Real-world experience with pembrolizumab in patients with advanced melanoma: A large retrospective observational study

Abstract

Pembrolizumab has been approved in the United States for treating advanced melanoma for >4 years. We examined real-world pembrolizumab use and associated outcomes in US oncology clinical practices, including patients who would not be eligible for clinical trials.Flatiron Health longitudinal database was used to identify adult patients with advanced melanoma initiating ≥1 dose of pembrolizumab from September 4, 2014, through December 31, 2016, with follow-up through December 31, 2017. Patients in any clinical trial during the study period were excluded. Overall survival (OS) and time on treatment from pembrolizumab initiation were analyzed using the Kaplan-Meier (KM) method. Subgroup analyses were conducted to examine OS for several patient characteristics including Eastern Cooperative Oncology Group (ECOG) performance status >1, brain metastases, and corticosteroids before pembrolizumab initiation.Pembrolizumab was administered to 315 (59%), 152 (29%), and 65 (12%) patients as first-, second-, and third-line/later therapy. Median age at pembrolizumab initiation was 68 years (range, 18-84); most patients were male (66%) and white (94%). Of those with available data, 38% had BRAF-mutant melanoma, 21% had elevated lactate dehydrogenase (LDH) level, and 23% had ECOG >1. Overall, 18% had brain metastases, and 23% were prescribed corticosteroids <3 months before initiating pembrolizumab. Median study follow-up was 12.9 months (range, 0.03-39.6). Median OS was 21.8 months (95% confidence interval [CI] 16.8-29.1); KM 1-year and 2-year survival rates were 61% and 48%, respectively; and median time on pembrolizumab treatment was 4.9 months (95% CI 3.7-5.5). Median OS for first-line pembrolizumab was not reached, and for second-line and third-line/later was 13.9 and 12.5 months, respectively (log-rank P = .0095). Significantly better OS (all P ≤.0014, log-rank test) was evident for patients with ECOG performance status (PS) of 0 to 1 (vs >1), normal (vs elevated) LDH level, and no (vs yes) corticosteroid prescription <3 months before. No difference was recorded in OS by brain metastases (log-rank P = .22) or BRAF mutation status (log-rank P = .90).These findings support effectiveness of pembrolizumab in the real-world clinical setting and provide important insights into patient characteristics and outcomes associated with pembrolizumab therapy for a heterogeneous patient population with advanced melanoma, including patients who would not be eligible for clinical trials.

Figure 1

Kaplan–Meier plots, overall and by pembrolizumab line of therapy, of (a) overall survival (OS): all lines median, 21.8 months (95% CI 16.8–29.1); first line (L1) median, not reached (21.2–NR); second line (L2) median, 13.9 (10.7–22.7); third line/later (L3+) median, 12.5 (8.2–24.8; log-rank P = .0095), (b) time on treatment with pembrolizumab: overall median, 4.9 months (95% CI, 3.7–5.5); L1 median, 4.9 (3.7–5.9); L2 median, 4.9 (3.5–6.0); L3+ median, 4.2 (2.4–6.2;log-rank P = .33), and (c) time to next line of treatment: overall median, 11.2 months (95% CI, 8.6–13.3); L1 median, 13.6 (9.8–19.0); L2 median, 9.2 (6.3–12.8); L3+ median, 6.3 (4.9–10.1;log-rank P = .021).

Figure 2

Kaplan–Meier plots of overall survival (OS) for subgroups, including only patients with no missing data (a) by age group: <55 years median, 19.8 months (10.8–NR); 55 to 74 years median, 35.3 months (19.4–NR); ≥75 years median, 15.1 (11.9–21.8; log-rank P = .0459), (b) by ECOG PS: of 0–1 median, 22.3 months (13.7–NR); ECOG PS of 2–4 median, 8.2 (3.6–12.5) (0–1 vs 2–4; log-rank P <.001), (c) by LDH level: normal LDH median, 29.1 months (21.9–NR); elevated LDH median, 11.2 (5.1–16.8) (normal vs elevated; log-rank P <.001), (d) by corticosteroid prescription within 3 months before pembrolizumab initiation: no, median, 25.9 months (95% CI, 19.2–NR); yes, median 12.2 (8.4–19.4) (no vs yes; log-rank P = .0014).