Atezolizumab

Atezolizumab, sold under the brand name Tecentriq, is used to treat urothelial carcinoma, non-small cell lung cancer (NSCLC), triple-negative breast cancer (TNBC), small cell lung cancer (SCLC), and heptatocellular carcinoma (HCC).[2] It is a fully humanized, engineered monoclonal antibody of IgG1 isotype against the protein programmed cell death-ligand 1 (PD-L1).[4]

Atezolizumab
Monoclonal antibody
TypeWhole antibody
SourceHumanized
TargetPD-L1
Clinical data
Trade namesTecentriq
Other namesMPDL3280A, RG7446
AHFS/Drugs.comMonograph
MedlinePlusa616035
License data
Pregnancy
category
  • AU: D
  • US: N (Not classified yet)
    Routes of
    administration    		Intravenous infusion
    Drug classAntineoplastic agent
    ATC code
    Legal status
    Legal status
    Identifiers
    CAS Number
    DrugBank
    ChemSpider
    • none
    UNII
    KEGG
    Chemical and physical data
    FormulaC6446H9902N1706O1998S42
    Molar mass144612.59 g·mol−1

    The most common side effects when used on its own include tiredness, reduced appetite, nausea (feeling sick), vomiting, cough, difficulty breathing, diarrhea, rash, fever, pain in the back, joints, muscles and bones, weakness, itching and urinary tract infection (infection of the structures that carry urine).[3]

    The most common side effects when used with other cancer medicines include peripheral neuropathy (nerve damage in the hands and feet), nausea, anaemia (low red blood cell counts), neutropenia (low white blood cell counts), thrombocytopenia (low platelet counts), rash, tiredness, constipation, reduced appetite, diarrhea, and cough.[3]

    Atezolizumab is the first PD-L1 inhibitor approved by the U.S. Food and Drug Administration (FDA).[5]

    Medical uses

    In the European Union atezolizumab as monotherapy is indicated for the treatment of adults with locally advanced or metastatic urothelial carcinoma (UC):

    • after prior platinum containing chemotherapy, or[3]
    • who are considered cisplatin ineligible, and whose tumors have a PD-L1 expression ≥ 5%.[3]

    Atezolizumab, in combination with bevacizumab, paclitaxel, and carboplatin, is indicated for the first-line treatment of adults with metastatic non-squamous non small cell lung cancer (NSCLC).[3] In adults with EGFR mutant or ALK-positive NSCLC, atezolizumab, in combination with bevacizumab, paclitaxel and carboplatin, is indicated only after failure of appropriate targeted therapies.[3]

    Atezolizumab as monotherapy is indicated for the treatment of adults with locally advanced or metastatic non-squamous non small cell lung cancer (NSCLC) after prior chemotherapy.[3] Adults with EGFR mutant or ALK positive NSLCLC should also have received targeted therapy before receiving atezolizumab.[3]

    In May 2016, the FDA granted accelerated approval to atezolizumab for locally advanced or metastatic urothelial carcinoma treatment after failure of cisplatin-based chemotherapy.[5][6] The confirmatory trial (to convert the accelerated approval into a full approval) failed to achieve its primary endpoint of overall survival.[7] 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.[8]

    In October 2016, FDA approved atezolizumab for the treatment of people with metastatic non-small cell lung cancer (NSCLC) whose disease progressed during or following platinum-containing chemotherapy.[9] People with EGFR or ALK genomic tumor aberrations should have disease progression on FDA-approved therapy for these aberrations prior to receiving atezolizumab.[9]

    Atezolizumab is also used to treat extensive stage small cell lung cancer.[10]

    In March 2019, the FDA approved atezolizumab for the treatment of people with triple-negative breast cancer.[11]

    Adverse effects

    The most common adverse effects in studies were fatigue, decreased appetite, nausea, and infections. Urinary tract infection was the most common severe adverse effect.[12]

    Pharmacology

    Mechanism of action

    Atezolizumab blocks the interaction of PD-L1 with programmed cell death protein 1 (PD-1) and CD80 receptors (B7-1Rs).[13] 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.[13] 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."[13]

    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.[13]

    History

    In 2015, it was in clinical trials as an immunotherapy for several types of solid tumors.[4] It was under investigation by Genentech/Roche.[4]

    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).[14]

    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.[15][5][15] In May 2017, atezolizumab failed a phase III trial for second line bladder cancer.[16]

    The safety and efficacy of atezolizumab were studied in a single-arm clinical trial involving 310 participants with locally advanced or metastatic urothelial carcinoma.[5][15][17] This trial measured the percentage of participants who experienced complete or partial shrinkage of their tumors (objective response rate).[5] 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.[5] 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.[5] 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).[5] The trial was conducted in the United States, Canada, Spain, France, Great Britain, Germany, Italy and the Netherlands.[17]

    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.[9] People with EGFR or ALK genomic tumor aberrations should have disease progression on FDA-approved therapy for these aberrations prior to receiving atezolizumab.[9]

    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.[9] 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.[9]

    Atezolizumab was approved for medical use in the European Union in September 2017.[3]

    In May 2018, atezolizumab used in combination with bevacizumab (Avastin) and standard chemotherapy for some people with lung cancer was granted priority review.[18]

    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.[19]

    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.[20]

    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.[21] 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.[21]

    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.[22] The FDA also approved the VENTANA PD-L1 (SP142) Assay as a companion diagnostic device for selecting TNBC patients for atezolizumab.[11]

    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.[11] 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.[11]

    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).[23]

    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.[23]

    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.[24]

    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.[24] 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).[24]

    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.[25]

    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.[25] Participants were randomized (1:1) to receive atezolizumab 1200 mg every three weeks until disease progression or unacceptable toxicity or platinum-based chemotherapy.[25]

    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.[26]

    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.[26] 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.[26]

    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.[27]

    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.[27] 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.[27]

    Society and culture

    Drug cost controversy

    Atezolizumab treatment costs on average US$13,200 per month in the United States, depending on the dosage schedule.[28] 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,[29] 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." [30][31] 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.[32][33]

    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.[34][35]

    Promising results have been observed for melanoma and non-small-cell lung cancer,[36] and bladder cancer.[4]

    A phase I trial reported a 19% objective response rate in metastatic triple-negative breast cancer.[37]

    As of 2019, atezolizumab is in trial for several types of cancer, such as pancreatic cancer, gastric cancer and ovarian Cancer.[38]

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    References
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    2. "Tecentriq- atezolizumab injection, solution". DailyMed. 3 June 2020. Retrieved 31 July 2020.
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    4. "Genentech Presents Positive Results of Atezolizumab in Advanced Bladder Cancer". 2 October 2015.
    5. "FDA approves new, targeted treatment for bladder cancer" (Press release). U.S. Food and Drug Administration (FDA). 18 May 2016. Retrieved 20 May 2016. This article incorporates text from this source, which is in the public domain.
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    37. "MPDL3280A Shows Activity in Triple-Negative Breast Cancer".
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    • "Atezolizumab". Drug Information Portal. U.S. National Library of Medicine.
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