Association of the advanced lung cancer inflammation index (ALI) with immune checkpoint inhibitor efficacy in patients with advanced non-small-cell lung cancer.

The advanced lung cancer inflammation index [ALI: body mass index × serum albumin/neutrophil-to-lymphocyte ratio (NLR)] reflects systemic host inflammation, and is easily reproducible. We hypothesized that ALI could assist guidance of non-small-cell lung cancer (NSCLC) treatment with immune checkpoint inhibitors (ICIs). This retrospective study included 672 stage IV NSCLC patients treated with programmed death-ligand 1 (PD-L1) inhibitors alone or in combination with chemotherapy in 25 centers in Greece and Germany, and a control cohort of 444 stage IV NSCLC patients treated with platinum-based chemotherapy without subsequent targeted or immunotherapy drugs. The association of clinical outcomes with biomarkers was analyzed with Cox regression models, including cross-validation by calculation of the Harrell's C-index. High ALI values (>18) were significantly associated with longer overall survival (OS) for patients receiving ICI monotherapy [hazard ratio (HR) = 0.402, P < 0.0001, n = 460], but not chemo-immunotherapy (HR = 0.624, P = 0.111, n = 212). Similar positive correlations for ALI were observed for objective response rate (36% versus 24%, P = 0.008) and time-on-treatment (HR = 0.52, P < 0.001), in case of ICI monotherapy only. In the control cohort of chemotherapy, the association between ALI and OS was weaker (HR = 0.694, P = 0.0002), and showed a significant interaction with the type of treatment (ICI monotherapy versus chemotherapy, P < 0.0001) upon combined analysis of the two cohorts. In multivariate analysis, ALI had a stronger predictive effect than NLR, PD-L1 tumor proportion score, lung immune prognostic index, and EPSILoN scores. Among patients with PD-L1 tumor proportion score ≥50% receiving first-line ICI monotherapy, a high ALI score >18 identified a subset with longer OS and time-on-treatment (median 35 and 16 months, respectively), similar to these under chemo-immunotherapy. The ALI score is a powerful prognostic and predictive biomarker for patients with advanced NSCLC treated with PD-L1 inhibitors alone, but not in combination with chemotherapy. Its association with outcomes appears to be stronger than that of other widely used parameters. For PD-L1-high patients, an ALI score >18 could assist the selection of cases that do not need addition of chemotherapy.

Copyright © 2021 The Author(s). Published by Elsevier Ltd.. All rights reserved.

Disclosure GM reports advisory/consultation fees from Roche, AstraZeneca, Bristol Myers Squibb (BMS), Merck Sharp & Dohme (MSD), Takeda, Pfizer, Amgen, and Merck outside from the submitted work. ES reports advisory/consultation fees from Roche, AstraZeneca, BMS, MSD, Pfizer, Amgen, and Merck outside from the submitted work. EZ reports advisory/consultation fees from MSD and Roche outside from the submitted work. KS reports advisory/consultation fees from MSD and Roche outside from the submitted work. SA reports advisory/consultation fees from Roche, AstraZeneca, BMS, MSD, Takeda, Pfizer, Amgen, and Merck outside from the submitted work. SB reports advisory/consultation fees from Roche, AstraZeneca, BMS, MSD, Takeda, Pfizer, and Amgen outside from the submitted work. IA reports advisory/consultation fees from Roche, AstraZeneca, BMS, MSD, Pfizer, Amgen, and Merck outside from the submitted work. AC reports advisory/consultation fees from Roche, AstraZeneca, BMS, MSD, Pfizer, and Amgen outside from the submitted work. GP reports advisory/consultation fees from Roche, AstraZeneca, BMS, MSD, Pfizer, Amgen, and Merck outside from the submitted work. EL reports advisory/consultation fees from Roche, AstraZeneca, MSD, and Pfizer outside from the submitted work. HL reports advisory/consultation fees from Roche, AstraZeneca, BMS, MSD, Pfizer, Amgen, and Merck outside from the submitted work. PK reports advisory/consultation fees from Roche, AstraZeneca, BMS, MSD, Pfizer, Amgen, and Merck outside from the submitted work. AP reports advisory/consultation fees from Roche, AstraZeneca, BMS, MSD, Pfizer, Amgen, and Merck outside from the submitted work. CA reports advisory/consultation fees from Roche, AstraZeneca, BMS, MSD, Pfizer, Amgen, and Merck outside from the submitted work. EF reports advisory/consultation fees from Roche, AstraZeneca, BMS, MSD, Pfizer, Amgen, and Merck outside from the submitted work. FJH reports advisory board fees and honoraria from Lilly, Roche, AstraZeneca, Novartis, Boehringer, Chiesi, Teva, Pulmonx BTG, and Olympus, as well as research funding from Lilly, Roche, AstraZeneca, Novartis, Boehringer, Chiesi, and Teva, outside of the submitted work. CE reports advisory/consultation fees from Roche, AstraZeneca, BMS, MSD, Pfizer, Amgen, and Merck outside from the submitted work. GO reports advisory/consultation fees from Roche, AstraZeneca, BMS, and MSD outside from the submitted work. TM reports research funding from Roche and patents with Roche, outside from the submitted work. ZS reports advisory/consultation fees from Roche, AstraZeneca, BMS, MSD, Pfizer, Amgen, and Merck outside from the submitted work. ER reports advisory/consultation fees from Roche, AstraZeneca, BMS, MSD, Pfizer, and Amgen outside from the submitted work. AS reports advisory board honoraria from BMS, AstraZeneca, ThermoFisher, Novartis, speaker's honoraria from BMS, Illumina, AstraZeneca, Novartis, ThermoFisher, MSD, Roche, and research funding from Chugai, outside from the submitted work. IB reports advisory/consultation fees from Roche, AstraZeneca, BMS, MSD, Pfizer, and Amgen outside from the submitted work. MR reports personal fees from Amgen, AstraZeneca, BMS, Boehringer-Ingelheim, Lilly, Merck, MSD, Novartis, Pfizer, Roche, and Samsung, outside the submitted work. KS reports advisory/consultation fees from Roche, AstraZeneca, BMS, and MSD. MT reports advisory board honoraria from Novartis, Lilly, BMS, MSD, Roche, Celgene, Takeda, AbbVie, Boehringer, speaker's honoraria from Lilly, MSD, Takeda, research funding from AstraZeneca, BMS, Celgene, Novartis, Roche, and travel grants from BMS, MSD, Novartis, Boehringer, outside from the submitted work. PC reports research funding from AstraZeneca, Novartis, Roche, Takeda, and advisory board/lecture fees from AstraZeneca, Boehringer Ingelheim, Chugai, Novartis, Pfizer, Roche, Takeda. All other authors have declared no conflicts of interest.