|Year : 2022 | Volume
| Issue : 2 | Page : 482-487
Camrelizumab (SHR-1210) with carboplatin and albumin-binding paclitaxel in patients with metastatic or recurrent cervical cancer: An open-label, phase 2 trial
Xiaoling Zhang1, Jinlong Chen1, Naifu Liu1, Qian Wang1, Qian Wu1, Fufeng Gao1, Yingchun Sang1, Ping Wang2
1 Department of Gynecologic Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, People's Republic of China
2 Department of Gynecology, People's Hospital of Zouping City, Binzhou, Shandong, People's Republic of China
|Date of Submission||15-Oct-2021|
|Date of Decision||16-Feb-2022|
|Date of Acceptance||03-Mar-2022|
|Date of Web Publication||20-May-2022|
Department of Gynecologic Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong
People's Republic of China
Source of Support: None, Conflict of Interest: None
Aims: This study evaluates the safety and preliminary antitumor efficacy of camrelizumab with albumin-binding paclitaxel and cisplatin as first-line therapy for patients with recurrent or metastatic cervical carcinoma.
Methods and Material: In this phase 2, open-label, prospective study, 35 patients with recurrent or metastatic cervical carcinoma with no previous systemic chemotherapy were included. The patients were treated with a maximum of six cycles of camrelizumab on day 1, albumin-binding paclitaxel, and carboplatin on day 2, every 3 weeks, followed by camrelizumab once every 3 weeks. The primary outcomes were objective response rate (ORR) and disease control rate (DCR). Secondary outcomes were duration of response (DoR) and safety. Furthermore, 27 patients were included in the per-protocol set for efficacy analysis, whereas for the safety analysis, all patients were included.
Results: The median follow-up was 4.53 months, and the complete response, partial response, and stable disease were also achieved in 4 (14.81%), 6 (22.22%), and 13 (48.15%) patients. The ORR and DCR were 40.00% (95% confidence interval: 21.13–61.33%) and 92.00% (73.97–99.01%), respectively. The median DoR was 6.70 months. In addition, the most common adverse events (AEs) were reactive cutaneous capillary endothelial proliferation (RCCEP) (23, 65.71%), gastrointestinal reaction (8, 22.86%), and fever (8, 22.86%). Grade 3 AEs included 5 (14.29%) myelosuppression, and grade 4 AEs included 1 (2.86%) RCCEP and 1 (2.86%) bladder inflammation.
Conclusions: Combination therapy of camrelizumab and albumin-bound paclitaxel and carboplatin shows promising efficacy and manageable toxicities in patients with recurrent or metastatic cervical cancer.
Keywords: Albumin-bound paclitaxel, camrelizumab (shr-1210), carboplatin, cervical cancer, prospective study
|How to cite this article:|
Zhang X, Chen J, Liu N, Wang Q, Wu Q, Gao F, Sang Y, Wang P. Camrelizumab (SHR-1210) with carboplatin and albumin-binding paclitaxel in patients with metastatic or recurrent cervical cancer: An open-label, phase 2 trial. J Can Res Ther 2022;18:482-7
|How to cite this URL:|
Zhang X, Chen J, Liu N, Wang Q, Wu Q, Gao F, Sang Y, Wang P. Camrelizumab (SHR-1210) with carboplatin and albumin-binding paclitaxel in patients with metastatic or recurrent cervical cancer: An open-label, phase 2 trial. J Can Res Ther [serial online] 2022 [cited 2022 Jul 7];18:482-7. Available from: https://www.cancerjournal.net/text.asp?2022/18/2/482/345533
| > Introduction|| |
Cervical cancer is the fourth most commonly diagnosed and deadliest cancer in women globally. In 2013, 485,000 women were diagnosed with cervical cancer globally, which resulted in 236,000 deaths. Although preventable, it remains one of the major cancers that cause death in women, especially in developing countries. Interestingly, early-stage cervical cancer can be eradicated, and platinum-based chemotherapy combined with radiation was deemed highly active in the treatment of advanced cervical cancer during the late 1990s; approximately three decades passed before the FDA approved a new, targeted therapy for cervical cancer, bevacizumab, to be used in addition to the traditional platinum chemotherapy doublet. However, despite active research, the prognosis for recurrent, persistent, or metastatic disease is still poor. Chemotherapy remains the treatment of choice for these patients; however, it poses a palliative character that is neither curative nor associated with long-term disease control. Clinical trials on novel developed therapies are currently being studied to increase the options for management in this patient population. Currently, data are limited but are increasing in the use of immune checkpoint inhibitors in cervical cancer.
An essential feature of cervical carcinoma is its association with human papillomavirus infection, demonstrating an upregulation of programmed cell death-1 (PD-1) and programmed cell death-ligand 1 (PD-L1) in cervical cancer tumor cells. This feature of cervical carcinoma makes patients potentially suitable for immunotherapy. Therefore, PD-1 (pembrolizumab, nivolumab, cemiplimab) and PD-L1 inhibitors (atezolizumab, avelumab, durvalumab) are being evaluated in other cervical cancer trials.
To date, pembrolizumab and nivolumab have been approved for the treatment of patients with relapsed or refractory metastatic squamous cell carcinoma of the cervix, following the results of the KEYNOTE-158,826 and CheckMate-358 studies. However, the two-phase double trials demonstrated the moderate antitumor activity of nivolumab and pembrolizumab, for recurrent or metastatic cervical carcinoma.
Therefore, further investigation of immunotherapy and target drugs in this setting is required.
Recently, immune checkpoint inhibitors, as demonstrated by the humanized monoclonal antibodies, have been extensively studied in various tumor types, showing that pembrolizumab and nivolumab target PD-1, whereas atezolizumab, durvalumab, and avelumab target PD-L1. However, none of these drugs have obtained recent approval for patients with recurrent or metastatic cervical carcinoma.
Camrelizumab (SHR-1210) is a high-affinity, fully humanized IgG4-κ PD-1 monoclonal antibody that blocks the binding of PD-1 to its ligands. This report presents results from the phase II trials evaluating the safety and preliminary antitumor activity of camrelizumab combined with albumin-binding paclitaxel and cisplatin as first-line therapy for patients with recurrent or metastatic cervical carcinoma.
| > Subjects and Methods|| |
Study design and participants
Phase 2, open-label, prospective study was conducted at the Shandong Cancer Hospital and Institute (Jinan, China). Women aged 30–71 years initially diagnosed with cervical squamous cell carcinoma, adenocarcinoma, or adenosquamous carcinoma had metastatic disease or locoregional recurrence, were unsuitable for surgery or radiotherapy (histologically or cytologically confirmed and assessed by trained pathologists at the research institution), and were eligible to partake in the study. Additionally, an Eastern Cooperative Oncology Group performance status of ≤1 and at least one measurable lesion were assessed using the Response Evaluation Criteria in Solid Tumors v. 1.1 (RECIST 1.1) by the investigators. This assessment included an estimated life expectancy of 3 months or more and adequate organ function (the following were calculated using the Cockcroft–Gault formula: white blood cell count, ≥3.0 × 109 cells per L; absolute neutrophil count, ≥1.5 × 109 cells per L; hemoglobin concentrations, ≥80 g/L; platelet cell count, ≥80 × 109 cells per L; total bilirubin concentration, <1.5 times the upper limit of normal [ULN]; aspartate transaminase and alanine transaminase concentrations, <2.5 times ULN [could be extended to 5× in case of liver metastases]; and creatinine clearance rate, >45 mL/min). This study was approved by the Ethical Committee of Shandong Cancer Hospital and Institute on September 4, 2019.
The key exclusion criteria included a history of or active autoimmune disease; other malignant diseases; medical conditions requiring immunosuppressive medications, including steroids, innate, or acquired immunodeficiency disease; autoimmune hepatitis or active CNS metastases; grade 3–4 cardiac insufficiency by NYHA standard or left ventricular ejection fraction displayed by color Doppler echocardiography; thyroid dysfunction; and previous treatment with anti-PD-1 or anti-PD-L1 antibodies.
Patients were required to have no previous systemic chemotherapy except for concurrent chemoradiotherapy in the study. Additional criteria for inclusion and exclusion are provided in the protocols.
The local institutional review board approved the trial protocol following the Declaration of Helsinki and Good Clinical Practice guidelines defined by the International Conference on Harmonization. Moreover, all patients provided written and informed consent before enrollment.
During the trial, a maximum of six cycles of camrelizumab 200 mg was administered for 30 min on day 1 and albumin-binding paclitaxel 260 mg/m2 for 30 min on day 2. Additionally, carboplatin area under the curve of 5 (calculated by a radioisotope measurement of glomerular filtration rate) for 4 h on day 2 was intravenously administered every 3 weeks sequentially, followed by camrelizumab 200 mg maintenance therapy once every 3 weeks. The treatment was continued until the disease progressed, the patient withdrew, unacceptable toxic effects appeared, or death occurred. Furthermore, dose modifications of camrelizumab were not permitted. The administration of camrelizumab was interrupted if the patients had grade 3 or worse hematological adverse occurrences or grade 2 or worse nonhematological adverse events (AEs) (these were not defined as dose-limiting toxic effects). The severity of AEs was graded by investigators using NCI-CTC AE 4.0. The effectiveness evaluation was conducted every two cycles (the time was calculated based on calendar days and unaffected by the drug withdrawal) according to RECIST 1.1, with the evaluation time performed within 7 days at the end of the cycle (except statutory holidays). Also, evaluation should be performed by CT or MRI; the same imaging techniques should be employed in the preevaluation and postevaluation of the same patient, and all imaging data should be retained. The subjects whose therapeutic effects reached complete response (CR), partial response (PR), and SD need to be re-examined and confirmed 4 weeks after the first evaluation.
Objective response rate (ORR) and disease control rate (DCR). ORR refers to the proportion of patients whose tumors shrink to certain levels and maintain a certain time, including CR and PR cases. DCR was defined as the proportion of patients who achieved a CR, a PR, or stable disease. The secondary outcomes were duration of response (DoR) and safety. DoR refers to dates of PD or death from the first CR or PR. Also, the safety of the treatment was evaluated by the occurrence of AEs and the severity graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events, v. 4.0.
The data cutoff date for this analysis was April 30, 2020. Data were expressed as mean ± standard deviation, median (minimum–maximum), frequency (constituent ratio), and rate with confidence interval (CI) where appropriate. Also, response and disease progression were expressed as rate (%) with 95% CI. The treatment efficacy was analyzed in the per-protocol set (PPS), and safety was analyzed in the safety set (SS). SPSS v. 22.0 was used for all analyses. This study is registered with the Chinese Clinical Trial Registry, ChiCTR1900025992.
| > Results and Discussion|| |
A total of 35 patients were enrolled in the study, and their baseline characteristics are presented in [Table 1]. All 35 patients were treated with the study medication at least once, and their safety data was recorded. They were also included in the SS for safety analysis. In addition, 27 patients were treated according to the protocol and then included in the PPS for efficacy analysis.
Till the data cutoff, the median follow-up was 4.53 (0.72–10.97) months until the data cutoff. Also, only two (7.41%) patients had disease progression, two (7.41) died, and three (11.11%) were lost to follow-up. CR, PR, SD was achieved in 4 (14.81%), 6 (22.22%), and 13 (48.15%) patients, respectively. The ORR and DCR were 40.00% (95% CI: 21.13–61.33%) and 92.00% (95% CI: 73.97–99.01%), respectively. These details are presented in [Table 2]. Also, the best percentage change for each patient is shown in [Figure 1].
|Figure 1: Waterfall plot of the best percent change from baseline in target lesion size (based on PPS)|
Click here to view
–7.60) months [Figure 2]. The most common AEs were reactive cutaneous capillary endothelial proliferation (RCCEP), observed in 23 (65.71%) patients, followed by gastrointestinal reaction (8, 22.86%) and fever (8, 22.86%). Also, grade 3 AEs included five (14.29%) myelosuppression, and grade four AEs included 1 (2.86%) RCCEP and one (2.86%) bladder inflammation. The detailed AEs are presented in [Table 3].
In this report, assessed the combined therapy of camrelizumab and albumin-binding paclitaxel with carboplatin in patients with metastatic or recurrent cervical cancer. Our results indicated that the addition of camrelizumab to chemotherapy with albumin-binding paclitaxel and carboplatin for these patients showed a favorable antitumor activity. We also observed that 40% (95% CI 21.13–61.33%) of the patients achieved an objective response, and the DCR has reached 92% (95% CI 73.97–99.01%). Furthermore, the combination of the regime showed a manageable toxicity profile.
Although cervical carcinoma is a chemosensitive tumor, a high proportion of patients with recurrent or metastatic cervical carcinoma can respond with platinum-based chemotherapy regimens during the first-line treatment, with patients who are persistent or progress after chemotherapy having few treatment options. In this setting, salvage chemotherapy and targeted drugs produce a moderate antitumor activity as second-line or later treatment.,,,,,, Compared with traditional medicines, albumin-bound paclitaxel is more efficient and less toxic.,,, A phase II study demonstrated that albumin-bound paclitaxel was effective in the second-line treatment of recurrent or persistent advanced cervical cancer, with an ORR and DCR of 28.6 and 71.5%, respectively. In addition, a subgroup analysis of another phase II study showed that the ORR of albumin-bound paclitaxel combined with nedaplatin in the first-line treatment of cervical cancer was as high as 66.7%. Only small studies in cervical carcinoma have been published for the immune checkpoint inhibitors. In the CheckMate 358 trial, the ORR was 26.3% (95% CI, 9.1–51.2) for cervical cancer, and the median overall survival was 21.9 months (95% CI, 15.1 months to not reached) among patients with cervical cancer. In the KEYNOTE-028 trial, the overall response rate was 17% (95% CI, 5–37%), and the DCR was 30%.
Whether pembrolizumab or nivolumab alone showed minimal activity in women with recurrent cervical cancer, the combination of immunity and chemotherapy could show good antitumor activity potential in patients with recurrent cervical cancer. Interestingly, in the KEYNOTE-189 study,, frontline pembrolizumab combined with pemetrexed and carboplatin improved the overall survival of advanced nonsquamous cell lung cancer, irrespective of the PD-L1 expression level. This combined approach is currently investigated in various cancer types.,, In this study, the combination of camrelizumab and albumin-bound paclitaxel and carboplatin as first-line treatment in recurrent or metastatic cervical carcinoma led to a proportion of 40.00% (95% CI 21.13–61.33) patients with objective response and 92.00% (73.97–99.01) of patients achieving disease control, including 14.81% (4/27 patients) CR and 22.22% (6/27 patients) PR. Also, the tumor shrinkage was large, and the response was durable. The results of this trial provide support for further assessment of this combination approach in phase 3 studies.
Additionally, fatigue and hypothyroidism are considered to be the most common AEs related to immunotherapy agents. Importantly, a frequent AE, capillary hemangioma with the hyperproliferative vascular response, was observed in about two-thirds of patients in our group, as previously reported in patients with both advanced esophageal and recurrent nasopharyngeal carcinoma treated with camrelizumab., Although neutropenia and anemia were the top grade 3 hematological toxicities caused by albumin-bound paclitaxel and carboplatin, there was no treatment-related death. These data revealed that camrelizumab combined with albumin-bound paclitaxel and carboplatin regimen is generally manageable in patients with recurrent or metastatic cervical carcinoma.
Its inadequate validation with randomization and the small sample size of patients treated with camrelizumab plus albumin-bound paclitaxel and carboplatin. Therefore, a phase 3 randomized, placebo-controlled trial will be needed to validate the results of the current study. In addition, this study was conducted in Chinese patients only, causing the results to differ from different ethnic groups. Finally, there is no clear basis for determining patient type that benefits from immunotherapy and a small amount of data supporting the PD-1-positive patients and microsatellite instability results. Our research results also support this point. We also analyze and compare the blood and tissue samples of patients with good or poor effects, hoping to find sensitive indicators to this treatment regimen.
Conclusively, our study demonstrated that the combination therapy of camrelizumab and albumin-bound paclitaxel and carboplatin had significant efficacy and manageable toxicities in patients with recurrent or metastatic cervical cancer; therefore, further study in phase 3 trials is warranted.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]