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. 2021 Dec 6;12(12):CD011300.
doi: 10.1002/14651858.CD011300.pub3.

Immunotherapy (excluding checkpoint inhibitors) for stage I to III non-small cell lung cancer treated with surgery or radiotherapy with curative intent

Jianwei Zhu  1 , Yun Yuan  2 , Xiaoyu Wan  2 , Dan Yin  2 , Rui Li  3 , Wenwen Chen  2 , Chen Suo  4 , Huan Song  2   5
Affiliations

Immunotherapy (excluding checkpoint inhibitors) for stage I to III non-small cell lung cancer treated with surgery or radiotherapy with curative intent

Jianwei Zhu et al. Cochrane Database Syst Rev. .

Abstract

Background: Non-small cell lung cancer (NSCLC) is the most common lung cancer, accounting for approximately 80% to 85% of all cases. For people with localised NSCLC (stages I to III), it has been speculated that immunotherapy may be helpful for reducing postoperative recurrence rates, or improving the clinical outcomes of current treatment for unresectable tumours. This is an update of a Cochrane Review first published in 2017 and it includes two new randomised controlled trials (RCTs).

Objectives: To assess the effectiveness and safety of immunotherapy (excluding checkpoint inhibitors) among people with localised NSCLC of stages I to III who received curative intent of radiotherapy or surgery.

Search methods: We searched the following databases (from inception to 19 May 2021): CENTRAL, MEDLINE, Embase, CINAHL, and five trial registers. We also searched conference proceedings and reference lists of included trials.

Selection criteria: We included RCTs conducted in adults (≥ 18 years) diagnosed with NSCLC stage I to III after surgical resection, and those with unresectable locally advanced stage III NSCLC receiving radiotherapy with curative intent. We included participants who underwent primary surgical treatment, postoperative radiotherapy or chemoradiotherapy if the same strategy was provided for both intervention and control groups.

Data collection and analysis: Two review authors independently selected eligible trials, assessed risk of bias, and extracted data. We used survival analysis to pool time-to-event data, using hazard ratios (HRs). We used risk ratios (RRs) for dichotomous data, and mean differences (MDs) for continuous data, with 95% confidence intervals (CIs). Due to clinical heterogeneity (immunotherapeutic agents with different underlying mechanisms), we combined data by applying random-effects models.

Main results: We included 11 RCTs involving 5128 participants (this included 2 new trials with 188 participants since the last search dated 20 January 2017). Participants who underwent surgical resection or received curative radiotherapy were randomised to either an immunotherapy group or a control group. The immunological interventions were active immunotherapy Bacillus Calmette-Guérin (BCG) adoptive cell transfer (i.e. transfer factor (TF), tumour-infiltrating lymphocytes (TIL), dendritic cell/cytokine-induced killer (DC/CIK), antigen-specific cancer vaccines (melanoma-associated antigen 3 (MAGE-A3) and L-BLP25), and targeted natural killer (NK) cells. Seven trials were at high risk of bias for at least one of the risk of bias domains. Three trials were at low risk of bias across all domains and one small trial was at unclear risk of bias as it provided insufficient information. We included data from nine of the 11 trials in the meta-analyses involving 4863 participants. There was no evidence of a difference between the immunotherapy agents and the controls on any of the following outcomes: overall survival (HR 0.94, 95% CI 0.84 to 1.05; P = 0.27; 4 trials, 3848 participants; high-quality evidence), progression-free survival (HR 0.94, 95% CI 0.86 to 1.03; P = 0.19; moderate-quality evidence), adverse events (RR 1.12, 95% CI 0.97 to 1.28; P = 0.11; 4 trials, 4126 evaluated participants; low-quality evidence), and severe adverse events (RR 1.14, 95% CI 0.92 to 1.40; 6 trials, 4546 evaluated participants; low-quality evidence). Survival rates at different time points showed no evidence of a difference between immunotherapy agents and the controls. Survival rate at 1-year follow-up (RR 1.02, 95% CI 0.96 to 1.08; I2 = 57%; 7 trials, 4420 participants; low-quality evidence), 2-year follow-up (RR 1.02, 95% CI 0.93 to 1.12; 7 trials, 4420 participants; moderate-quality evidence), 3-year follow-up (RR 0.99, 95% CI 0.90 to 1.09; 7 trials, 4420 participants; I2 = 22%; moderate-quality evidence) and at 5-year follow-up (RR 0.98, 95% CI 0.86 to 1.12; I2 = 0%; 7 trials, 4389 participants; moderate-quality evidence). Only one trial reported overall response rates. Two trials provided health-related quality of life results with contradicting results. AUTHORS' CONCLUSIONS: Based on this updated review, the current literature does not provide evidence that suggests a survival benefit from adding immunotherapy (excluding checkpoint inhibitors) to conventional curative surgery or radiotherapy, for people with localised NSCLC (stages I to III). Several ongoing trials with immune checkpoints inhibitors (PD-1/PD-L1) might bring new insights into the role of immunotherapy for people with stages I to III NSCLC.

Trial registration: ClinicalTrials.gov NCT00409188 NCT00960115 NCT00290355 NCT00480025 NCT01015443.

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Conflict of interest statement

JZ: declares no conflict of interest

YY: declares no conflict of interest

XW: declares no conflict of interest

DY: declares no conflict of interest

RL: declares no conflict of interest

WC: declares no conflict of interest

CS: declares no conflict of interest

HS: declares no conflict of interest

Figures

1
1
Schematic diagram of the immune components and events involved in cancer immunotherapy APCs: antigen‐presenting cells; MHC: major histocompatibility complex; NK: natural killer
2
2
3
3
Risk of bias graph: review authors' judgements about each risk of bias domain, presented as percentages across all included trials.
4
4
Risk of bias summary: review authors' judgements about each risk of bias domain, for each included trial.
5
5
Forest plot of comparison: Effect of immunotherapy for surgically‐treated NSCLC patients: main analyses, outcome: Overall survival.
6
6
Forest plot of comparison: Effect of immunotherapy for surgically‐treated NSCLC patients: main analyses, outcome: Progression‐free survival.
1.1
1.1. Analysis
Comparison 1: Effect of immunotherapy for surgically treated NSCLC patients: main analyses, Outcome 1: Overall survival
1.2
1.2. Analysis
Comparison 1: Effect of immunotherapy for surgically treated NSCLC patients: main analyses, Outcome 2: Progression‐free survival
1.3
1.3. Analysis
Comparison 1: Effect of immunotherapy for surgically treated NSCLC patients: main analyses, Outcome 3: Overall survival rate, 1‐year
1.4
1.4. Analysis
Comparison 1: Effect of immunotherapy for surgically treated NSCLC patients: main analyses, Outcome 4: Overall survival rate, 2‐year
1.5
1.5. Analysis
Comparison 1: Effect of immunotherapy for surgically treated NSCLC patients: main analyses, Outcome 5: Overall survival rate, 3‐year
1.6
1.6. Analysis
Comparison 1: Effect of immunotherapy for surgically treated NSCLC patients: main analyses, Outcome 6: Overall survival rate, 5‐year
1.7
1.7. Analysis
Comparison 1: Effect of immunotherapy for surgically treated NSCLC patients: main analyses, Outcome 7: Adverse events (any)
1.8
1.8. Analysis
Comparison 1: Effect of immunotherapy for surgically treated NSCLC patients: main analyses, Outcome 8: Adverse events (severe, grade > 2)
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