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E. Mauro: Andrew K. Burroughs Short-Term Training Fellowship 2021 from EILF-EASL. M. Sanduzzi-Zamparelli received a grant from Instituto de Salud Carlos III (FI19/00222). G. Iserte received grant support from Asociacion Espanola para el Estudio del Higado (Beca de Enfermeria). Grant support from Societat Catalana de Digestologia. A. Forner: Grant from Instituto de Salud Carlos III (PI15/01229 and PI18/00542). The authors thank Jose Rios PhD from the Biostatistics Consulting Center, clinical research support section from IDIBAPS/FCRB and Hospital Clinic for providing statistical consulting services. CIBERehd is funded by the Instituto de Salud Carlos III. Some of the authors of this article are members of the European Reference Network (ERN) RARE-LIVER. Some of the authors of this article are members of the European Network for the Study of Cholangiocarcinoma (ENS-CCA) and participate in the initiative COST Action Precision-BTC-Network granted by the COST Association (CA22125).

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Evaluation of Overall Survival by Restricted Mean Survival Time of Advanced Biliary Tract Cancer treated with Immunotherapy: A Systematic Review and Meta-Analysis

Publicated to:Cancers. 16 (11): 2077- - 2024-06-01 16(11), DOI: 10.3390/cancers16112077

Authors: Mauro, Ezequiel; Sanduzzi-Zamparelli, Marco; Sauri, Tamara; Soler, Alexandre; Iserte, Gemma; Fortuny, Marta; Forner, Alejandro

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Abstract

Background: For biliary tract cancer (BTC), the addition of immunotherapy (durvalumab or pembrolizumab) to gemcitabine and cisplatin (GemCis) significantly improved overall survival (OS) in phase 3 clinical trials (RCTs). However, the interpretation and magnitude of the treatment effect is challenging because OS Kaplan-Meier curves violate the proportional hazards (PH) assumption. Analysis using restricted mean survival time (RMST) allows quantification of the benefits in the absence of PH. This systematic review and meta-analysis aims to assess the benefit of immunotherapy-based regimens for OS at 24 months using RMST analysis. Methods: A systematic review was conducted using studies published up to 8 November 2023. Only phase 3 RCTs evaluating the use of anti-PD-1/PD-L1 combined with GemCis and reporting OS were included. KM curves for OS were digitized, and the data were reconstructed. A meta-analysis for OS by RMST at 24 months was performed. Results: A total of 1754 participants from the TOPAZ-1 and KEYNOTE-966 trials were included. In TOPAZ-1, RMSTs at 24 months were 13.52 (7.92) and 12.21 (7.22) months with GemCis plus durvalumab and GemCis alone, respectively. In KEYNOTE-966, RMSTs at 24 months were 13.60 (7.76) and 12.45 (7.73) months with GemCis plus pembrolizumab and GemCis alone, respectively. Immunotherapy-based regimens showed a mean OS difference at 24 months by an RMST of 1.21 months [(95% CI: 0.49-1.93), p < 0.001, I-2 = 0%]. Conclusions: Immunotherapy-based regimens improve OS in advanced BTC. Given this magnitude of benefit, it is essential to weigh up individual patient factors, preferences, and potential risks. RMST analysis provides valuable information to patients and physicians, facilitating decision-making in a value-based medical environment.

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