Atezolizumab

Atezolizumab
Antigen-binding fragment of atezolizumab (pale blue) in complex with PD-L1 (pink).PDB: 5X8L​.
Monoclonal antibody
TypeWhole antibody
SourceHumanized
TargetPD-L1
Names
Trade namesTecentriq
Other namesMPDL3280A, RG7446
Clinical data
Drug classAntineoplastic agent
Main usesUrothelial carcinoma, non-small cell lung cancer (NSCLC), small cell lung cancer (SCLC), hepatocellular carcinoma (HCC), triple-negative breast cancer, melanoma[1][2]
Side effectsTiredness, reduced appetite, nausea, cough, difficulty breathing, diarrhea, rash, fever, muscle pain, weakness, itching, urinary tract infection[2]
Pregnancy
category
  • AU: D
    Routes of
    use    		Intravenous infusion
    External links
    AHFS/Drugs.comMonograph
    US NLMAtezolizumab
    MedlinePlusa616035
    Legal
    License data
    Legal status
    Chemical and physical data
    FormulaC6446H9902N1706O1998S42
    Molar mass144612.59 g·mol−1

    Atezolizumab, sold under the brand name Tecentriq, is a medication used to treat urothelial carcinoma, non-small cell lung cancer (NSCLC), small cell lung cancer (SCLC), hepatocellular carcinoma (HCC), triple-negative breast cancer, and melanoma.[1][2] Use is often only when specific mutations are present.[1][2] It is given by gradual injection into a vein.[4]

    Common side effects include tiredness, reduced appetite, nausea, cough, difficulty breathing, diarrhea, rash, fever, muscle pain, weakness, itching, and urinary tract infection.[2] Other side effects may include immune-mediated disorders including pneumonitis, colitis, and hepatitis.[1] Use in pregnancy may harm the baby.[1] It is a monoclonal antibody that attaches to and blocks programmed cell death-ligand 1 (PD-L1).[2] This allows the immune system to attack cancer cells.[2]

    Atezolizumab was approved for medical use in the United States in 2016 and Europe in 2017.[1][2] In the United Kingdom 1.2 grams costs the NHS about £3,800 as of 2021.[4] This amount in the United States costs about 10,300 USD.[5]

    Medical uses

    In the European Union atezolizumab is indicated for the treatment of urothelial carcinoma, non-small cell lung cancer (NSCLC), small cell lung cancer (SCLC), hepatocellular carcinoma, and breast cancer.[2][6]

    In the United States, atezolizumab is indicated for the treatment of urothelial carcinoma, non-small cell lung cancer (NSCLC), triple-negative breast cancer (TNBC), small cell lung cancer (SCLC), hepatocellular carcinoma (HCC), and melanoma.[1][7]

    Side effects

    The most common side effects in studies were fatigue, decreased appetite, nausea, and infections. Urinary tract infection was the most common severe adverse effect.[8]

    Pharmacology

    Mechanism of action

    Non-small cell lung cancer (NSCLC) cells expressing programmed death-ligand 1 (PD-L1) could interact with programmed death receptor 1 (PD-1) expressed on the surface of T cells, and result in decreased tumor cell kill by the immune system. Atezolizumab is an anti PD-L1 monoclonal antibody. Nivolumab and Pembrolizumab are anti PD-1 monoclonal antibodies. Ipilimumab is a monoclonal antibody that targets cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) on the surface of T cells. Bevacizumab is a monoclonal antibody that targets Vascular Endothelial Growth Factor (VEGF) in the circulation and functions as an angiogenesis inhibitor.[9]

    Atezolizumab blocks the interaction of PD-L1 with programmed cell death protein 1 (PD-1) and CD80 receptors (B7-1Rs).[10] PD-L1 can be highly expressed on certain tumors, which is thought to lead to reduced activation of immune cells (cytotoxic T-cells in particular) that might otherwise recognize and attack the cancer.[10] Inhibition of PD-L1 by atezolizumab can remove this inhibitor effect and thereby engender an anti-tumor response. It is one of several ways to block inhibitory signals related to T-cell activation, a more general strategy known as "immune checkpoint inhibition."[10]

    For some cancers (notably bladder) the probability of benefit is related to PD-L1 expression, but most cancers with PD-L1 expression still do not respond, and many (about 15%) without PD-L1 expression do respond.[10]

    History

    History of PD-1 research

    In 2015, it was in clinical trials as an immunotherapy for several types of solid tumors.[11] It was under investigation by Genentech/Roche.[11]

    In April 2016, Roche announced that atezolizumab had been granted fast track status for lung cancer by the U.S. Food and Drug Administration (FDA).[12] Atezolizumab is the first PD-L1 inhibitor approved by the U.S. Food and Drug Administration (FDA).[13]

    In May 2016, the FDA granted accelerated approval to atezolizumab for locally advanced or metastatic urothelial carcinoma treatment after failure of cisplatin-based chemotherapy.[13][14] The confirmatory trial (to convert the accelerated approval into a full approval) failed to achieve its primary endpoint of overall survival.[15] In 2018, FDA altered the use of atezolizumab as a first-line treatment for metastatic bladder cancer in people who can't receive cisplatin-based chemotherapy and have high levels of PD-L1.[16]

    In May 2016, atezolizumab was approved by the FDA for the treatment of people with locally advanced or metastatic urothelial carcinoma who have disease progression during or following platinum-containing chemotherapy or have disease progression within twelve months of neoadjuvant or adjuvant treatment with platinum-containing chemotherapy.[17][13] In May 2017, atezolizumab failed a phase III trial for second line bladder cancer.[18]

    The safety and efficacy of atezolizumab were studied in a single-arm clinical trial involving 310 participants with locally advanced or metastatic urothelial carcinoma.[13][17][19] This trial measured the percentage of participants who experienced complete or partial shrinkage of their tumors (objective response rate).[13] The study also looked at the difference in effect based on "positive" versus "negative" expression of the PD-L1 protein on participants' tumor-infiltrating immune cells.[13] In all participants, 14.8 percent of participants experienced at least a partial shrinkage of their tumors, an effect that lasted from more than 2.1 to more than 13.8 months at the time of the response analysis.[13] In participants who were classified as "positive" for PD-L1 expression, 26 percent of participants experienced a tumor response (compared to 9.5 percent of participants who were classified as "negative" for PD-L1 expression).[13] The trial was conducted in the United States, Canada, Spain, France, Great Britain, Germany, Italy and the Netherlands.[19]

    In October 2016, atezolizumab was approved by the FDA for the treatment of people with metastatic non-small cell lung cancer (NSCLC) whose disease progressed during or following platinum-containing chemotherapy.[20] People with EGFR or ALK genomic tumor aberrations should have disease progression on FDA-approved therapy for these aberrations prior to receiving atezolizumab.[20]

    This approval was based on two international, randomized, open-label clinical trials (OAK and POPLAR) that demonstrated consistent results in efficacy and safety in a total of 1137 participants with NSCLC.[20] Compared with docetaxel, treatment with atezolizumab in the intended participants population in the two trials resulted in a 4.2 and a 2.9 month improvement in overall survival (OS), respectively.[20]

    Atezolizumab was approved for medical use in the European Union in September 2017.[2]

    In May 2018, atezolizumab used in combination with bevacizumab (Avastin) and standard chemotherapy for some people with lung cancer was granted priority review.[21]

    In August 2018, the FDA updated the prescribing information for atezolizumab to require the use of an FDA-approved companion diagnostic test to determine PD-L1 levels in tumor tissue from people with locally advanced or metastatic urothelial cancer who are cisplatin-ineligible.[22]

    In September 2018, it was announced that atezolizumab prolongs survival in extensive stage small cell lung cancer treatment, according to study results presented at the 19th World Conference on Lung Cancer (WCLC) in Toronto, Canada.

    In October 2018, a combined clinical trial of the drug with nab-paclitaxel on people with advanced triple negative breast cancer concluded.[23]

    Atezolizumab, in combination with bevacizumab, paclitaxel, and carboplatin, was approved in the United States in December 2018, for the first-line treatment of people with metastatic non-squamous, non-small cell lung cancer (NSq NSCLC) with no EGFR or ALK genomic tumor aberrations.[24] Approval was based on the IMpower150 trial (NCT02366143), an open-label, randomized (1:1:1), three-arm trial enrolling 1202 participants receiving first-line treatment for metastatic NSq NSCLC.[24]

    In March 2019, it was approved in the United States, in combination with paclitaxel protein-bound, for adults with unresectable locally advanced or metastatic triple-negative breast cancer (TNBC) whose tumors express PD-L1 (PD-L1 stained tumor-infiltrating immune cells [IC] of any intensity covering ≥ 1% of the tumor area), as determined by an FDA-approved test.[25] The FDA also approved the VENTANA PD-L1 (SP142) Assay as a companion diagnostic device for selecting TNBC patients for atezolizumab.[26]

    Approval was based on IMpassion130 (NCT02425891), a multicenter, international, double-blinded, placebo-controlled, randomized trial that included 902 participants with unresectable locally advanced or metastatic TNBC who had not received prior chemotherapy for metastatic disease.[26] Participants were randomized (1:1) to receive either atezolizumab (840 mg) or placebo intravenous infusions on days 1 and 15 of every 28-day cycle, plus paclitaxel protein-bound (100 mg/m2) administered via intravenous infusion on days 1, 8, and 15 of every 28-day cycle.[26]

    In March 2019, it was approved in the United States, in combination with carboplatin and etoposide, for the first-line treatment of adults with extensive-stage small cell lung cancer (ES-SCLC).[27]

    Approval was based on IMpower133 (NCT02763579), a randomized (1:1), multicenter, double-blind, placebo-controlled trial in 403 participants with ES-SCLC who received no prior chemotherapy for extensive stage disease and had ECOG performance status 0 or 1.[27]

    In December 2019, atezolizumab in combination with paclitaxel protein-bound and carboplatin was approved by the FDA for the first-line treatment of adults with metastatic non-squamous non-small cell lung cancer (NSCLC) with no EGFR or ALK genomic tumor aberrations.[28]

    Efficacy was evaluated in IMpower130 (NCT02367781), a multicenter, randomized (2:1), open-label trial in participants with stage IV non-squamous NSCLC who had received no prior chemotherapy for metastatic disease, but could have received prior EGFR or ALK kinase inhibitor, if appropriate.[28] The trial randomized 724 participants (ITT) to receive atezolizumab, paclitaxel protein-bound, and carboplatin, followed by single-agent atezolizumab or to receive paclitaxel protein-bound and carboplatin, followed by maintenance pemetrexed at the investigator's discretion (control).[28]

    In May 2020, the atezolizumab was approved by the FDA or the first-line treatment of adults with metastatic non-small cell lung cancer (NSCLC) whose tumors have high PD-L1 expression (PD-L1 stained ≥ 50% of tumor cells [TC ≥ 50%] or PD-L1 stained tumor-infiltrating immune cells [IC] covering ≥ 10% of the tumor area [IC ≥ 10%]), with no EGFR or ALK genomic tumor aberrations.[29]

    Efficacy was evaluated in IMpower110 (NCT02409342), a multicenter, international, randomized, open-label trial in participants with stage IV NSCLC whose tumors express PD-L1 (TC ≥ 1% or IC ≥ 1%), who had received no prior chemotherapy for metastatic disease.[29] Participants were randomized (1:1) to receive atezolizumab 1200 mg every three weeks until disease progression or unacceptable toxicity or platinum-based chemotherapy.[29]

    In May 2020, atezolizumab in combination with bevacizumab was approved by the FDA for people with unresectable or metastatic hepatocellular carcinoma who have not received prior systemic therapy.[30]

    Efficacy was investigated in IMbrave150 (NCT03434379), a multicenter, international, open-label, randomized trial in participants with locally advanced unresectable or metastatic hepatocellular carcinoma who had not received prior systemic therapy.[30] A total of 501 participants were randomized (2:1) to receive either atezolizumab 1200 mg as an intravenous infusion (IV) followed by bevacizumab 15 mg/kg IV on the same day, every 3 weeks, or sorafenib orally twice daily.[30]

    In July 2020, it was approved in the United States, in combination with cobimetinib and vemurafenib, for the treatment of people with BRAF V600 mutation-positive unresectable or metastatic melanoma.[31]

    Efficacy in combination with cobimetinib and vemurafenib was evaluated in a double-blind, randomized (1:1), placebo-controlled, multicenter trial (IMspire150, NCT02908672) in 514 participants.[31] After a 28-day cycle of cobimetinib and vemurafenib, participants received atezolizumab 840 mg intravenous infusion every 2 weeks in combination with cobimetinib 60 mg orally once daily and vemurafenib 720 mg orally twice daily, or placebo in combination with cobimetinib 60 mg orally once daily (21 days on/7 days off) and vemurafenib 960 mg orally twice daily.[31]

    Patients median survival with Atezolizumab (Atezo) for treatment of non small cell lung cancer in the first line, IMpower 110 comparing Atezo to chemotherapy , IMpower 130 comparing Atezo+chemotherapy to chemotherapy, and IMpower150 comparing Atezo+chemotherapy+bevacizumab versus chemotherapy+bevacizumab.[32]

    IMpower110 randomized patients with stage IV NSCLC with PD-L1 expression ≥ 1% to Atezolizumab single agent or to chemotherapy.[9] The chemotherapy used was Cisplatin or Carboplatin, combined with Gemcitabine for patient with squamous cell NSCLC, or pemetrexed for patients with nonsquamous disease.[9] Atezolizumab was better tolerated than chemotherapy. In the subgroup of patients with EGFR and ALK wild-type tumors who had PD-L1 stained ≥ 50% of tumor cells (205 patients), the overall survival was 20.2 months with Atezolizumab, and 13.1 months with chemotherapy.[9] FDA approval is for patients with PD-L1 stained ≥ 50% of tumor cells, or PD-L1 stained tumor-infiltrating immune cells covering ≥ 10% of the tumor area, with no EGFR or ALK genomic tumor aberrations.[9]

    IMpower130 was an open-label, phase 3 trial that compared Atezolizumab in combination with carboplatin plus nab-paclitaxel chemotherapy, with chemotherapy alone as first-line treatment for metastatic non-squamous NSCLC.[9] About half of the patients had PD-L1 negative tumors. Median overall survival was 18.6 months in the atezolizumab plus chemotherapy group and 13.9 months in the chemotherapy group; HR 0.79, p = 0.033.[9] Subgroup analysis showed progression free survival benefit, and a trend toward overall survival benefit in all PD-L1 expression levels.[9]

    IMpower150 randomized patients with nonsquamous NSCLC to treatment with chemotherapy plus Bevacizumab, chemotherapy plus atezolizumab or chemotherapy plus Bevacizumab and atezolizumab.[33][9] The chemotherapy used was Carboplatin, and Paclitaxel.[9] Median overall survival was 19.8 and 14.9 months for patients treated with chemotherapy plus Bevacizumab, with or without atezolizumab, respectively.[9] Median OS with Atezolizumab and chemotherapy alone was 19.5 months, raising question with regard to the added value of Bevacizumab to this combination for the general patients population.[9] Importantly, patients with baseline liver metastases had an improved overall survival with Atezolizumab, Bevacizumab, and chemotherapy combination, compared to Bevacizumab and chemotherapy alone, with a median OS of 13.3 and 9.4 months, respectively, HR 0.52.[9] No improvement in overall survival was observed for patients with liver metastasis treated with chemotherapy and atezolizumab compared to patients treated with chemotherapy and Bevacizumab.[9] Recent report about safety and patient-reported outcomes of atezolizumab plus chemotherapy and Bevacizumab shows that this drug combination seems tolerable and with manageable toxicities.[34][9] For patients with nonsquamous NSCLC, with baseline liver metastases, the combination of chemotherapy, Atezolizumab and Bevacizumab could be an important option to consider in the first line.[9]

    Society and culture

    Cost

    Atezolizumab treatment costs on average US$13,200 per month in the United States, depending on the dosage schedule.[35] Despite updated data showing 30% more people with extensive stage small cell lung cancer are alive at 24 months compared to those who received chemotherapy alone,[36] Canadian regulator had rejected to fund atezolizumab for extensive stage small-cell lung cancer "as too costly" followed by United Kingdom also citing "drug's cost-effectiveness."[37][38] However, U.K. reversed its previous decision and approved tecentriq for extensive stage small cell lung cancer after price re-think on May 27, 2020.[39][40]

    Research

    As of 2016, it is in clinical trials for colorectal cancer, melanoma, breast cancer, non-small-cell lung carcinoma, bladder cancer, renal cell carcinoma.[41][42]

    Promising results have been observed for melanoma and non-small-cell lung cancer,[43] and bladder cancer.[11]

    A phase I trial reported a 19% objective response rate in metastatic triple-negative breast cancer.[44]

    As of 2019, atezolizumab is in trial for several types of cancer, such as pancreatic cancer, gastric cancer and ovarian Cancer.[45]

    References

    1. 1 2 3 4 5 6 7 8 "Tecentriq- atezolizumab injection, solution". DailyMed. 3 June 2020. Archived from the original on 4 May 2021. Retrieved 31 July 2020.
    2. 1 2 3 4 5 6 7 8 9 10 11 "Tecentriq EPAR". European Medicines Agency. Archived from the original on 24 May 2021. Retrieved 31 July 2020. Text was copied from this source which is © European Medicines Agency. Reproduction is authorized provided the source is acknowledged.
    3. ↑ "Tecentriq 1,200 mg concentrate for solution for infusion - Summary of Product Characteristics (SmPC)". (emc). Archived from the original on 4 May 2021. Retrieved 4 March 2020.
    4. 1 2 BNF 81: March-September 2021. BMJ Group and the Pharmaceutical Press. 2021. p. 908. ISBN 978-0857114105.
    5. ↑ "Tecentriq Prices, Coupons & Patient Assistance Programs". Drugs.com. Archived from the original on 20 April 2021. Retrieved 16 January 2022.
    6. ↑ "EMA reminds physicians to use Tecentriq with nab-paclitaxel for treating breast cancer". European Medicines Agency (EMA). Archived from the original on 21 May 2021. Retrieved 23 May 2021.
    7. ↑ "FDA approves atezolizumab as adjuvant treatment for non-small cell lun". U.S. Food and Drug Administration. 15 October 2021. Archived from the original on 15 October 2021. Retrieved 15 October 2021.
    8. ↑ FDA Professional Drug Information for Tecentriq.
    9. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Nasser, Nicola J.; Gorenberg, Miguel; Agbarya, Abed (November 2020). "First line Immunotherapy for Non-Small Cell Lung Cancer". Pharmaceuticals. 13 (11): 373. doi:10.3390/ph13110373. PMC 7695295. PMID 33171686. Text was copied from this source, which is available under a Creative Commons Attribution 4.0 International License Archived 2017-10-16 at the Wayback Machine.
    10. 1 2 3 4 Syn NL, Teng MW, Mok TS, Soo RA (December 2017). "De-novo and acquired resistance to immune checkpoint targeting". The Lancet. Oncology. 18 (12): e731–e741. doi:10.1016/s1470-2045(17)30607-1. PMID 29208439.
    11. 1 2 3 "Genentech Presents Positive Results of Atezolizumab in Advanced Bladder Cancer". Oct 2, 2015. Archived from the original on January 24, 2021. Retrieved October 17, 2021.
    12. ↑ Shields M (11 Apr 2016). "Roche says FDA fast tracks atezolizumab in specific type of lung cancer". Reuters. Archived from the original on 8 November 2020. Retrieved 11 Apr 2016.
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    26. 1 2 3 "FDA approves atezolizumab for PD-L1 positive unresectable locally advanced or metastatic triple-negative breast cancer". U.S. Food and Drug Administration (FDA) (Press release). 18 March 2019. Archived from the original on 5 December 2019. Retrieved 4 December 2019.
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    28. 1 2 3 "FDA approves atezolizumab with nab-paclitaxel and carboplatin for metastatic NSCLC without EGFR/ALK aberrations". U.S. Food and Drug Administration (FDA) (Press release). 3 December 2019. Archived from the original on 1 August 2020. Retrieved 31 July 2020. Public Domain This article incorporates text from this source, which is in the public domain.
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    31. 1 2 3 "FDA approves atezolizumab for BRAF V600 unresectable or metastatic melanoma". U.S. Food and Drug Administration (Press release). 30 July 2020. Archived from the original on 8 June 2021. Retrieved 31 July 2020. Public Domain This article incorporates text from this source, which is in the public domain.
    32. ↑ Nasser, NJ; Gorenberg, M; Agbarya, A (8 November 2020). "First line Immunotherapy for Non-Small Cell Lung Cancer". Pharmaceuticals (Basel, Switzerland). 13 (11). doi:10.3390/ph13110373. PMID 33171686.
    33. ↑ Socinski, Mark A.; Jotte, Robert M.; Cappuzzo, Federico; Orlandi, Francisco; Stroyakovskiy, Daniil; Nogami, Naoyuki; Rodríguez-Abreu, Delvys; Moro-Sibilot, Denis; Thomas, Christian A.; Barlesi, Fabrice; Finley, Gene (2018-06-04). "Atezolizumab for First-Line Treatment of Metastatic Nonsquamous NSCLC". New England Journal of Medicine. 378 (24): 2288–2301. doi:10.1056/NEJMoa1716948. PMID 29863955.
    34. ↑ Reck, Martin; Wehler, Thomas; Orlandi, Francisco; Nogami, Naoyuki; Barone, Carlo; Moro-Sibilot, Denis; Shtivelband, Mikhail; González Larriba, Jose Luis; Rothenstein, Jeffrey; Früh, Martin; Yu, Wei (2020-05-27). "Safety and Patient-Reported Outcomes of Atezolizumab Plus Chemotherapy With or Without Bevacizumab Versus Bevacizumab Plus Chemotherapy in Non–Small-Cell Lung Cancer". Journal of Clinical Oncology. 38 (22): 2530–2542. doi:10.1200/JCO.19.03158. ISSN 0732-183X. PMC 7392741. PMID 32459597.
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    44. ↑ "MPDL3280A Shows Activity in Triple-Negative Breast Cancer". Cancer Network. Archived from the original on 2021-10-17. Retrieved 2021-10-17.
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