Supplementary Figure S5: Survival by ERBB2 status.

PURPOSE:Cabozantinib, a multi-kinase inhibitor, improves progression-free survival (PFS) in patients with advanced extrapancreatic neuroendocrine tumors (epNET). Cabozantinib alters the tumor microenvironment to be more permissive to immune cells by reducing the presence of regulatory T cells and CD14+ monocytes. This trial investigated the efficacy and safety of cabozantinib in combination with nivolumab in patients with advanced epNET. PATIENTS AND METHODS:This was an open-label, single-arm, phase II trial, which enrolled patients with advanced epNET. Patients received nivolumab 240 mg i.v. on days 1 and 15 and cabozantinib 40 mg orally once daily on a 28-day cycle. The primary endpoint was objective response rate (ORR) by RECIST v1.1. Using a Simon two-stage design, 19 patients were enrolled in the first stage. Secondary objectives included ORR by immune-related RECIST, PFS, and safety. Exploratory objectives included correlation between immune and angiogenic proteomic profile and clinical outcomes. RESULTS:Eighteen of the 19 enrolled patients were evaluable for response. Best response was partial response in one (5%), stable disease in 16 (90%), and progressive disease in one patient (5%). The ORR did not meet goal for the first stage, so enrollment was terminated. The median PFS was 5.6 months (95% confidence interval, 3.5-9.9). Grade 3 toxicities attributed to the combination included tumor lysis (n = 1, 5%), elevated transaminases (n = 1, 5%), and fatigue (n = 2, 10%). Immune and angiogenic proteomic profiles demonstrated trends associated with longer time on therapy. CONCLUSIONS:Cabozantinib and nivolumab were associated with limited response in patients with epNET. Alternative strategies to enhance the immune response in epNET are needed.

e24186 Background: Chemotherapy-induced peripheral neuropathy (CIPN) is a common toxicity of taxane chemotherapy and includes both sensory neuropathy and neuropathic pain. The longitudinal course of these symptoms among patients without neuropathy at treatment initiation is not well characterized. Describing symptom trajectories during taxane therapy may inform monitoring and prevention strategies. Methods: PACT, a multinational coordinated study, pooled data from three parallel randomized trials in patients with early-stage breast cancer receiving taxane chemotherapy. Participants screened negative for neuropathy at baseline using PRO-CTCAE items. Trials compared acupuncture with an active relaxation–nature-video control. Sensory neuropathy was assessed using the EORTC CIPN-20 sensory subscale (0–100), and neuropathic pain using a 0–10 worst pain Likert scale at baseline, week 12 (primary timepoint), and week 24 (follow-up). Longitudinal mixed-effects models estimated symptom trajectories, adjusting for site, chemotherapy schedule, and number of neurotoxic agents. Pairwise time comparisons use model-adjusted estimates with Tukey–Kramer adjustment. Given no treatment differences, values are presented as averages across arms. Results: Among 127 evaluable participants, model-adjusted mean CIPN-20 sensory scores increased 7.7 points (95% adj CI: 4.8 to 10.6, adj p<0.0001) from baseline to week 12 and remained stable at 24 weeks. Worst neuropathic pain increased 0.64 points (95% adj CI: 0.18–1.09; adj p=0.004) at 12 weeks with no further significant change at 24 weeks. Median worst pain scores remained 0 at all timepoints, while sensory scores rose from 0 at baseline to 3.7 at week 12. (Table 1) Conclusions: Sensory neuropathy and worst pain scores increased during taxane chemotherapy. Sensory changes were clinically significant, while changes in pain were subclinical and the majority of patients remained free of pain at all time points. These findings highlight the heterogeneous manifestation of CIPN during standard chemotherapy in an integrative medicine primary CIPN prevention trial and underscore the importance of carefully assessing both sensory and pain-related outcomes in prevention strategies. Clinical trial information: NCT05528263, ChiCTR2200066714, KCT0008470 . Model-adjusted symptom trajectories. Mean Change (95% adj CI; adj p-value) Outcome Baseline Week 12 Week 24 Week 12 - Baseline Week 24 – Week 12 Week 24 - Baseline CIPN-20 sensory(0–100) 0.6 8.3 8.5 7.7 (4.8 to 10.6; <0.0001) 0.2 (-2.8 to 3.1; 0.99) 7.8 (4.7 to 10.9; <0.0001) Worst neuropathic pain(0–10) 0.33 0.97 1.19 0.64 (0.18 to 1.09; 0.004) 0.22 (-0.16 to 0.60; 0.35) 0.86 (0.35 to 1.36; 0.0003) Predicted means and pairwise changes averaged across arms; CI and p-values adjusted for multiple comparisons (Tukey–Kramer).

Representativeness of Study Participants

Supplementary Figure S3: Tumor immune microenvironment of colorectal cancer cohort.

Background:Despite advances in treatment, brain metastasis (BM) management remains a significant challenge. Adagrasib is a brain-penetrant KRASG12C inhibitor active in patients with BM. KRAS mutations are linked with immune escape and may contribute to the limited clinical benefit from single-agent immune checkpoint inhibitors (ICI) targeting PD-1/PD-L1 in BM. Although adagrasib sensitizes extracranial tumors to ICI, its intracranial benefit combined with immunotherapy remains unknown. Here, we evaluate adagrasib with ICI in mouse models that mimic the BM immune microenvironment. Methods:We tested the in vitro efficacy of adagrasib on two KrasG12C-mutant murine cancer cells: colorectal CT26G12C and lung cancer KPARG12C. Murine BM models resembling the immunologic characteristics of BM were established by subcutaneous and intracranial injection of these cells. Animals were treated with adagrasib combined with anti-PD-1 and monitored for intracranial tumor growth and survival. Disease-free mice after 11-13 weeks were rechallenged with a higher tumor cell dose to assess tumor-specific memory. Results:Three-week adagrasib monotherapy and combination therapy with ICI demonstrated benefit in colorectal and lung cancer BM models. Adagrasib alone and in combination demonstrated similarly potent anti-tumor effects against extracranial tumors. While monotherapies reduced intracranial tumor growth, adagrasib with ICI showed the most favorable outcome. Although both adagrasib monotherapy and combination therapy extended survival, long-term intracranial disease control after rechallenge was the greatest with combination therapy. Conclusions:Adagrasib with ICI improved long-term survival and blocked CNS progression in dual extra- and intracranial BM models.  These findings support investigation of adagrasib with ICI in patients with KRASG12C-mutant BM.

PURPOSE:Healthy lifestyle behaviors, including regular exercise and balanced nutrition, affect quality of life in cancer survivors. However, barriers to adopting these behaviors across the cancer continuum are poorly understood. We evaluated barriers to adopting healthy lifestyle behaviors in a national cohort of patients and survivors of cancer. METHODS:ASCO distributed an online survey to adult patients with cancer in the United States from March to June 2020. In this secondary analysis, we evaluated the perceived barriers to incorporating healthy lifestyle behaviors after cancer diagnosis and how they differ by disease stage and treatment status. Descriptive statistics summarized barriers to lifestyle changes. Comparisons across disease stage and treatment status were assessed using Rao-Scott chi-square tests, and weighted multivariable logistic regression modeling identified associated factors. RESULTS:Of 2,419 survey respondents, 1,987 were included in this analysis and grouped by disease stage: early stage on-treatment (n = 461), early stage post-treatment (n = 916), and metastatic on-treatment (n = 610). The most common barriers to healthy behaviors included lack of energy (58.7%) and physical limitations (52.0%), with significant differences (P < .05) in barriers related to time, logistics, cancer effects, and physical limitations across disease stages and treatment groups. Among those not meeting lifestyle guidelines, lack of motivation (51.3%-62.0%) and lack of energy (59.5%-77.0%) were major barriers, with barriers related to time, cancer effects, and physical limitations varying significantly by disease stage and treatment status. CONCLUSION:Patients with cancer face multiple barriers to adopting healthy lifestyle behaviors after diagnosis. Targeted interventions based on disease stage and treatment status may help address these challenges.

The spatial organization of immune and tumor cells within the tumor microenvironment (TME) has a critical influence on antitumor immunity and patient survival. However, hand-engineered metrics such as cell densities or pairwise proximity scores fail to capture the complexity of local cell-cell interactions. Understanding these higher-order spatial patterns and their relation to patient outcomes is especially important for non-small cell lung cancer (NSCLC), the deadliest cancer worldwide. Here, we elucidate the NSCLC TME using a graph neural network (GNN)-based framework to model spatially localized cellular neighborhoods in multiplex immunofluorescence data from a clinical cohort of 506 patients. The GNN predicted patient survival with high accuracy (concordance index: 0.82) and remained a significant prognostic factor when adjusted for clinical covariates. Interpretability analyses revealed that specific combinations of cell types, particularly involving CD8+ T cells, PD-L1+ immune cells, and FOXP3+ regulatory T cells, modulated predictions depending on their spatial context. In-silico manipulation experiments applied to the trained GNN, used here as an interpretable surrogate model, suggested that the impact of CD8+ cells on survival were estimated as favorable when in direct tumor contact and less favorable when adjacent to immunosuppressive cells. Latent-space clustering identified distinct TME states predictive of outcome, reflecting varying balances of immune activation and evasion. Our approach underscores the prognostic significance of spatially resolved immune-tumor interactions, providing a blueprint for developing next-generation spatial biomarkers to guide precision treatment strategies in NSCLC.

Sample Preparation for CyTOF and Olink

Gene expression (TPM) data from the bulk RNA-seq analysis.

Volcano plots for EDIL3, MFGE8 and CTNNB1, with each spot representing Kendall rank correlation for dysfunction or exclusion across TCGA tumor types.

ImportanceUV-induced mutagenesis leads to a higher tumor mutational burden (TMB) in cutaneous melanoma relative to other cancer types. TMB is an important prognostic marker in advanced melanoma; higher TMB is associated with greater clinical response to immune checkpoint inhibition and improved survival.ObjectiveTo evaluate the association between cutaneous melanoma TMB and indoor tanning exposure, as well as other demographic, dermatologic, and tumor characteristics.Design, Setting, and ParticipantsThis retrospective cohort study took place at Dana-Farber Cancer Institute, a tertiary-care cancer treatment center in Boston, Massachusetts, between 2013 and 2022. Patients with a diagnosis of cutaneous melanoma for whom next-generation sequencing data and tanning bed exposure history were available were included.ExposuresIndoor tanning exposure history, tumor characteristics, demographics, and dermatologic history were collected via retrospective medical record review.Main Outcomes and MeasuresThe association of tanning bed use with TMB was modeled using inverse probability of treatment weighted, multivariable modeling.ResultsAmong 617 patients (median [IQR] age at diagnosis, 61 [50-71] years; 337 [62.9%] male), there was no association between indoor tanning exposure and TMB after adjustment for demographic, tumor, and dermatologic characteristics (yes vs no: log2 TMB [SE], 4.07 [0.44] vs 3.97 [0.45]; P = .39). However, there was a statistically significant association between higher TMB and older age at diagnosis, history of nonmelanoma skin cancer, and head and neck tumors relative to other primary sites. Average TMB was statistically significantly lower in patients with a history of abnormal nevi (yes vs no: log2 TMB [SE], 3.89 [0.44] vs 4.15 [0.44]; P = .01).Conclusions and RelevanceThis cohort study suggests that indoor tanning exposure, while known to increase risk of melanoma, may not be meaningfully associated with melanoma TMB. Additional characteristics were associated with higher TMB and, thus, potentially improved immune checkpoint inhibitor response.

Nivolumab plus ipilimumab (aCTLA-4/aPD-1) combination therapy has significantly improved clinical outcomes in patients with metastatic melanoma, with 50%-60% of patients responding to treatment, but predictors of response are poorly characterized. We hypothesized that circulating cytokines and peripheral white blood cells may predict response to therapy and evaluated 15 cytokines and complete blood counts (CBC with differentials) from 89 patients with advanced melanoma treated with combination therapy from three points in time: pre-treatment, one month and approximately three months after starting therapy. Clinical endpoints evaluated included durable clinical benefit (DCB), progression-free survival (PFS), and overall survival (OS). A parsimonious predictive model was developed to identify cytokines predictors of response to combination therapy. In this study, we found that pre-treatment, patients with DCB had higher IL-23, lower CXCL6, and lower IL-10 levels. Lower NLR one month after starting therapy predicted better PFS and OS, primarily driven by an increase in absolute lymphocytes. A multivariate model demonstrated that baseline CXCL6, IL-10, IL-23 were independent predictors of therapy response, and the combined model has reached an area under the curve (AUC) of 0.79 in prediction of response to combination therapy. Our study identified baseline CXCL6, IL-23, and IL-10 as predictors of response to aCTLA4/aPD1 combination therapy among patients with metastatic melanoma. This study also provides a framework for identifying patients who are likely to respond to combination ICB, as well as a subset of patients with high risk of developing resistance and are thus in need of alternative therapeutic options, such as clinical trials.