Clinical trials frequently include multiple end points that mature at different times. The initial report, typically based on the primary end point, may be published when key planned co-primary or secondary analyses are not yet available. Clinical Trial Updates provide an opportunity to disseminate additional results from studies, published in JCO or elsewhere, for which the primary end point has already been reported. PURPOSE: The phase III ADAURA (ClinicalTrials.gov identifier: NCT02511106 ) primary analysis demonstrated a clinically significant disease-free survival (DFS) benefit with adjuvant osimertinib versus placebo in EGFR-mutated stage IB-IIIA non–small-cell lung cancer (NSCLC) after complete tumor resection (DFS hazard ratio [HR], 0.20 [99.12% CI, 0.14 to 0.30]; P < .001). We report an updated exploratory analysis of final DFS data. METHODS: Overall, 682 patients with stage IB-IIIA (American Joint Committee on Cancer/Union for International Cancer Control, seventh edition) EGFR-mutated (exon 19 deletion/L858R) NSCLC were randomly assigned 1:1 (stratified by stage, mutational status, and race) to receive osimertinib 80 mg once-daily or placebo for 3 years. The primary end point was DFS by investigator assessment in stage II-IIIA disease analyzed by stratified log-rank test; following early reporting of statistical significance in DFS, no further formal statistical testing was planned. Secondary end points included DFS in stage IB-IIIA, overall survival, and safety. Patterns of recurrence and CNS DFS were prespecified exploratory end points. RESULTS: At data cutoff (April 11, 2022), in stage II-IIIA disease, median follow-up was 44.2 months (osimertinib) and 19.6 months (placebo); the DFS HR was 0.23 (95% CI, 0.18 to 0.30); 4-year DFS rate was 70% (osimertinib) and 29% (placebo). In the overall population, DFS HR was 0.27 (95% CI, 0.21 to 0.34); 4-year DFS rate was 73% (osimertinib) and 38% (placebo). Fewer patients treated with osimertinib had local/regional and distant recurrence versus placebo. CNS DFS HR in stage II-IIIA was 0.24 (95% CI, 0.14 to 0.42). The long-term safety profile of osimertinib was consistent with the primary analysis. CONCLUSION: These updated data demonstrate prolonged DFS benefit over placebo, reduced risk of local and distant recurrence, improved CNS DFS, and a consistent safety profile, supporting the efficacy of adjuvant osimertinib in resected EGFR-mutated NSCLC.

High tumor mutational burden (TMB), which represents genomic instability, has the potential to induce neoantigen production and further immunogenicity improvement.¹ Recent studies have confirmed that TMB measured by whole-exome sequencing (WES) or a next-generation sequencing (NGS) cancer gene panel (CGP) can serve as a candidate biomarker of clinical outcome from immune checkpoint blockades (ICBs)^2,3 in melanoma,^4,5 lung cancer,^6-9 and urothelial carcinoma.¹⁰ However, a considerable proportion of patients with advanced cancer could not provide sufficient tumor tissue for molecular testing.^8,11 Therefore, whether TMB can be measured using circulating tumor DNA (ctDNA) (namely, blood TMB [bTMB]) as a noninvasive approach to guide ICB therapies has attracted widespread attention from practitioners. A previous study¹² found that blood-derived variants of unknown significance were correlated with ICB responses. More recently, Gandara et al¹³ reported that bTMB is associated with progression-free survival (PFS) benefit from atezolizumab over docetaxel in non–small cell lung cancers (NSCLCs). Further evaluation of bTMB will be performed in patients undergoing first-line treatment in a prospective, phase 3 randomized clinical trial (A Study of Atezolizumab as First-line Monotherapy for Advanced or Metastatic Non–Small Cell Lung Cancer [B-F1RST]).¹⁴ However, the reliability of ctDNA detection is still under debate^15,16; thus, more supported evidence of bTMB is needed to promote its clinical value on guiding ICB delivery. In this study, we aimed to explore the optimal gene panel size and algorithm to design a CGP for TMB estimation, evaluate the panel reliability, and further validate the feasibility of bTMB as a clinically actionable biomarker for immunotherapy.

Lung cancer is a leading cause of cancer incidence and death.¹ As most squamous non–small-cell lung cancers (sq-NSCLCs) are diagnosed at an advanced stage,² disease management can be challenging.³ Prognosis has been poor for patients treated with standard platinum-based chemotherapy, highlighting a high unmet medical need.^3-6 Combining standard first-line regimens with monoclonal antibodies that block programmed cell death receptor 1 (PD-1) and its ligand (PD-L1) has led to improvements in the treatment of NSCLC.^2,7

Immunotherapy is one of the most important breakthroughs in cancer treatment, especially immune checkpoint inhibitors targeting programmed cell death 1 (PD-1) and PD ligand 1 (PD-L1), which significantly prolonged overall survival (OS) and possessed superior safety profile in patients with cancer compared with standard therapies across a wide range of tumor types.^1,2 With the increasing studies in immunotherapy, differences between the clinical performance of anti–PD-1 and anti–PD-L1 started to be reported. For example, recent findings from the KEYNOTE-426 study demonstrated significant OS improvement with the combination of anti–PD-1 (pembrolizumab) plus axitinib vs sunitinib in previously untreated patients with advanced renal cell carcinoma (RCC)³; however, anti–PD-L1 (avelumab) plus axitinib failed to demonstrate OS superiority over sunitinib in the same settings.⁴ In addition, anti–PD-1 (pembrolizumab) plus carboplatin and nab-paclitaxel has been approved by the US Food and Drug Administration for first-line treatment of metastatic, squamous non–small cell lung cancer (NSCLC) based on the positive results from KEYNOTE-407,⁵ while anti–PD-L1 (atezolizumab) plus carboplatin and nab-paclitaxel failed to show an OS benefit compared with chemotherapy in squamous NSCLC in IMpower131.^6,7 Such disparities have attracted widespread attention by clinicians, and there is a need to better understand the similarities and differences between anti–PD-1 and anti–PD-L1 for the ultimate benefit of patients with cancer.

T-cell receptor (TCR)–based biomarkers might predict patient response to immune checkpoint blockade (ICB) but need further exploration and validation for that use. We sequenced complementarity-determining region 3 of TCRβ chains isolated from PD-1+ CD8+ T cells to investigate its value for predicting the response to anti–programmed cell death 1 (PD-1)/PD-ligand 1 (PD-L1) therapy in patients with non–small cell lung cancer (NSCLC). Two independent patient cohorts (cohort A, n = 25; cohort B, n = 15) were used as discovery and validation sets, respectively. Pre- and post-ICB peripheral blood samples were collected. In cohort A, patients with high PD-1+ CD8+ TCR diversity before ICB treatment showed better response to ICB and progression-free survival (PFS) compared with patients with low diversity [6.4 months vs. 2.5 months, HR, 0.39; 95% confidence interval (CI), 0.17–0.94; P = 0.021]. The results were validated in cohort B. Pre-ICB PD-1+ CD8+ TCR diversity achieved an optimal Youden's index of 0.81 (sensitivity = 0.87 and specificity = 0.94) for differentiating the ICB response in the merged dataset (cohort A plus cohort B). Patients with increased PD-1+ CD8+ TCR clonality after ICB treatment had longer PFS (7.3 months vs. 2.6 months, HR, 0.26; 95% CI, 0.08–0.86; P = 0.002) than those with decreased clonality. Thus, TCR diversity and clonality in peripheral blood PD-1+ CD8+ T cells may serve as noninvasive predictors of patient response to ICB and survival outcomes in NSCLC.

PURPOSE: The CHOICE-01 study investigated the efficacy and safety of toripalimab in combination with chemotherapy as a first-line treatment for advanced non–small-cell lung cancer (NSCLC). PATIENTS AND METHODS: Patients (N = 465) with treatment-naive, advanced NSCLC without EGFR/ALK mutations were randomly assigned 2:1 to receive toripalimab 240 mg (n = 309) or placebo (n = 156) once every 3 weeks in combination with chemotherapy for 4-6 cycles, followed by the maintenance of toripalimab or placebo once every 3 weeks plus standard care. Stratification factors included programmed death ligand-1 expression status, histology, and smoking status. The primary end point was progression-free survival (PFS) by investigator per RECIST v1.1. Secondary end points included overall survival and safety. RESULTS: At the final PFS analysis, PFS was significantly longer in the toripalimab arm than in the placebo arm (median PFS, 8.4 v 5.6 months, hazard ratio = 0.49; 95% CI, 0.39 to 0.61; two-sided P < .0001). At the interim OS analysis, the toripalimab arm had a significantly longer OS than the placebo arm (median OS not reached v 17.1 months, hazard ratio = 0.69; 95% CI, 0.53 to 0.92; two-sided P = .0099). The incidence of grade ≥ 3 adverse events was similar between the two arms. Treatment effects were similar regardless of programmed death ligand-1 status. Genomic analysis using whole-exome sequencing from 394 available tumor samples revealed that patients with high tumor mutational burden were associated with significantly better PFS in the toripalimab arm (median PFS 13.1 v 5.5 months, interaction P = .026). Notably, patients with mutations in the focal adhesion-PI3K-Akt signaling pathway achieved significantly better PFS and OS in the toripalimab arm (interaction P values ≤ .001). CONCLUSION: Toripalimab plus chemotherapy significantly improves PFS and OS in patients with treatment-naive advanced NSCLC while having a manageable safety profile. Subgroup analysis showed the OS benefit was mainly driven by the nonsquamous subpopulation.