Abstract
Background
Evidence about the comparative effectiveness of chemoimmunotherapy vs. immunotherapy
alone in patients with advanced non–small cell lung cancer (aNSCLC) and high PD-L1
expression (≥50%) or very high PD-L1 expression (≥90%) is limited because of the lack
of head-to-head clinical trials.
Objective
To compare survival in aNSCLC patients receiving first-line chemoimmunotherapy vs.
immunotherapy in both the PD-L1 expression ≥50% or ≥90% subgroups, accounting for
potential confounders that may influence physician decision-making.
Methods
This cohort study used a nationwide electronic health record derived database to identify
newly diagnosed cases of aNSCLC patients with PD-L1 expression of ≥50% who initiated
first-line systemic therapy between October 2016 and October 2021.
The exposure of interest was first-line therapy with chemoimmunotherapy or immunotherapy
among patients with PD-L1 expression ≥50% or ≥90%.
Survival was assessed using Kaplan-Meier curves and Cox regression. Propensity score-based
inverse probability of weighting (IPW) was used to control for confounding. Because
of nonproportionality of hazards, we estimated hazard ratios over the first 6 months
and after 6 months for the overall cohort, and over the first 12 months and after
12 months for a subgroup of persons with a PD-L1 expression ≥90%.
Results
We identified 3086 subjects who met inclusion criteria, of whom 32% received chemoimmunotherapy
and 68% received immunotherapy alone. Chemoimmunotherapy was associated with no survival
advantage vs. immunotherapy alone during the entire follow-up period (IPW-adjusted
Hazard Ratio [aHR] 0.98, 95% CI, 0.86-1.12), but was associated with a survival benefit
during the first 6 months (aHR 0.74, 95% CI, 0.61-0.90). Similarly, in the subgroup
of patients with a PD-L1 expression ≥90%, chemoimmunotherapy was associated with no
overall survival advantage during the entire follow-up period (aHR 0.99, 95% CI, 0.87-1.22),
but was associated with a survival benefit during the first 12 months (aHR 0.74, 95%
CI, 0.57-0.97).
Conclusion
Chemoimmunotherapy was not associated with an overall benefit over immunotherapy alone,
although was associated with an early survival advantage in both the overall cohort
and the subgroup of patients with a PD-L1 expression ≥90%. Future studies should focus
on identifying the characteristics of higher risk patients that may benefit from the
addition of chemotherapy.
Keywords
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Article info
Publication history
Published online: February 28, 2023
Accepted:
February 16,
2023
Received in revised form:
February 16,
2023
Received:
November 24,
2022
Publication stage
In Press Journal Pre-ProofIdentification
Copyright
© 2023 Elsevier Inc. All rights reserved.
