Eligibility and workload implications of adjuvant immunotherapy in patients with resected esophageal and gastroesophageal junction (ESO/GEJ) cancer

Background

The CheckMate (CM) 577 trial demonstrated the efficacy of 12 months of adjuvant nivolumab for esophageal (ESO)/gastroesophageal junction (GEJ) cancer patients with residual pathological disease after neoadjuvant chemoradiation. Nivolumab is now an approved and funded regimen in British Columbia (BC). This retrospective study examines its real-world eligibility and resource implications.

Materials and methods

We conducted an ethics board-approved chart review of patients who underwent CROSS chemoradiation at BC Cancer from January 2016 to December 2020. Patient eligibility was determined per CM577 and GIAJNIV criteria. We assessed the resource impact of nivolumab by projecting the number of MD and chemotherapy visits, and anticipated G3/4 toxicity events per the CM577 trial.

Results

We identified 677 patients (63% ESO and 37% GEJ; 74% adenocarcinomas and 25% squamous cell carcinomas). Among the 460 who had resection, 79% had residual pathological disease. 68% (n = 249) and 88% (n = 321) were eligible for adjuvant nivolumab per CM577 and GIAJNIV criteria, respectively. In BC, this equates to ∼60 patients/year, resulting in 768 additional chemotherapy and potentially an equal number of MD visits, totaling 256 MD workhours annually. With a 34% G3/4 toxicity rate, an estimated 20 patients/year may require medical intervention.

Conclusions

Adjuvant nivolumab is an important treatment option for resected ESO/GEJ cancer patients. Our findings suggest that a substantial portion (88%) of those with residual pathological disease would be eligible for 12 months of therapy. In addition to treatments costs, the implementation of new therapy indications should consider the additional workload impact on oncologists.