Lei Deng, MD
Assistant Professor/Medical Oncologist
Thoracic, Head & Neck Medical Oncology
University of Washington/Fred Hutchinson Cancer Center
For early-stage resectable non-small cell lung cancer without EGFR/ALK alterations, current FDA approved options include 1) adjuvant pembrolizumab (PEARLS/KEYNOTE-091) and atezolizumab (Impower010) followed by adjuvant chemotherapy; 2) neoadjuvant nivolumab plus chemotherapy (CheckMate-816); and very recently perioperative pembrolizumab (KEYNOTE-671), which was just approved by US FDA on October 16, 20231-4. However, the details of the survival results remain unknown.
The updated overall survival of KEYNOTE-671 was presented at 2023 ESMO congress in Madrid, Spain (Abstract Number: LBA56). This randomized, double-blinded trial enrolled 797 patients with resectable stage II, IIIA and IIIB (T3-4N2, AJCC 8). Patients were randomized to neoadjuvant pembrolizumab plus chemotherapy for 4 cycles followed by adjuvant pembrolizumab for up to 13 cycles versus neoadjuvant placebo plus chemotherapy for 4 cycles followed by placebo treatment. Of note, the trial’s dual primary endpoints are event-free survival (EFS) and overall survival (OS).
In this updated analysis, the median time from randomization was 36.6 months. A total of 254 (31.9%) death events happened. OS was statistically improved in the pembrolizumab arm (HR 0.72 [95% CI 0.56-0.93]. The 36-month OS rates were 71.3% vs 64.0%, respectively. Benefit seems to correlate with PD-L1 status, with higher PD-L1 expression associated with larger OS improvement. EGFR mutation was included, but with only 33 patients, no conclusions can be drawn.
The neoadjuvant only regimen of CheckMate-816 requires only 3 cycles of treatment before surgery, while KEYNOTE-671 regimen consists of 4 cycles preoperatively followed by adjuvant therapy for a year. With FDA approval, KEYNOTE-671 is a standard of care option for early-stage non-small cell lung cancer. It remains unclear which approach would be the best for patients or what biomarker can help identify the suitable population for each one. However, KEYNOTE-671 is the first trial reporting significant OS improvement among trials of chemoimmunotherapy administered before surgery for patients with non-small cell lung cancer.
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