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Purpose of Review The treatment strategy for BRAF-mutated melanoma remains unsatisfactory, although the advent of immune checkpoint inhibition has improved the prognosis of advanced melanoma. This article reports current evidence on the efficacy and safety of sequential immunotherapy with targeted therapy in patients with BRAF-mutated melanoma. It discusses criteria for the use of available options in clinical practice. Recent Findings Targeted therapy provides rapid disease control in a relatively high proportion of patients, although the development of secondary resistance limits the duration of responses; in contrast, immunotherapy may induce slow but more durable responses in a subset of patients. Summary Therefore, the identification of a combination strategy for the use of these therapies seems a promising perspective. Currently, inconsistent data have been obtained, but most studies indicate that the administration of BRAFi/MEKi prior to immune checkpoint inhibitors appears to reduce the efficacy of immunotherapy. On the contrary, several clinical and real-life studies suggest that frontline immunotherapy with subsequent targeted therapy may be associated with better tumor control than immunotherapy alone. Larger clinical studies are ongoing to confirm the efficacy and safety of this sequencing strategy for treating BRAF-mutated melanoma with immunotherapy followed by targeted therapy.

This dataset contains data of patient characteristics and IL6 in a cohort of patients with advanced cutaneous squamous cell carcinoma treated with cemiplimab.

Liquid biopsy has emerged as a minimally invasive alternative to tumor tissue analysis for the management of lung cancer patients, especially for epidermal growth factor receptor (EGFR) oncogene addicted tumor. In these patients, despite the clear benefits of tyrosine kinase inhibitors therapy, the development of acquired resistance and progressive disease is inevitable in most cases and liquid biopsy is important for molecular characterization at resistance and, being non-invasive, may be useful for disease monitoring. In this review, the authors will focus on the applications of liquid biopsy in EGFR-mutated non small cells lung cancer at diagnosis, during treatment and at progression, describing available data and possible future scenarios.

The azygos system is the most important pathway for decompression of the superior vena cava (SVC) when a blood flow obstruction to the right atrium is present. Thoracic and mediastinal malignancies, mainly lung cancers, are responsible for 60%-85% of superior vena cava syndrome (SVCS) cases. An uncommon origin of SVCS is primary malignant mediastinal germ cell tumor (PMMGCT) which represent 1%-4% of all mediastinal tumors and can be divided into two broad groups: seminomas and nonseminomatous germ cell tumors (NSGCTs). Primary mediastinal seminomas clinical presentation is often nonspecific, even if the majority of patients present with superior vena cava involvement. Here, we present the radiologic features of asymptomatic azygos system overflow in a patient with primary mediastinal seminoma.

Head and neck cancers (HNC) represent the seventh most frequent cancer worldwide, with squamous cell carcinomas as the most frequent histologic subtype. Standard treatment for early stage diseases is represented by single modality surgery or radiotherapy, whereas in the locally advanced and recurrent or metastatic settings a more aggressive multi-modal approach is needed with locoregional intervention and/or systemic therapies. Epidermal Growth Factor Receptor (EGFR) plays an important role in HNC biology and has been studied extensively in preclinical and clinical settings. In this scenario, anti-EGFR targeted agent cetuximab, introduced in clinical practice a decade ago, represents the only approved targeted therapy to date, while the development of immune-checkpoint inhibitors has recently changed the available treatment options. In this review, we focus on the current role of anti-EGFR therapies in HNCs, underlying available clinical data and mechanisms of resistance, and highlight future perspectives regarding their role in the era of immunotherapy.

Background: The introduction of immunotherapy has improved the prognosis of patients with Non-Small Cell Lung Cancer (NSCLC). However, data in poor ECOG Performance Status (PS) patients remain scant due to their exclusion from randomized trials. Material and methods: We analyzed data of patients with advanced NSCLC treated with immunotherapy in two Italian Centers, to evaluate the impact of PS (0-1 vs 2) on disease control rate (DCR), progression free survival (PFS) and overall survival (OS). Chi-square test was used to compare clinical-pathological variables, their impact on survival was evaluated through Cox proportional hazard models. Results: Among 404 patients included, PS was 0 in 137 (33.9 %), 1 in 208 (51.5 %) and 2 in 59 (14.6 %) patients; 143 were female and 90 had squamous NSCLC. Clinical-pathological variables were uniformly distributed except for higher prevalence of liver metastases in patients with poor PS. We found that PS2 patients showed worse outcomes in terms of DCR (21.8 % vs 50.3 %, p = 0.001), PFS [2.0 (95 % CI 1.6–3.0) vs 3.0 (95 % CI 2.7–4.0) months, p < 0.0001] and OS [4.0 (95 % CI 2.8–5.7) vs 13.2 (95 % CI 11.0−15.8) months, p < 0.0001]. PS2 status, negative PDL1 expression and early corticosteroids exposure as well as higher Neutrophil to Lymphocyte Ratio and LDH at baseline were associated with worse outcomes at univariate and multivariable analysis. Subgroup analysis confirmed poor outcomes in PS2 patients with high LDH and concomitant corticosteroid therapies. The incidence of Grade 3/4 adverse events was 11.3 % in PS 0−1 and 10.2 % in PS 2 patients (p = 0.81). Conclusion: Our data confirm reduced efficacy of immunotherapy in patients with poor PS even though a good safety. Despite PS remains the most powerful independent prognostic factor for NSCLC, LDH levels and steroids exposure could support the decision making in PS2 patients.

Background: Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal human malignancies: novel therapeutic approaches beyond conventional chemotherapy are still lacking and prognosis remains poor, even for resectable patients (pts). Furthermore, there is an almost complete absence of validated predictive factors. Consequently, robust biomarkers for the early diagnosis and the prognostic stratification are urgently needed in clinical practice, especially in the context of neoadjuvant and adjuvant settings. In the last years, evidence revealed the crucial role of miRNAs in cancer initiation and progression, as well as in the chemo-resistance mechanisms, suggesting their use as clinical biomarkers. Material and methods: In this pilot study, we performed a microarray analysis to characterize global miRNA expression profile from surgical tissue samples collected from 20 resected PDAC pts pooled into 4 groups according to different clinico-pathological features: nodal metastases (N+/N-) and tumor grading (G2/G3). Results: According to expression patterns, we identified, among 384 miRNAs, a significant different modulation for 11 miRNAs associated to G2 vs G3 and for 7 miRNAs in N+ vs N- disease, suggesting a possible specific signature reflecting histological grade and nodal metastasis occurrence, respectively. We focused on 2 up-regulated (miR-138-5p and miR-518-3p) and 3 down-regulated (miR-215-5p, miR-519a-3p and miR-576-5p) miRNAs in N+ pts, and on 3 up-regulated (miR-1-3p, miR-31-5p and miR-205-5p) in G3 pts, in order to verify their possible implication in the molecular changes behind tumor differentiation and spread, as well as their potential use for prognostic and therapeutic purpose. A bio-informatic analysis was also performed, using different in silico tools, to study both high affinity miRNA targets and cross-regulated pathways among the upand down-regulated miRNAs. The results identified several associated targets involved in multiple signaling pathways commonly dysregulated in cancer. Finally, BRCA1/2 and RB1 miRNAs-mediated-modulation is actually ongoing, considering the pivotal role of these genes in some PDAC pts. Conclusion: These preliminary data provide a strong rationale to further investigate miRNAs expression in larger cohorts of PDAC pts, possibly integrating validated tissue miRNAs data with circulating miRNAs, in order to identify strong (and easily accessible) potential biomarker(s) with prognostic and/or predictive significance. Citation Format: Luca Pompella, Michela Falco, Carlo Caputo, Anna Grimaldi, Giuseppe Tirino, Severo Campione, Francesca Sparano, Maria Lucia Iacovino, Chiara Carmen Miceli, Carlo Molino, Marco Montella, Renato Franco, Gennaro Galizia, Giovanni Conzo, Vincenzo Napolitano, Annamaria Auricchio, Francesca Cardella, Fortunato Ciardiello, Michele Caraglia, Angela Lombardi, Gabriella Misso, Ferdinando De Vita. A pilot study of miRNA expression profile in surgically resected pancreatic ductal adenocarcinoma: Initial report from a bi-institutional cohort [abstract]. In: Proceedings of the AACR Virtual Special Conference on Pancreatic Cancer; 2021 Sep 29-30. Philadelphia (PA): AACR; Cancer Res 2021;81(22 Suppl):Abstract nr PO-052.

Background Pioglitazone, a synthetic peroxisome proliferator activated receptor (PPAR-γ) ligand, is known as an antidiabetic drug included in the thiazolidinediones (TZDs) class. It regulates the lipid and glucose cell metabolism and recently a role in the inhibition of numerous cancer cell processes has been described. Methods In our work we investigate the anti-tumor effects of pioglitazone in in vitro models of non small cell lung cancer (NSCLC) and also, we generated ex-vivo three-dimensional (3D) cultures from human lung adenocarcinoma (ADK) as a model to test drug efficacy observed in vitro. The inhibitory effect of pioglitazone on cell proliferation, apoptosis and cell invasion in a panel of human NSCLC cell lines was evaluated by multiple assays. Results Pioglitazone reduced proliferative and invasive abilities with an IC50 ranging between 5 and 10 μM and induced apoptosis of NSCLC cells. mRNA microarray expression profiling showed a down regulation of MAPK, Myc and Ras genes after treatment with pioglitazone; altered gene expression was confirmed by protein analysis in a dose-related reduction of survivin and phosphorylated proteins levels of MAPK pathway. Interestingly mRNA microarray analysis showed also that pioglitazone affects TGFβ pathway, which is important in the epithelial-to-mesenchimal transition (EMT) process, by down-regulating TGFβR1 and SMAD3 mRNA expression. In addition, extracellular acidification rate (ECAR) and a proportional reduction of markers of altered glucose metabolism in treated cells demonstrated also cell bioenergetics modulation by pioglitazone. Conclusions Data indicate that PPAR-γ agonists represent an attractive treatment tool and by suppression of cell growth (in vitro and ex vivo models) and of invasion via blockade of MAPK cascade and TGFβ/SMADs signaling, respectively, and its role in cancer bioenergetics and metabolism indicate that PPAR-γ agonists represent an attractive treatment tool for NSCLC.

e21601 Background: The introduction of Immunotherapy (IO) has dramatically improved the prognosis of patients (pts) with advanced Non-Small Cell Lung Cancer (NSCLC). However, data regarding the role of IO in ECOG Performance Status (PS) 2 pts are generally limited in randomized trials, and real-world evidences could support clinical decision-making. Methods: We retrospectively analyzed data about pts with stage IV NSCLC treated with IO between April 2013 and December 2019 in two Italian Centers. The aim of our study was to assess the impact of PS status (0-1 vs 2) on disease control rate (DCR), progression-free survival (PFS) and overall survival (OS). Response was classified according to RECIST v1.1 criteria. PFS and OS were estimated by the Kaplan-Meier method. Chi-square test was used to compare clinical-pathological variables: gender, age ( < 70, 70-79, ≥80 years-old), smoking status, histology (squamous, non-squamous), PDL1 expression ( < 1%, ≥1%), IO line (1°, ≥2°), number (N) of metastatic sites (1, ≥2), presence of liver and/or brain metastasis. Their impact on survival was evaluated through Cox proportional hazard models. Results: Four-hundred-one pts (35.7% female) with median age of 65.4 years (range 27-88) were studied. Baseline PS was 0 in 134 pts (33.4%), 1 in 209 pts (52.1%) and 2 in 58 pts (14.5%). 312 pts had non-squamous NSCLC, 89 squamous NSCLC. Clinical-pathological variables were uniformly distributed across PS groups except for a higher rate of liver metastasis in PS2 pts ( p= 0.046). Response evaluation was available for 386 pts. DCR was 49.7% in PS0-1 pts and 25.9% in PS2 pts ( p= 0.006). At a median follow-up of 29 months (mos), median PFS was 3.0 mos (95% CI 2.63-4.00) and 2.04 mos (95% CI 1.84-3.00) in pts with PS0-1 and 2 ( p< 0.0001). Median OS was 13.2 mos (95% CI 11.18-15.78) and 4.0 mos (95% CI 2.66-5.62) in pts with PS 0-1 and 2 respectively ( p< 0.0001). Univariate analysis showed significant correlation of PS2 status, negative PDL1, IO line ≥2, N of metastatic sites ≥2 and liver metastasis, for both PFS and OS. Multivariate analysis confirmed an independent association of PS ( p= 0.0013 for PFS, p< 0.0001 for OS), PDL1 ( p= 0.0002 for PFS, p= 0.02 for OS) and liver metastasis ( p= 0.017 for PFS, p= 0.02 for OS). The incidence of Grade 3/4 adverse events was 10.5% in PS 0-1 pts and 13.7% in PS 2 pts ( p= 0.41). Conclusions: Our data confirm reduced efficacy of IO in pts with poor PS, regardless of the N of prior therapy lines or PDL1 expression. Despite IO appears to be safe and tolerable its role remains uncertain in PS2 pts based on worse survival outcomes.

Background Antibody-dependent cell-mediated cytotoxicity (ADCC) may mediate antitumour activity of IgG1-isotype monoclonal antibody (mAb), suggesting as potential treatment combination of IgG1-mAbs, anti-epidermal growth factor receptor cetuximab and anti-programmed death-ligand-1 avelumab. Methods We evaluated ADCC induction in lung cancer cells by lactate dehydrogenase (LDH) release assay. Antitumour activity and safety of cetuximab plus avelumab were explored in a single-arm proof-of-concept study in pre-treated non-small cell lung cancer (NSCLC) patients (pt) (Cetuximab-AVElumab-lung, CAVE-Lung). Search for predictive biomarkers of response was done. Results Avelumab plus cetuximab induced ADCC in NSCLC cells in vitro in presence of natural killers (NK) from healthy donors (HD) or NSCLC pt, as effectors. Sixteen relapsed NSCLC pt were treated with avelumab plus cetuximab. Antitumour activity was observed in 6/16 pt, defined by progression free survival (PFS) ≥8 months, with 4 of them still on treatment at data lock time (range, 14–19 months). Of note, 3/6 responders had received as previous line anti-programmed death-1 therapy. In responders, clinical benefit was accompanied by significant increase in LDH release over baseline at the first radiological evaluation (8 weeks) (p=0.01) and by early skin toxicity; while in the 10 non-responders, that had PFS ≤5 months, LDH release tends to reduce. Baseline circulating DNA levels were higher in non-responders compared with responders and HD (p=0.026) and decrease in responders during therapy. Mutations in DNA damage responsive family genes were found in responders. Conclusion Cetuximab and avelumab activates NSCLC pt NK cells. Ex vivo evaluation of ADCC, circulating DNA levels and early skin toxicity may predict response to cetuximab plus avelumab in NSCLC. EUDRACT 2017-004195-58

Background Immune checkpoint inhibitors (ICIs) in patients with pretreated advanced NSCLC (aNSCLC) showed an overall survival (OS) benefit over standard chemotherapy in phase III randomized clinical trials (RCTs). Nevertheless, a significant portion of patients do not benefit from ICIs. The identification of biomarkers to select patients most likely to respond to ICIs is greatly needed in clinical practice. The role of baseline clinical and blood biomarkers as prognostic of response to ICIs was investigated in patients with aNSCLC and a prognostic ImmunoScore is defined. Methods We retrospectively reviewed clinical data of aNSCLC patients consecutively treated with single agents anti PD-1 or anti PD-L1 as 2nd (81.8%) or ≥ 3rd (18.2%) line at University Hospitals of Valencia and Naples. ECOG PS, sites of metastases, neutrophil to lymphocyte ratio (NLR), LDH and albumin levels were recorded at baseline. The impact of these variables on PFS and OS was assessed through survival analyses (Kaplan Meier method), univariate (log rank test) and multivariate analyses (Cox proportional hazard model). Results The analysis included 132 pts. Median PFS and OS were 3 (95% CI 2.74-3.26) and 9 (95% CI 5.90-12.02) months respectively. The univariate analysis for PFS showed that baseline NLR>4 (p = 0.001), albumin 1 (HR 2.96, p 400 U/l (p = 0.089). The multivariate analysis for PFS confirmed as statistically significant independent negative prognostic factors PS > 1 (p = 0.001) and liver metastases (p = 0.011). Finally, according to PS, liver metastases, NLR and albumin three different prognostic groups at high (3-4 RF), intermediate (1-2 RF) and low (0 RF) risk for OS were defined. Median OS was respectively 5 (95% CI 3.45-6.55), 7 (95% CI 4.98-9.02) and 23 (95% CI 16.53-29.47) months (p Conclusion Baseline evaluation of clinical and blood biochemical parameters can be a tool to predict outcome in patients treated with ICIs for aNSCLC. Moreover, combining them in ImmunoScore may help to identify pts candidates to second or subsequent Iines of therapy who most likely will benefit from ICIs. Legal entity responsible for the study The authors. Funding Has not received any funding. Disclosure All authors have declared no conflicts of interest.

Background Previous studies have demonstrated that IgG1 mAbs as cetuximab, stimulate Antibody-Dependent Cell Cytotoxicity (ADCC). Among immune checkpoint inhibitors, avelumab is the only fully human IgG1 anti-PD-L1 mAb with ADCC properties. Anti-PD-L1 and anti-EGFR mediated NK cytotoxicity is evaluated. Methods LDH release was analyzed to study NK-mediated cytotoxicity by LDH Cytotoxicity Assay Kit and results was correlated to the level of PD-L1, EGFR and MHC-I cell surface expression analyzed by flow cytometry. NK-mediated cytotoxicity of the combination of anti-PD-L1 and anti-EGFR mAbs was studied in a panel of NSCLC cells lines encompassing different tumor types, using as effector NK cells isolated from healthy donors or NSCLC patients. Results PD-L1/EGFR/MHC-I expression levels correlated with enhanced ADCC lysis by the combination of avelumab and cetuximab as demonstrated by LDH assay, CD16 and CD107a mRNA. No significant difference in avelumab plus cetuximab-mediated ADCC between NK cells from healthy donors or from NSCLC patients was observed with a trend in favor of cancer patients, indicating that NK from cancer patients maintain lytic activity. ADCC capability of NK cells isolated from patients enrolled in the phase II study CAVE (Cetuximab-AVElumab)-lung, a single arm phase II clinical study of the combination of avelumab plus cetuximab in the second line treatment of metastatic non small cell lung cancer (NSCLC) patients (EUDRACT 2017- 004195-58) study resulted significantly enhanced after the experimental treatment compared to untreated baseline and healthy donors samples. Conclusions The combination of anti-EGFR and anti PD-L1 IgG1 antibodies is synergistic in terms of ADCC, where each antibody complements each other by promoting a more permissive immune reaction against the tumor, active also in otherwise immune-resistant cancers. Legal entity responsible for the study Universita degli studi della Campania Luigi Vanvitelli. Funding Merck KGaA. Disclosure F. Ciardiello: Advisory / Consultancy, Research grant / Funding (institution): Roche; Advisory / Consultancy, Research grant / Funding (institution): Bayer; Advisory / Consultancy, Research grant / Funding (institution): Amgen; Advisory / Consultancy: Merck; Advisory / Consultancy: Pfizer; Advisory / Consultancy: Sanofi; Advisory / Consultancy: Servier; Advisory / Consultancy: BMS; Advisory / Consultancy: Cellgene; Advisory / Consultancy: Lilly; Research grant / Funding (institution): AstraZeneca; Research grant / Funding (institution): Ipsen. F. Morgillo: Advisory / Consultancy: MSD; Advisory / Consultancy: Lilly; Research grant / Funding (institution): AstraZeneca. All other authors have declared no conflicts of interest.

Background cfDNA analysis could represent an alternative to invasive biopsy in patients with NSCLC to better understand disease profile. We report a real-world experience of genomic assessment of an Italian patients’ cohort. Methods We evaluated 58 non-oncogene-addicted aNSCLC patients treated at our Institution from January 2018 to May 2019. All patients were characterized using cfDNA NGS Guardant360® platform (Guardant Health, Redwood City, CA). Association between a positive result (defined as cfDNA detected) and clinical features was assessed using logistic regression test. Using online library dataset (mycancergenome.org) and literature data, we divided patients in genomic clusters and performed a descriptive analysis. Results The median age of patients was 67 (range 38-85), 44 men and 14 women, 8.6% never smokers, 41.4% former and 50% current smokers. 14 patients (24.2%) had squamous cell carcinoma and 44 (75.8%) had non-squamous NSCLC, 50 of 58 at stage IV at the time of testing. Most patients were PS 0-1 per ECOG scale and has been treated with at least one systemic regimen before performing NGS. 47 of 58 patients (81%) has been considered positive at the analysis. No targetable genomic alterations per local authority has been found. More than 40 different mutated genes were detected, the most common alterations involved TP53 (60% of patients), KRAS (34%), PDGFRα (17%), EGFR (15% - not-TKI-sensitive), PI3KCA (15%), CDKN2A (15%). Chemotherapy (but not immunotherapy) and extra-thoracic radiotherapy before testing increased the probability to result positive at NGS of 4.5 and 2 folds respectively. Six mutational clusters have been identified. Most patients had genomic alterations in Replication Stress - DNA damage/repair, cell cycle - (72%) and Tyrosine Kinase Receptor/Growth Factor pathway (62%), less common mutations affected PI3K/AKT/mTOR and Hormone signaling (26% and 9% respectively). Conclusions Our experience demonstrated the feasibility of NGS-based NSCLC patients genomic profiling. The widespread of NGS platforms (and the subsequent reduction of costs) should encourage clinicians to use these methods with all patients to guarantee access to developing therapeutics and clinical trials. Legal entity responsible for the study The authors. Funding Has not received any funding. Disclosure F. Ciardiello: Advisory / Consultancy, Research grant / Funding (institution): Roche; Advisory / Consultancy, Research grant / Funding (institution): Amgen; Advisory / Consultancy, Research grant / Funding (institution): Merck; Research grant / Funding (institution): AstraZeneca; Research grant / Funding (institution): Ipsen; Advisory / Consultancy, Research grant / Funding (institution): Bayer; Advisory / Consultancy: BMS; Advisory / Consultancy: Sanofi; Advisory / Consultancy: Servier; Advisory / Consultancy: Celgene; Advisory / Consultancy: Lilly; Advisory / Consultancy: Pfizer. F. Morgillo: Advisory / Consultancy: MSD; Advisory / Consultancy: Lilly; Research grant / Funding (institution): AstraZeneca. All other authors have declared no conflicts of interest.

Background In the era of precision medicine, cancer treatment strategies are aimed to be patient-tailored. Here, we report a translational study conducted on a NSCLC patient where the potentiality of ex vivo spheroidal cultures and peripheral blood biomarkers were investigated to analyze correspondence with treatment response. Methods We developed a protocol to generate ex vivo spheroidal cultures from patient’s surgical sample that has been used to assess drug sensitivity through cell proliferation MTT assay. Primary tumor tissue, patient-derived spheroids and patient’s circulating tumor DNA (ctDNA) were characterized through immunohistochemistry (IHC), immunofluorescence and next generation sequencing (NSG) analysis. Tumor infiltrating lymphocytes (TILs) from surgical specimen were analyzed by FACS and the analysis of TCR repertoire was conducted using Spectratyping technique. Moreover, peripheral blood samples collected at different time points underwent qPCR analysis to assess cytokines expression and flow cytometry to study peripheral blood mononuclear cells (PBMCs). All these data were correlated with clinical and radiological evaluations. Results Immunohistochemistry, immunofluorescence, NGS analysis and TCR repertoire assay showed elevated concordance among primary tumor tissue, spheroids and ctDNA. Cisplatin-based chemotherapy and anti-PD-1 treatment sensitivity assessed in spheroidal cultures allowed us to anticipate patient response to chemo- and immunotherapy. Furthermore, circulating cytokines expression levels and lymphocytes subpopulations profiling correlated with clinical and radiological response to first line anti-PD-1 therapy. Conclusions This approach demonstrated the feasibility of using spheroidal cultures, cytokines expression levels and PBMCs profiling to follow patient’s disease history and response to treatment in parallel with clinical and radiological evaluation. Legal entity responsible for the study Universita degli Studi della Campania Luigi Vanvitelli. Funding Has not received any funding. Disclosure F. Ciardiello: Advisory / Consultancy, Research grant / Funding (institution): Roche; Advisory / Consultancy, Research grant / Funding (institution): Bayer; Advisory / Consultancy, Research grant / Funding (institution): Amgen; Advisory / Consultancy: Merck; Advisory / Consultancy: Pfizer; Advisory / Consultancy: Sanofi; Advisory / Consultancy: Servier; Advisory / Consultancy: BMS; Advisory / Consultancy: Cellgene; Advisory / Consultancy: Lilly; Research grant / Funding (institution): AstraZeneca; Research grant / Funding (institution): Ipsen. F. Morgillo: Advisory / Consultancy: MSD; Advisory / Consultancy: Lilly; Research grant / Funding (institution): AstraZeneca. All other authors have declared no conflicts of interest.