Effects of Acetaminophen Exposure on Outcomes of Patients Receiving Immune Checkpoint Inhibitors for Advanced Non-Small-Cell Lung Cancer: A Propensity Score-Matched Analysis

Round 1

Reviewer 1 Report

In this manuscript, the authors discussed the results of a retrospective analysis on the impact of concomitant Acetaminophen (APAP) intake on the clinical benefit and survival outcomes of patients with advanced non-small cell lung cancer (NSCLC) undergoing PD-1/PD-L1 blockade therapy. The study found that a high level of APAP exposure between 30 days before and 90 days after the first cycle of immunotherapy resulted in an increased risk of treatment failure and shorter progression-free survival (PFS) and overall survival (OS). The research utilized real-life data from a single center, and though it has some limitations, it provided evidence of APAP's potential to suppress the anticancer immune response.

1.       As the study is retrospective, which limits the generalizability of the results, the authors could consider conducting a prospective study to confirm the findings.

2.       The study is relatively small, which limits the power of the study to detect statistically significant differences.

3.       The authors could also consider adjusting for other factors that could influence ICI outcomes, such as the patient's age, performance status, and tumor burden.

Author Response

Reviewer 1

Answers to Comments and Suggestions for Authors

In this manuscript, the authors discussed the results of a retrospective analysis on the impact of concomitant Acetaminophen (APAP) intake on the clinical benefit and survival outcomes of patients with advanced non-small cell lung cancer (NSCLC) undergoing PD-1/PD-L1 blockade therapy. The study found that a high level of APAP exposure between 30 days before and 90 days after the first cycle of immunotherapy resulted in an increased risk of treatment failure and shorter progression-free survival (PFS) and overall survival (OS). The research utilized real-life data from a single center, and though it has some limitations, it provided evidence of APAP's potential to suppress the anticancer immune response.

1. As the study is retrospective, which limits the generalizability of the results, the authors could consider conducting a prospective study to confirm the findings.

- The study has a retrospective design, in that all patients' concomitant drug prescriptions were reviewed during the period of interest. However, the assessment of clinical outcomes, including disease response, PFS, and OS, was conducted on a prospective basis, in accordance with the rules of the National registry for monitoring the reimbursement of high-cost drugs [Registri farmaci sottoposti a monitoraggio. https://www.aifa.gov.it/registri-farmaci-sottoposti-a-monitoraggio]. Close adherence to the data from this registry can ensure the reliability of our findings, even if they are retrospective, and acceptably support their generalizability. On the other hand, we fully agree with the Reviewer that a prospective study, even an observational one, would be ideal for more reliably defining the safety of not only APAP but also other concomitant medications during treatment with ICIs. Such research is challenging to conduct considering that prescribers' attitudes and the availability of different concurrent drugs can vary significantly among oncology facilities. As proof of this, we should also note that all previous investigations on this topic, in every therapeutic setting, have been conducted with a retrospective design. Based on the results of this study, in an effort to obtain relevant prospective data, we asked the National Agency for prescription monitoring to include the most important concomitant medications among the basic requirements for authorizing the use of ICIs.

2. The study is relatively small, which limits the power of the study to detect statistically significant differences.

- As suggested by the Reviewer, we have further emphasized this methodological constraint of the study in the part of the "Discussion" addressing its limitations. The most important methodological flaws of this study are the sample size and the duration of follow-up after first-line treatment, both of which are limited. PSM mitigated potential confounders from selection bias, but resulted in a numerical reduction of cases in both treatment settings. The power of the study to detect statistically significant differences is consequently blunted. This also implies that multivariate statistical analyses may increase the occurrence of false-positive results. Their significance should be properly considered as a means of generating research hypotheses.

3. The authors could also consider adjusting for other factors that could influence ICI outcomes, such as the patient's age, performance status, and tumor burden.

- We reprocessed the multivariate survival analysis following the Reviewers' recommendations. Hazard ratios (HRs) with 95% CI for PFS and OS were analyzed using multivariable Cox proportional hazards models adjusted for age, sex, ECOG PS, histology, disease burden, and disease burden categories (all covariates potentially affecting time-to-event outcomes). Each part of the manuscript (Statistical analysis and Survival analysis sections, and Table 4) has been consistently modified.

Author Response File: Author Response.docx

Reviewer 2 Report

1.This research focused on Effects of acetaminophen exposure on outcomes of patients receiving immune checkpoint inhibitors for advanced non-small- cell lung cancer: a propensity score-matched analysis

, after check the pubmed, there were few related references, so this manuscript was very prospective and significant.

2.This was a very interesting question, to relieve the pain  some drug such as acetaminophen was used but maybe these drugs can influenced the OS or PFS of the advanced non-small- cell lung cancerpatients . 

3.Do the drug acetaminophen influence the pharmacological activity of the immune checkpoint inhibitors ? or use some cell or animal lab  to identify, some references also ok.

4.Which drug can relieve the pain but no potient hamful to the NSCLC patients?Can you give some suggesitons?Such as some TCM.

5.Do you think the acetaminophen use was a independent factor of the NSCLC patients? Aslo you at last discuss the restrict of this study the Nnmber of patients not enough.

6.English should be more polish.

Maybe ok

Author Response

Reviewer 2

Answers to Comments and Suggestions for Authors

1.This research focused on Effects of acetaminophen exposure on outcomes of patients receiving immune checkpoint inhibitors for advanced non-small- cell lung cancer: a propensity score-matched analysis, after check the pubmed, there were few related references, so this manuscript was very prospective and significant.

- Besides the pivotal study by Bassede et al. [1], the present is the first investigation that attempts to address this issue. This evidence probably reflects the challenges of conducting such clinical research. The methodological difficulties consist in the complex accountability of APAP intake owing to its over-the-counter medication status.

2.This was a very interesting question, to relieve the pain  some drug such as acetaminophen was used but maybe these drugs can influenced the OS or PFS of the advanced non-small- cell lung cancer patient.

- The question this study seeks to answer is clinically relevant for three main reasons. First, cancer-related pain is one of the most frequently symptoms reported by patients with advanced lung cancer. Second, APAP, alone or in combination, is the most commonly used drug by these patients to relieve mild or moderate pain. The latter evidence implies that most patients in this condition will take APAP episodically or regularly. Third, after initial preclinical evidence, recent demonstrations at the clinical level suggest that APAP intake may result in detrimental effects on the antitumor immune response [1]. It follows that our findings, if supported by further experimental confirmation, could change prescribing attitudes toward many cancer patients.

3.Do the drug acetaminophen influence the pharmacological activity of the immune checkpoint inhibitors ? or use some cell or animal lab  to identify, some references also ok.

- Immune checkpoint inhibitors (ICIs) targeting PD-1 or its ligand PD-L1 (including nivolumab, atezolizumab, and pembrolizumab) are human monoclonal antibodies, as such pharmacokinetic interaction studies have not been conducted. As monoclonal antibodies are not metabolized by cytochrome P450 (CYP) enzymes or other drug metabolizing enzymes, inhibition or induction of these enzymes by co-administered medicinal products is not anticipated to affect their pharmacokinetics. The metabolic pathway of these agents has not been characterized. They are expected to be degraded into small peptides and amino acids via catabolic pathways in the same manner as endogenous IgG [2-4]. The interaction between APAP and ICIs would occur at the immunological level, but data on the potential impact of APAP on anticancer immunity are almost nonexistent. Bassede et al. suggested that the detrimental effect of APAP on the immune response would occur through increased function of regulatory T cells and enhanced signaling of their crucial mediator IL-10 [1]. Besides the experimental evidence provided by the French authors, only a few preclinical studies support this hypothesis [5-7]. According to the Reviewer's suggestion, we have quoted all relevant references in the "Discussion" section.

4.Which drug can relieve the pain but no potient hamful to the NSCLC patients?Can you give some suggesitons?Such as some TCM.

- The clinical findings of Bassede et al. and those of the present research are concerning with regard to the indiscriminate use of APAP for the treatment of cancer pain in patients undergoing ICIs.  However, this evidence needs validation before it can be translated into a therapeutic recommendation. Similarly, the use of oral opioids has also been challenged by the demonstration of a potential detrimental effect on the efficacy of immunotherapy [8-9]. Conversely, nonsteroidal anti-inflammatory drugs (NSAIDs) have been associated with improved outcomes in the same condition [10]. Their prescription for cancer pain cannot be recommended as preferred because of the well-known side effect profile that limits their manageability in this treatment setting. The use of traditional Chinese medicine (TCM) to relieve cancer pain is certainly attractive because, being a nonpharmacological intervention, it should not interfere with the systemic immune response [11]. The greatest uncertainties about the use of this alternative method concern its applicability outside China and other East Asian countries.

5.Do you think the acetaminophen use was a independent factor of the NSCLC patients? Aslo you at last discuss the restrict of this study the Nnmber of patients not enough.

- Our data expand on previous findings by Bassede et al. [1] suggesting that excessive APAP intake (pronounced and/or prolonged dosages) may be harmful to the therapeutic success of anti-PD1/PD-L1 agents in advanced NSCLC.  While the constraints of this research mandate further experimental verification, we would advise against the indiscriminate use of APAP in these patients. As suggested by the Reviewer, we have further emphasized this methodological constraint of the study in the part of the "Discussion" addressing its limitations. The most important methodological flaw of this study is the limited sample size. PSM mitigated potential confounders from selection bias, but resulted in a numerical reduction of cases in both treatment settings. The power of the study in detecting statistically significant differences is consequently blunted. This also implies that multivariate statistical analyses may increase the occurrence of false-positive results. Their significance should be properly considered as a means of generating research hypotheses.

6.English should be more polish.

 - We revised the entire manuscript to improve the quality and fluency of English.

References

1. Bessede, A.; Marabelle, A.; Guégan, J.P.; Danlos, F.X.; Cousin, S.; Peyraud, F.; Chaput, N.; Spalato, M.; Roubaud, G.; Cabart, M.; et al. Impact of acetaminophen on the efficacy of immunotherapy in cancer patients. Ann Oncol. 2022, 33, 909-915.
2. Nivolumab: summary of product characteristics. https://www.ema.europa.eu/en/documents/product-information/opdivo-epar-product-information_en.pdf
3. Atezolizumab: summary of product characteristics. https://www.ema.europa.eu/en/documents/product-information/tecentriq-epar-product-information_en.pdf
4. Pembrolizumab: summary of product characteristics. https://www.ema.europa.eu/en/documents/product-information/keytruda-epar-product-information_en.pdf
5. Wang, X.; Sun, R.; Chen, Y.; Lian, Z.X.; Wei, H.; Tian, Z. Regulatory T cells ameliorate acetaminophen-induced immune-mediated liver injury. Int Immunopharmacol. 2015,25, 293-301.
6. Kim, H.; Keum, D.J.; Kwak, J.W.; Chung, H.S.; Bae, H. Bee venom phospholipase A2 protects against acetaminophen-induced acute liver injury by modulating regulatory T cells and IL-10 in mice. PLoS One. 2014, 9, e114726.
7. Thiele, K.; Solano, M.E.; Huber, S.; Flavell, R.A.; Kessler, T.; Barikbin, R.; et al. Prenatal acetaminophen affects maternal immune and endocrine adaptation to pregnancy, induces placental damage, and impairs fetal development in mice. Am J Pathol. 2015, 185, 2805-2818.
8. Mock, J.; Wynter, E.; Young, P.; Sytov, A.; Elghawy, O.; Gentzler, R.; Novicoff, W.; Martin, L.; Hall, R. MO01.12 Association of Opioid Use with Survival in Non-Small Cell Lung Cancer Patients Treated with Immune Checkpoint Inhibitor Therapy. J. Thorac.Oncol. 2021, 16, S20–S21.
9. Cani, M.; Bironzo, P.; Garetto, F.; Buffoni, L.; Cotogni, P.Immune Checkpoint Inhibitors and Opioids in Patients with Solid Tumours: Is Their Association Safe? A Systematic Literature Review. Healthcare (Basel). 2022, 11, 116.
10. Sebastian, N.T.; Stokes, W.A.; Behera, M.; Jiang, R.; Gutman, D.A.; Huang, Z.; Burns, A.;Sukhatme, V.; Lowe, M.C.; Ramalingam, S.S.; et al. The Association of Improved Overall Survival with NSAIDs in Non-Small Cell Lung Cancer Patients Receiving Immune Checkpoint Inhibitors. Clin Lung Cancer. 2023, 24, 287-294.
11. Zhang X, Qiu H, Li C, Cai P, Qi F. The positive role of traditional Chinese medicine as an adjunctive therapy for cancer. Biosci Trends. 2021 Nov 21;15(5):283-298. doi: 10.5582/bst.2021.01318.

Author Response File: Author Response.docx

Round 2

Reviewer 1 Report

The Authors have addressed all of my concerns with the original manuscript. I have no further comments.