Rodríguez-Abreu D
      • Gadgeel S
      • et al.
      Pembrolizumab plus Chemotherapy in Metastatic Non-Small-Cell Lung Cancer.
      • Paz-Ares L
      • Luft A
      • Vicente D
      • et al.
      Pembrolizumab plus Chemotherapy for Squamous Non-Small-Cell Lung Cancer.
      • Socinski MA
      • Jotte RM
      • Cappuzzo F
      • et al.
      Atezolizumab for First-Line Treatment of Metastatic Nonsquamous NSCLC.
      • West H
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      • et al.
      Atezolizumab in combination with carboplatin plus nab-paclitaxel chemotherapy compared with chemotherapy alone as first-line treatment for metastatic non-squamous non-small-cell lung cancer (IMpower130): a multicentre, randomised, open-label, phase 3 trial.
      .
      Gut microbiome has modulated the efficacy of anti-PD-1 antibodies in preclinical models
      • Routy B
      • Le Chatelier E
      • Derosa L
      • et al.
      Gut microbiome influences efficacy of PD-1-based immunotherapy against epithelial tumors.
      . Melanoma patients with high diversity fecal microbiome had longer PFS and certain commensal bacteria (Bifidobacterium longum, Collinsella aerofaciens, and Enterococcus faecium) were associated with better responses to anti-PD-1 therapy
      • Gopalakrishnan V
      • Spencer CN
      • Nezi L
      • et al.
      Gut microbiome modulates response to anti-PD-1 immunotherapy in melanoma patients.
      ,
      • Matson V
      • Fessler J
      • Bao R
      • et al.
      The commensal microbiome is associated with anti-PD-1 efficacy in metastatic melanoma patients.
      . Thus, changes in gut microbiome after exposure to antibiotic treatment (ABT) might mediate the negative effect of ABT on the efficacy of cancer immunotherapy.
      In retrospective studies, early ABT 3 months before to 1 month after the initiation of immune checkpoint inhibitors has been associated with inferior response rates, PFS, and OS in advanced melanoma, NSCLC, and renal cell carcinoma patients
      • Elkrief A
      • El Raichani L
      • Richard C
      • et al.
      Antibiotics are associated with decreased progression-free survival of advanced melanoma patients treated with immune checkpoint inhibitors.
      • Pinato DJ
      • Howlett S
      • Ottaviani D
      • et al.
      Association of Prior Antibiotic Treatment With Survival and Response to Immune Checkpoint Inhibitor Therapy in Patients With Cancer.
      • Mohiuddin JJ
      • Chu B
      • Facciabene A
      • et al.
      Association of Antibiotic Exposure With Survival and Toxicity in Patients With Melanoma Receiving Immunotherapy.
      • Tinsley N
      • Zhou C
      • Tan G
      • et al.
      Cumulative Antibiotic Use Significantly Decreases Efficacy of Checkpoint Inhibitors in Patients with Advanced Cancer.
      • Derosa L
      • Hellmann MD
      • Spaziano M
      • et al.
      Negative association of antibiotics on clinical activity of immune checkpoint inhibitors in patients with advanced renal cell and non-small-cell lung cancer.
      • Ouaknine Krief J
      • Helly de Tauriers P
      • Dumenil C
      • et al.
      Role of antibiotic use, plasma citrulline and blood microbiome in advanced non-small cell lung cancer patients treated with nivolumab.
      whereas concurrent ABT during immunotherapy did not impair treatment outcomes
      • Pinato DJ
      • Howlett S
      • Ottaviani D
      • et al.
      Association of Prior Antibiotic Treatment With Survival and Response to Immune Checkpoint Inhibitor Therapy in Patients With Cancer.
      . ABT was also associated with shorter OS in completely resected stage III melanomas treated with adjuvant immunotherapy
      • Mohiuddin JJ
      • Chu B
      • Facciabene A
      • et al.
      Association of Antibiotic Exposure With Survival and Toxicity in Patients With Melanoma Receiving Immunotherapy.
      . Patients with multiple courses of ABT had shorter PFS and OS compared to patients with single course or without ABT suggesting that the duration and the spectrum of ABT affect the efficacy of immunotherapy
      • Tinsley N
      • Zhou C
      • Tan G
      • et al.
      Cumulative Antibiotic Use Significantly Decreases Efficacy of Checkpoint Inhibitors in Patients with Advanced Cancer.
      .
      Other prognostic factors might confound the effect of ABT on cancer immunotherapy. Shorter PFS and OS were observed in NSCLC patients with tumor PD-L1 expression ≥50% and early ABT but not in patients with PD-L1 expression <50% and early ABT
      • Ochi N
      • Ichihara E
      • Takigawa N
      • et al.
      The effects of antibiotics on the efficacy of immune checkpoint inhibitors in patients with non-small-cell lung cancer differ based on PD-L1 expression.
      . Therefore, it is still controversial if ABT is an independent risk factor or just commonly used among patients with other poor prognostic factors
      • Elkrief A
      • El Raichani L
      • Richard C
      • et al.
      Antibiotics are associated with decreased progression-free survival of advanced melanoma patients treated with immune checkpoint inhibitors.
      • Pinato DJ
      • Howlett S
      • Ottaviani D
      • et al.
      Association of Prior Antibiotic Treatment With Survival and Response to Immune Checkpoint Inhibitor Therapy in Patients With Cancer.
      • Mohiuddin JJ
      • Chu B
      • Facciabene A
      • et al.
      Association of Antibiotic Exposure With Survival and Toxicity in Patients With Melanoma Receiving Immunotherapy.
      • Tinsley N
      • Zhou C
      • Tan G
      • et al.
      Cumulative Antibiotic Use Significantly Decreases Efficacy of Checkpoint Inhibitors in Patients with Advanced Cancer.
      • Derosa L
      • Hellmann MD
      • Spaziano M
      • et al.
      Negative association of antibiotics on clinical activity of immune checkpoint inhibitors in patients with advanced renal cell and non-small-cell lung cancer.
      • Ouaknine Krief J
      • Helly de Tauriers P
      • Dumenil C
      • et al.
      Role of antibiotic use, plasma citrulline and blood microbiome in advanced non-small cell lung cancer patients treated with nivolumab.
      . In this study, we aimed to investigate if ABT is an independent risk factor for inferior outcomes of anti-PD-1/L1 monotherapy in advanced melanoma and NSCLC patients while accounting for other relevant risk factors.

      Material and methods

      This study included patients from four university hospitals (Helsinki, Turku, Tampere, and Kuopio) and one central hospital (Vaasa) covering 85% of the population of Finland. The study investigators reviewed electronic medical records of all patients who had received anti-PD-1 monotherapy for advanced cutaneous or unknown primary melanomas (uveal and mucosal melanomas excluded) at Helsinki, Turku, Tampere, Kuopio, and Vaasa, as well as all advanced NSCLC patients who had received anti-PD-1/L1 monotherapy at Turku, Tampere, Kuopio, and Vaasa between 1st of January 2014 and 31st of December 2020.
      Patient characteristics at the time of the first anti-PD-1/L1 antibody infusion were collected along with the information on radiological response, disease progression, and overall survival. The use of ABT (indication, class, and duration) three months before the initiation and during anti-PD-1/L1 therapy and corticosteroid treatment (oral prednisolone >10mg daily, oral dexamethasone, and intravenous methylprednisolone) during anti-PD-1/L1 therapy were manually obtained from the electronic medical records of each study hospital and from national electronic medical records to cover visits outside hospitals.

      Study objectives

      The primary objective of our study was to analyze the association of ABT with PFS and OS of melanoma and NSCLC patients treated with anti-PD-1/L1 monotherapy. The effect of early ABT (the use of antibiotics within 1−3 months before and after the initiation of immunotherapy) has been most widely studied. Therefore, we decided to determine ABT patients as the group of patients who had received antibiotics three months before to one month after the first anti-PD-1/L1 antibody infusion.

      Statistical analysis

      The results of continuous variables are presented as median (range) and those of categorical variables as numbers and percentages. OS was measured from the first anti-PD-1/L1 antibody infusion to the date of death or the last follow-up visit. PFS was calculated similarly to the date of disease progression, death, or the last follow-up visit. Kaplan-Meier curves were used to illustrate survival analyses of PFS and OS. Kaplan-Meier estimates of OS and PFS are presented with 95% confidence intervals (95% CI) and the log-rank test was used to calculate statistical significance.
      The multivariable Cox regression analysis was performed to study if early ABT is an independent risk factor for inferior PFS and OS after adjusted for other relevant risk factors. Analyses were performed separately for melanoma and NSCLC patients because of differences in relevant prognostic factors and outcomes of cancer immunotherapy. In melanoma, other prognostic factors included sex (male, female), ECOG performance status (0−1, ≥2), age (≥65 years, <65 years), Charlson comorbidity index score, treatment line (first-line, later line), corticosteroid treatment (yes, no), BRAF mutation status (BRAF V600 mutated, no known mutation), lactate dehydrogenase (LDH) level (elevated, normal), and stage according to AJCC 8th edition (M1a, M1b, M1c, M1d). In NSCLC, sex, ECOG performance status, age, Charlson comorbidity index score, smoking status (ever-smoker, never-smoker), treatment line, corticosteroid treatment, histological type (adenocarcinoma, other, squamous cell carcinoma), C-reactive protein (CRP) level (normal, elevated), PD-L1 expression of tumor cells (≥50%, <50%), brain metastases (yes, no), and stage according to AJCC 8th edition (stage III, M1a, M1b, M1c) were included into the multivariable Cox model along with early ABT. While there were missing values in the risk factors, their proportion was assessed to be so small that imputation was not required and effective N in the final multivariable models were the fully observed portions of data.
      All statistical analyses and visualizations were performed with R statistical software (version 4.2.0; R Core Team (2022). R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. URL https://www.R-project.org/).

      Ethical approval statement

      This study was approved by the institutional review boards of Helsinki (license HUS/239/2017), Turku (license T88/2020), Tampere (license R20618F), Kuopio (license 5654213 (TJ 8/2020, RPL 51/2020)), and Vaasa (license VKS – JYL/25/2020) hospitals. Data was anonymized before statistical analyses and handled in a manner that met general regulations on data protection.

      Results

      Patient characteristics

      222 advanced cutaneous melanoma patients and 199 advanced NSCLC patients had been treated with anti-PD-1/L1 monotherapy during 2014−2020 (Table 1). 164 (74%) melanoma patients had received anti-PD-1 antibodies for first-line treatment and 58 (26%) during later treatment lines (Figure 1A). 45 (23%) NSCLC patients had received anti-PD-1/L1 antibodies as first-line treatment and 154 (77%) during later treatment lines (Figure 1B). 38 (84%) first-line patients had PD-L1 ≥50% compared to 76 (49%) later line patients. 71 (32%) melanoma and 61 (31%) NSCLC patients had received early ABT in our study. There was not a statistically significant difference in the exposure to early ABT in different treatment lines in melanoma (early ABT 48 (29%) first-line treatment vs early ABT 23 (40%) later line treatment, chi-squared test p=0.1957) or in NSLCL patients (early ABT 12 (27%) first-line treatment vs early ABT 49 (32%) later line treatment, p=0.6344). In addition, 67 (30%) melanoma and 56 (28%) NSCLC patients had been treated with corticosteroids during anti−PD-1/L1 monotherapy, typically because of immune related adverse events.
      Table 1Clinical characteristics and survival outcomes of advanced melanoma and NSCLC patients.
      VariableMelanoma n=222VariableNSCLC n=199
      Median Age years (min max)65 (24 83)Median Age years (min max)68 (37 81)
      Male131 (59%)Male133 (67%)
      Female91 (41%)Female66 (33%)
      Median Charlson comorbidity index (min max)6 (4 – 13)Median Charlson comorbidity index (min max)9 (6 – 13)
      ECOG 0128 (58%)ECOG 040 (20%)
      ECOG 186 (39%)ECOG 1126 (63%)
      ECOG ≥28 (4%)ECOG ≥233 (17%)
      LDH normal122 (55%)CRP normal80 (40%)
      LDH elevated88 (40%)CRP elevated106 (53%)
      Unknown12 (5%)Unknown13 (7%)
      BRAF V600 positive90 (41%)Targetable mutation11 (6%)
      BRAF V600 negative127 (57%)No mutation or unknown188 (94%)
      Unknown5 (2%)
      M1a59 (27%)Stage III37 (19%)
      M1b55 (25%)M1a66 (33%)
      M1c85 (38%)M1b30 (15%)
      M1d (brain metastases)23 (10%)M1c66 (33%)
      With brain metastases13 (7%)
      Without brain metastases186 (93%)
      Current smoker83 (42%)
      Ex-smoker101 (51%)
      Never-smoker13 (7%)
      Unknown2 (1%)
      PD-L1 high (≥50%)114 (57%)
      PD-L1 low (<50%)51 (26%)
      Unknown34 (17%)
      Adenocarcinoma106 (53%)
      Squamous cell carcinoma83 (42%)
      Other histology9 (5%)
      Unknown1 (1%)
      First-line anti-PD-1164 (74%)First-line anti-PD-1/L145 (23%)
      Later line anti-PD-158 (26%)Later line anti-PD-1/L1154 (77%)
      Corticosteroid treatment67 (30%)Corticosteroid treatment56 (28%)
      No corticosteroids155 (70%)No corticosteroids142 (71%)
      Unknown0 (0%)Unknown1 (1%)
      Early ABT71 (32%)Early ABT61 (31%)
      No ABT151 (68%)No ABT138 (69%)
      Anti-PD-1 therapyAnti-PD-1/L1 therapy
      nivolumab120 (54%)nivolumab61 (31%)
      pembrolizumab100 (45%)pembrolizumab89 (45%)
      nivolumab and pembrolizumab
      nivolumab switched to pembrolizumab or vice versa, PD=disease progression
      2 (1%)atezolizumab46 (23%)
      durvalumab3 (2%)
      Survival outcomesSurvival outcomes
      OS, death observed108 (49%)OS, death observed138 (69%)
      OS, alive111 (50%)OS, alive61 (31%)
      OS status unknown3 (1%)OS status unknown0 (0%)
      PFS, PD or death observed156 (70%)PFS, PD or death observed163 (82%)
      PFS, alive without PD61 (27%)PFS, alive without PD36 (18%)
      PFS status unknown5 (2%)PFS status unknown0 (0%)
      low asterisk nivolumab switched to pembrolizumab or vice versa, PD=disease progression
      Figure 1
      Figure 1Prior and subsequent cancer treatments in melanoma (panel A) and NSLCL patients (panel B) who had received anti-PD-1/L1 monotherapy
      Continuous values are reported as median (min – max) and categorical/ordinal variables as counts (percentages).

      Treatment outcomes

      The median follow-up times (until censoring or death) were 21.9 (first-line treatment) and 17.6 months (later line treatment) in melanoma patients and 17.3 and 14.6 months in NSCLC patients, respectively. Survival outcomes of anti-PD-1/L1 monotherapy were better in advanced melanoma patients compared to NSCLC patients. First-line patients had longer median survival times in comparison with later line patients in both cancers. In melanoma, the mPFS was 10.83 (7.1−15.6) months and the mOS was 31.6 (25.0 −45.0) months with first-line anti-PD-1 monotherapy. The mPFS was 4.77 (2.1−10.3) months and the mOS 23.5 (9.63−NA) months with later line anti-PD-1 monotherapy. In NSCLC, the mPFS was 7.4 (4.87−12.7) months and the mOS was 21.1 (14.8−NA) months with first-line anti-PD-1/L1 monotherapy. The median PFS was 3.9 (2.57−5.5) months and the median OS 14.6 (11.5−17.7) months with later line anti-PD-1/L1 monotherapy.

      Early ABT and treatment outcomes

      In melanoma patients, early ABT was associated with worse OS (mOS early ABT 19.2 (17.6−43.7) vs no ABT 29.3 (35.6−NA) months, hazard ratio (HR) 1.53 (1.03−2.26), log-rank test p=0.033, Figure 2A) but was not associated with worse PFS (mPFS early ABT 5.8 (3.0−12.6) vs no ABT 10.2 (7.7−15.3) months, HR 1.20 (0.85−1.68), p=0.3, Figure 2B). In NSCLC patients, early ABT was associated with worse OS (mOS early ABT 8.6 (6.4−12.3) vs no ABT 18.5 (15.1−21.6) months, HR 1.86 (1.31−2.65), p<0.001, Figure 2C) as well as with worse PFS (mPFS early ABT 2.8 (2.1−4.5) vs no ABT 5.6 (4.4−8.0) months, HR 1.55 (1.12−2.15), p=0.0081, Figure 2D).
      Figure 2
      Figure 2OS and PFS of anti-PD-1/L1 monotherapy by early ABT in melanoma (panels A−B) and NSCLC (panels C−D).
      Early ABT had negative impact on OS and PFS especially in later line anti-PD-1/L1 monotherapy with near borderline statistical significance in melanoma patients (OS p=0.079, Figure 3A and PFS p=0.094, Figure 3B) and highly statistically significant association in NSCLC patients (OS p<0.001, Figure 3C and PFS p=0.013, Figure 3D). There were no differences in OS and PFS according to ABT-use in the subgroup of patients with first-line anti-PD-1/L1 therapy in melanoma and NSCLC. However, there was a statistically significant difference in the OS of patients with early ABT vs no ABT in the subgroup of melanoma patients with later line anti-PD-1 therapy (HR of death 2.09 (1.04−4.18)), Figure 3A). There were statistically significant differences in the OS (HR of death 1.99 (1.35−2.93)) and the PFS (HR of disease progression or death 1.72 (1.19−2.50)) of patients with early ABT vs no ABT in the subgroup of NSCLC patients with later line anti-PD-1/L1 therapy (Figure 3C and D).
      Figure 3
      Figure 3OS and PFS in first-line and later line treatment by early ABT in melanoma (panels A-B) and NSCLC (panels C-D).
      In multivariable Cox regression analysis, early ABT was not an independent risk factor for inferior PFS and OS in melanoma patients after addressing potential confounding factors (Figure 4). Elevated LDH and brain metastases (M1d) were associated with inferior PFS in melanoma. Male sex, corticosteroid treatment during immunotherapy, visceral metastases outside lungs and central nervous system (M1c), and brain metastases (M1d) were associated with inferior OS in melanoma. Impaired performance status (ECOG PS ≥2) was also associated with inferior OS in melanoma with borderline statistical significance.
      Figure 4
      Figure 4Multivariable Cox model for OS (panel A) and PFS (panel B) in melanoma patients.
      Early ABT was an independent risk factor for inferior PFS (HR of PD or death 1.65 (1.10−2.47) and OS (HR of death 2.12 (1.37−3.28) in NSCLC patients in multivariable analysis (Figure 5). Male sex, age ≥65 years, ever-smokers, and corticosteroid treatment during immunotherapy were associated with improved PFS, whereas early ABT brain metastases, stage M1a, and stage M1c were associated with inferior PFS in NSCLC. First-line treatment with anti-PD-1/L1 monotherapy was associated with improved OS, whereas early ABT, elevated CRP, brain metastases, stage M1a, stage M1b, and stage M1c were associated with inferior OS.
      Figure 5
      Figure 5Multivariable Cox model for OS (panel A) and PFS (panel B) in NSCLC patients.

      Discussion

      Anti-PD-1/L1 antibodies belong to the standard treatment of advanced melanoma and NSCLC. However, some tumors are primarily refractory, and some develop acquired resistance against immunotherapy. Gut microbiome interacts with immune system and may also play a role in cancer immunotherapy. Fecal transplants from immunotherapy responders have even induced responses among initially immunotherapy refractory melanoma patients
      • Davar D
      • Dzutsev AK
      • McCulloch JA
      • et al.
      Fecal microbiota transplant overcomes resistance to anti-PD-1 therapy in melanoma patients.
      ,
      • Baruch EN
      • Youngster I
      • Ben-Betzalel G
      • et al.
      Fecal microbiota transplant promotes response in immunotherapy-refractory melanoma patients.
      .
      In previous studies, the use of antibiotics has been associated with inferior benefit from immunotherapy in different advanced cancers
      • Elkrief A
      • El Raichani L
      • Richard C
      • et al.
      Antibiotics are associated with decreased progression-free survival of advanced melanoma patients treated with immune checkpoint inhibitors.
      • Pinato DJ
      • Howlett S
      • Ottaviani D
      • et al.
      Association of Prior Antibiotic Treatment With Survival and Response to Immune Checkpoint Inhibitor Therapy in Patients With Cancer.
      • Mohiuddin JJ
      • Chu B
      • Facciabene A
      • et al.
      Association of Antibiotic Exposure With Survival and Toxicity in Patients With Melanoma Receiving Immunotherapy.
      • Tinsley N
      • Zhou C
      • Tan G
      • et al.
      Cumulative Antibiotic Use Significantly Decreases Efficacy of Checkpoint Inhibitors in Patients with Advanced Cancer.
      • Derosa L
      • Hellmann MD
      • Spaziano M
      • et al.
      Negative association of antibiotics on clinical activity of immune checkpoint inhibitors in patients with advanced renal cell and non-small-cell lung cancer.
      • Ouaknine Krief J
      • Helly de Tauriers P
      • Dumenil C
      • et al.
      Role of antibiotic use, plasma citrulline and blood microbiome in advanced non-small cell lung cancer patients treated with nivolumab.
      and the negative effect is suggested to be mediated by the transformation of gut microbiome
      • Routy B
      • Le Chatelier E
      • Derosa L
      • et al.
      Gut microbiome influences efficacy of PD-1-based immunotherapy against epithelial tumors.
      • Gopalakrishnan V
      • Spencer CN
      • Nezi L
      • et al.
      Gut microbiome modulates response to anti-PD-1 immunotherapy in melanoma patients.
      • Matson V
      • Fessler J
      • Bao R
      • et al.
      The commensal microbiome is associated with anti-PD-1 efficacy in metastatic melanoma patients.
      . ABT is used for cancer patients with symptoms related to bacterial infection, such as fever and elevated CRP, often without verification of bacterial disease. In an Australian study, 56% of the episodes of suspected infections in cancer patients were microbiologically or clinically documented but the remaining 44% had no focus of infection
      • De Silva N
      • Jackson J
      • Steer C
      Infections, resistance patterns and antibiotic use in patients at a regional cancer centre.
      .
      In this study, early ABT was associated with inferior OS in melanoma and with inferior PFS and OS in NSCLC patients who had received anti-PD-1/L1 monotherapy. The negative effect was most pronounced in later treatment lines. Similar proportion (31−32%) of melanoma and NSCLC patients had received ABT within three months before to 1 month after the first anti-PD-1/L1 antibody infusion which is also comparable to the rates of 18.5−39% observed in previous studies
      • Elkrief A
      • El Raichani L
      • Richard C
      • et al.
      Antibiotics are associated with decreased progression-free survival of advanced melanoma patients treated with immune checkpoint inhibitors.
      • Pinato DJ
      • Howlett S
      • Ottaviani D
      • et al.
      Association of Prior Antibiotic Treatment With Survival and Response to Immune Checkpoint Inhibitor Therapy in Patients With Cancer.
      • Mohiuddin JJ
      • Chu B
      • Facciabene A
      • et al.
      Association of Antibiotic Exposure With Survival and Toxicity in Patients With Melanoma Receiving Immunotherapy.
      • Tinsley N
      • Zhou C
      • Tan G
      • et al.
      Cumulative Antibiotic Use Significantly Decreases Efficacy of Checkpoint Inhibitors in Patients with Advanced Cancer.
      • Derosa L
      • Hellmann MD
      • Spaziano M
      • et al.
      Negative association of antibiotics on clinical activity of immune checkpoint inhibitors in patients with advanced renal cell and non-small-cell lung cancer.
      • Ouaknine Krief J
      • Helly de Tauriers P
      • Dumenil C
      • et al.
      Role of antibiotic use, plasma citrulline and blood microbiome in advanced non-small cell lung cancer patients treated with nivolumab.
      . We did not find statistically significant difference in the proportion of patients who had received early ABT in first-line or later line treatment.
      In multivariable Cox model, early ABT was an independent poor risk factor doubling the risk of disease progression and death in NSCLC patients when accounting for relevant prognostic factors. However, early ABT was not significantly associated with inferior OS and PFS in melanoma patients in multivariable analysis. This suggests that the weight of ABT as a poor risk factor might be confounded by other prognostic factors and the effect of ABT on immunotherapy might be different across different cancers and treatment lines. In the first-line treatment of NSCLC patients, the effect of ABT has depended on PD-L1 expression levels
      • Ochi N
      • Ichihara E
      • Takigawa N
      • et al.
      The effects of antibiotics on the efficacy of immune checkpoint inhibitors in patients with non-small-cell lung cancer differ based on PD-L1 expression.
      . In this study, PD-L1 expression levels were not associated with PFS and OS in multivariable analysis which could have been explained by the larger proportion of later line patients. In addition to early ABT, brain metastases and more advanced stage were poor risk factors in NSCLC. In melanoma patients, other prognostic factors such as male sex, elevated LDH, more advanced stage, and corticosteroid treatment seemed to be more relevant poor risk factors than early ABT according to our findings.
      The limitations of this study are attributed to the retrospective collection of study data. Study patients were treated within routine clinical practice. Therefore, response evaluation with thoracic and abdominal CT was performed according to local follow-up guidelines which could have affected PFS results. The use of anti-PD-1/L1 antibodies was comprehensively obtained from hospital medical records as well as the use of corticosteroid and antibiotic treatment in each study hospital. Antibiotics prescribed outside hospital visits were manually searched from national electronic medical records. Therefore, we might have missed some prescriptions. The use of anti-PD-1/L1 antibodies reflects the clinical practice during the study period from 2014 to 2020 and differ greatly between melanoma and NSCLC. There has been a shift towards earlier use of immunotherapy as well as towards the use of combination therapies instead of anti-PD-1/L1 monotherapy. At this stage, we did not evaluate the duration of ABT and the use of broad-spectrum antibiotics as risk factors, and this will be the target of our further analyses. Because of the lack of fecal and blood samples during immunotherapy from our patients, the direct effect of ABT on patients` gut microbiome and immune cells was not possible to analyze. Prospective evaluation of fecal and blood samples during cancer immunotherapy will shed light on this question.

      Conclusions

      There are lots of intertwined risk factors affecting outcomes of cancer immunotherapy. According to this study, early ABT was an independent risk factor for inferior PFS and OS in NSCLC patients who had received anti-PD-1/L1 monotherapy but not in melanoma patients. The use of antibiotics should be weighed against potential negative impact on cancer immunotherapy and patients who have recently received ABT may need more than anti-PD-1/L1 monotherapy for cancer treatment.

      Clinical Practice Points

      Recent antibiotic treatment (ABT) has been shown reduce the efficacy of cancer immunotherapy in different cancer types including melanoma, non-small cell lung cancer (NSCLC), and kidney cancer. The negative effect of ABT on treatment results is suggested to be mediated by detrimental changes in gut microbiome. There is still a controversy if ABT is an independent poor risk factor or commonly used among patients with other poor risk factors.
      In this study, the association of ABT and survival outcomes were retrospectively analyzed in melanoma and NSCLC patients who had received anti-PD-1/L1 antibodies. Early ABT 3 months before to 1 months after the first anti-PD-1/L1 antibody infusion was an independent poor risk factor doubling the risk of disease progression and death in NSCLC patients irrespective of other prognostic factors including performance and smoking status, histological type, PD-L1 expression, and CRP levels. However, early ABT was not associated with inferior OS and PFS in melanoma patients while accounting for age, sex, performance status, LDH levels, and BRAF mutation status. This suggests that the weight of ABT as a poor risk factor might be confounded by other risk factors in different cancer types.
      The current study adds evidence that ABT is a poor prognostic factor in NSCLC patients who are eligible for immunotherapy. The use of antibiotics should be weighed against potential negative impact on cancer immunotherapy and patients who have recently received ABT may need more than anti-PD-1/L1 monotherapy for cancer treatment.

      Data availability

      Data is available upon reasonable request from the corresponding author

      Author contributions

      HV, AJ, and KEM had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: KEM. Acquisition of data: HV, AJ, KEM, NW, LP, TK, AR, LT, TS, LK, SK, HK, MH. Analysis and interpretation of data: TDL, HV, AJ, KEM. Drafting of the manuscript HV, AJ, TDL, NW, LP, TK, AR, LT, TS, LK, SK, HK, MH, MS, KEM. Statistical analysis: TDL, HV, AJ, KEM. Obtaining funding: KEM. Supervision: KEM, LT, TS, MH.

      Funding

      HV, AJ and HK report grants from the Finnish Melanoma Group
      TDL was funded by the Finnish Cancer Institute as FICAN Cancer Researcher
      KEM reports grants from the Finnish Melanoma Group and the Cancer Society of South-West Finland

      Conflicts of interest statement

      TK has received consulting or advisory honoraria from Eli Lilly, Bristol-Myers Squibb, Merck, Novartis and Daiichi Sankyo; LT has received consulting or advisory honoraria from Amgen, Bristol-Myers Squibb, Merck, Novartis, Pierre-Fabre, Pfizer, Roche, and Sanofi ; TS has received consulting or advisory honoraria from Astra Zeneca, Merck, Bristol-Myers Squibb, and Faron ; ST has received advisory board honoraria from Novartis and speaker honoraria from Finnish Melanoma group, society of Finnish outpatient clinic nurses, society of Finnish cancer nurses, and Bristol-Myers Squibb; MH has received consulting or advisory honoraria from Merck, Bristol-Myers Squibb, Incite, Varian, Novartis, and Roche; speakers’ bureau honoraria from Merck, Novartis, and Bristol-Myers Squibb; MS has received consulting or advisory honoraria from MSD, Bristol-Myers Squibb, Takeda, Roche, AstraZeneca, Amgen, Novartis, Merck, and Janssen ; KEM has received consulting or advisory honoraria from Astellas, Bayer, Bristol-Myers Squibb, GlaxoSmithKline, Ipsen, Janssen, Merck Sharp & Dohme, Merck−Pfizer alliance, Novartis, Roche, and Sanofi; HV, AJ, TDL, NW, LP, TK, AR, HK have no conflicts of interest to declare

      Acknowledgements

      We thank Elisa Koskelainen who helped to collect data from melanoma patients at Helsinki University Hospital.

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