Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia; Royal North Shore and Mater Hospitals, Sydney, Australia.
Service de Dermatologie, Centre Hospitalo-Universitaire Timone, Aix Marseille Université, Marseille CEDEX 05, France.
Lancet Oncol. 2016 Dec;17(12):1743-1754. doi: 10.1016/S1470-2045(16)30578-2. Epub 2016 Nov 16.
BACKGROUND: Dabrafenib plus trametinib treatment provides significant benefits over BRAF-inhibitor monotherapy in patients with BRAF-mutant or BRAF-mutant advanced melanoma; however, in many patients the disease progresses, leading to death. With many treatment options available, understanding clinical factors that predict long-term response and survival for treatments is important for optimisation of patient management. We aimed to identify clinical factors associated with long-term response and survival using pooled data from randomised trials of dabrafenib plus trametinib in patients with metastatic BRAF-mutant melanoma. METHODS: We did a retrospective individual data analysis based on all published randomised trials that included treatment-naive patients with BRAF-mutant or BRAF-mutant metastatic melanoma who received the approved dose of dabrafenib 150 mg twice daily plus trametinib 2 mg once daily. Data were pooled from patients in the BRF113220 (part C; March 26, 2010, to Jan 15, 2015), COMBI-d (May 4, 2012, to Jan 12, 2015), and COMBI-v (June 4, 2012, to March 13, 2015) randomised trials. Patients with untreated brain metastases were not permitted to enrol in these trials. Baseline factors, identified a priori based on known melanoma clinical or prognostic characteristics, were analysed for association with progression-free survival and overall survival using univariate and multivariate analyses and assessed for hierarchical effect on outcomes using regression tree analyses. We also analysed factors identified after baseline, on treatment, and at progression, for associations with survival after progression. The trials included in this analysis are registered with ClinicalTrials.gov: BRF113220, number NCT01072175; COMBI-d, number NCT01584648; COMBI-v, number NCT01597908. FINDINGS: 617 patients were included in this analysis with a median follow-up of 20·0 months (range 0-48·0, IQR 10·1-24·8); 396 patients had progression events (ie, disease progression or death) and 290 patients had died. Median progression-free survival (11·1 months [95% CI 9·7-12·9]), median overall survival (25·6 months [23·1-34·3]), 1-year progression-free survival (48% [44-52]) and overall survival (74% [71-78]), and 2-year progression-free survival (30% [26-34]) and overall survival (53% [49-57]) were consistent with those in the individual trials. Patients with normal lactate dehydrogenase (LDH) concentration and fewer than three organ sites containing metastases (n=237) had the longest 1-year progression-free survival (68% [95% CI 62-74]) and overall survival (90% [87-94]) and 2-year progression-free survival (46% [40-54]) and overall survival (75% [70-81]), whereas patients with LDH concentration at least two times the upper limit of normal (n=70) had the shortest 1-year progression-free survival (8% [3-19]) and overall survival (40% [29-55]) and 2-year progression-free survival (2% [0-13]) and overall survival (7% [3-19]). Of patients with disease progression (n=379), survival after progression was longest in those with progression in baseline or new non-CNS lesions (n=205; median 10·0 months [95% CI 7·9-12·0]) and shortest in those with new CNS lesions or concurrent progression in baseline and new lesions (n=171; median 4·0 months [3·5-4·9]). INTERPRETATION: Several patient and clinical characteristics at and after baseline are associated with outcomes with dabrafenib plus trametinib, and durable benefit is possible with targeted treatment in defined patient subsets. FUNDING: Novartis.
背景:达拉非尼联合曲美替尼治疗可为 BRAF 突变或 BRAF 突变晚期黑色素瘤患者提供显著优于 BRAF 抑制剂单药治疗的获益;然而,在许多患者中疾病会进展,导致死亡。有许多治疗方案可供选择,了解预测治疗长期反应和生存的临床因素对于优化患者管理非常重要。我们旨在使用达拉非尼联合曲美替尼治疗转移性 BRAF 突变黑色素瘤患者的随机试验汇总数据,确定与长期反应和生存相关的临床因素。
方法:我们进行了基于所有已发表的随机试验的回顾性个体数据分析,这些试验纳入了初治的 BRAF 突变或 BRAF 突变转移性黑色素瘤患者,他们接受了批准剂量的达拉非尼 150 mg 每日两次联合曲美替尼 2 mg 每日一次治疗。数据来自 BRF113220 部分 C(2010 年 3 月 26 日至 2015 年 1 月 15 日)、COMBI-d(2012 年 5 月 4 日至 2015 年 1 月 12 日)和 COMBI-v(2012 年 6 月 4 日至 2015 年 3 月 13 日)随机试验。这些试验不允许未经治疗的脑转移患者入组。根据已知的黑色素瘤临床或预后特征,我们预先确定了基线因素,并使用单变量和多变量分析评估了这些因素与无进展生存期和总生存期的关系,并使用回归树分析评估了这些因素对结局的分层影响。我们还分析了基线后、治疗期间和进展时确定的因素与进展后生存的关系。这项分析中纳入的试验在 ClinicalTrials.gov 注册:BRF113220,编号 NCT01072175;COMBI-d,编号 NCT01584648;COMBI-v,编号 NCT01597908。
结果:这项分析纳入了 617 例患者,中位随访时间为 20·0 个月(范围 0-48·0,IQR 10·1-24·8);396 例患者发生了进展事件(即疾病进展或死亡),290 例患者死亡。中位无进展生存期(11·1 个月[95%CI 9·7-12·9])、中位总生存期(25·6 个月[23·1-34·3])、1 年无进展生存率(48%[44-52])和总生存率(74%[71-78]),以及 2 年无进展生存率(30%[26-34])和总生存率(53%[49-57])与各试验中的结果一致。乳酸脱氢酶(LDH)浓度正常且转移灶不超过三个器官部位的患者(n=237)的 1 年无进展生存率(68%[95%CI 62-74])和总生存率(90%[87-94])最长,2 年无进展生存率(46%[40-54])和总生存率(75%[70-81])也最长,而 LDH 浓度至少为正常值两倍的患者(n=70)的 1 年无进展生存率(8%[3-19])和总生存率(40%[29-55])以及 2 年无进展生存率(2%[0-13])和总生存率(7%[3-19])最短。在发生疾病进展的患者(n=379)中,基线或新非中枢神经系统病变进展的患者(n=205;中位生存时间 10·0 个月[95%CI 7·9-12·0])的生存时间最长,而新中枢神经系统病变或基线和新病变同时进展的患者(n=171;中位生存时间 4·0 个月[3·5-4·9])的生存时间最短。
结论:达拉非尼联合曲美替尼治疗时的几个患者和临床特征与结局相关,在特定患者亚组中进行靶向治疗可能获得持久的获益。
资助:诺华公司。
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