Effect of concomitant medications with immune-modulatory properties on the outcomes of patients with advanced cancer treated with immune checkpoint inhibitors: development and validation of a novel prognostic index.

Background: Concomitant medications are known to impact on clinical outcomes of patients treated with immune checkpoint inhibitors (ICIs). We aimed weighing the role of different concomitant baseline medications to create a drug-based prognostic score.
Methods: We evaluated concomitant baseline medications at immunotherapy initiation for their impact on objective response rate (ORR), progression-free survival (PFS) and overall survival (OS) in a single-institution cohort of patients with advanced cancer treated with ICIs (training cohort, N = 217), and a drug-based prognostic score with the drugs resulting significantly impacting the OS was computed. Secondly, we externally validated the score in a large multicenter external cohort (n = 1012).
Results: In the training cohort (n = 217), the median age was 69 years (range: 32-89), and the primary tumours were non-small-cell lung cancer (70%), melanoma (14.7%), renal cell carcinoma (9.2%) and others (6%). Among baseline medications, corticosteroids (hazard ratio [HR] = 2.3; 95% confidence interval [CI]: 1.60-3.30), systemic antibiotics (HR = 2.07; 95% CI: 1.31-3.25) and proton-pump inhibitors (PPIs) (HR = 1.57; 95% CI: 1.13-2.18) were significantly associated with OS. The prognostic score was calculated using these three drug classes, defining good, intermediate and poor prognosis patients. Within the training cohort, OS (p < 0.0001), PFS (p < 0.0001) and ORR (p = 0.0297) were significantly distinguished by the score stratification. The prognostic value of the score was also demonstrated in terms of OS (p < 0.0001), PFS (p < 0.0001) and ORR (p = 0.0006) within the external cohort.
Conclusion: Cumulative exposure to corticosteroids, antibiotics and PPIs (three likely microbiota-modulating drugs) leads to progressively worse outcomes after ICI therapy. We propose a simple score that can help stratifying patients in routine practice and clinical trials of ICIs.
Competing Interests: Conflict of interest statement M.B. reports receiving research funding by Roche, Seqirus, Pfizer and Novartis and personal fees as a speaker/consultant from AstraZeneca, Novartis, Pfizer and BMS. M.T. reports receiving speaker fees and grant consultancies from AstraZeneca, Pfizer, Eli-Lilly, BMS, Novartis, Roche, MSD, Boehringer Ingelheim, Otsuka, Takeda and Pierre Fabre. A.C. reports receiving speaker fees and grant consultancies from Roche, MSD, BMS, AstraZeneca, Novartis and Astellas. R.G. reports receiving speaker fees and grant consultancies from AstraZeneca and Roche. M.G.V. reports receiving speaker fees, grant consultancies and travel support from BMS, Ipsen, Novartis, Pfizer, Astellas, Jansen and Pierre-Fabre. A.R. reports receiving grant consultancies from AstraZeneca and MSD. F.S. reports receiving speaker fees and grant consultancies from Roche, Novartis, BMS, MSD, Pierre-Fabre, Sanofi, Merck and Sunpharma. D.J.P. reports receiving lecture fees from ViiV Healthcare and Bayer Healthcare; travel expenses from BMS and Bayer Healthcare; consulting fees for Mina Therapeutics, EISAI, Roche and AstraZeneca and research funding (to institution) from MSD and BMS. P.A.A. reports receiving speaker fees and grant consultancies from BMS, Roche-Genentech, MSD, Dohme, Array, Novartis, Merck-Serono, Pierre-Fabre, Incyte, New Link Genetics, Genmab, Medimmune, AstraZeneca, Syndax, SunPharma, Sanofi, Idera, Ultimovacs, Sandoz, Immunocore, 4SC, Alkermes, Italfarmaco, Nektar and Boehringer-Ingelheim and research funds from BMS, Roche-Genentech and Array. All other authors declared no competing interests.
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