Clinical analysis of ECOG PS and adverse reactions in patients with anlotinib at advanced NSCLC as the third or further line treatment: a retrospective observational study

Background: Previous studies have shown that anlotinib be a decent choice in third- or futher line treatment of advanced NSCLC. However, the study anslysis of relationship between Eastern Cooperative Oncology Group performance status(ECOG PS) and adverse reactions in advanced NSCLC with anlotinib therapy is less. Methods: We evaluated the ecacy and toxicity of anlotinib in patients with previously treated advanced NSCLC from June 2018 to March 2019. Survival analysis was performed by the Kaplan–Meier method. Results: According to ECOG PS devided into PS 0-1 group(n=63) and PS 2 group(n=28) . The PS 0-1 of median progression-free survival (mPFS, 5.5 vs.2.7 months, P (cid:0) 0.05) , overall survival (mOS, 9.2 vs.4.7 months (cid:0) P (cid:0) 0.05) was longer than PS 2. The PS 0-1 of objective remission rate(ORR, 45.1% vs 6.6%), disease control rate(DCR, 8.8% vs 1.1%) was signicanly more than PS 2. The PS 0-1 group of I-II adverse reactions was high than PS 2 group(52.3% vs 32.1%), but the III-IV adverse reactions were less than PS 2 group(9.5% vs 10.7%). Moreover, multivariate analysis indicated that PS was independent risk factor of PFS (cid:0) HR=2.816, 95%CI (cid:0) 1.661-4.773 (cid:0) P<0.0001 (cid:0) as well as OS(HR=3.188, 95%CI (cid:0) 1.789-5.682 (cid:0) P=0.0001) for anlotinib therapy in NSCLC. Conclusions: Patients in advanced NSCLC with PS 0–1 get better PFS and OS than PS 2 followed by anlotinib treatment in NSCLC. Advanced lung squamous cell carcinoma(LUSC) recived anlotinib treatment with the same ecacy comparable


new treatment methods.
Tyrosine kinase is a key component of intracellular signal transduction pathway, and many cancer cells show abnormal tyrosine kinase activity [7][8] . To control this abnormal activity, the researchers found that small molecule inhibitors could block tyrosine kinase-mediated phosphorylation [9] . Molecular targeting therapy with tyrosine kinase inhibitors is usually more speci c and less toxic to cancer cells than cytotoxic chemotherapy drugs [10] . As a new type of small molecule multi-target TKI, anlotinib has broad-spectrum anti-angiogenesis and anti-tumor growth effects, especially in the inhibition of targets such as vascular endothelial growth factor R2(VEGFR2), vascular endothelial growth factor R3(VEGFR3), PDGFR β and c-Kit [11][12] . Many studies have further identi ed that anlotinib has broader and more effective anti-tumor effects in vivo than Sunitinib and Sorafenib [11][12]13] . Moreover, pre-Phase II and Phase III clinical studies had preliminarily validated the e cacy and safety of anlotinib in the treatment of advanced NSCLC [14][15] .
Many studies shown that performance status (PS) is the strongest predictor of survival in patients with andvanced NSCLC [16][17] .
It has a greater impact on the choice of treatment options and drug tolerance, and is also an important indicator re ecting the severity of patients' condition for advance NSCLC treatment [18] . And Felip et al. [19] showed that the advanced lung squamous cell cancer(LUSC) of patients in ECOG PS 2 received the nivolumab with a worse OS and di cult to treat, and poor prognosis.
Furthermore, the antiangiogenic drugs of bevacizumab with PS 0-1were more effective or less adverse drug reactions than PS 2 in non-squamous of NSCLC [20] . So what the antiangiogenic drugs of anlotinib relationship with ECOG PS both in adenocarcinoma and squamous cell carcinoma, there were less studies reported that. Moreover, there are still some patients with poor e cacy and intolerance of adverse reactions of anlotinib, and which groups of people can get the best effect from anlotinib treatment, which is rarely reported. In this study, we retrospectively analyzed the results of anlotinib treatment with PS 0-2 patients in our cohort.

Main grouping criteria
The inclusion criteria were as follows: (1) recurrent or advanced NSCLC (stage IIIB, IIIC, or IV, American Joint Committee on Cancer Cancer Staging Manual, 8th edition) with failure of at least two lines of chemotherapy or EGFR-TKIs targeted drugs, and the third-line treatment with single-drug anlotinib. (2) The patients were older than 18 years old, Karnofsky Performance Status was greater than 60 or PS was 0-2. (3) All patients were diagnosed as advanced NSCLC by histopathology or cytology combined with imaging examination. (4) All patients should receive two courses of treatment and then progress, with complete imaging data and at least one assessable target lesion. The size of the lesion could be measured by CT. (5) The patient of relevant laboratory tests and cardiopulmonary function were basically normal. The exclusion criteria were as follows: (1) Patients with poor physical condition can not tolerate adverse drug reactions. (2) Patients with brain metastasis.

Therapeutic method
This study was approved by the ethics institution committee of First A liated Hospital of Nanchang University, Jiangxi P.R. China. All patients received the treatment of anlotinib must be obtained the consent and signed the informed consent form.
Anlotinib hydrochloride capsules (Fukewei, 12 mg, 10 mg, 8 mg, Zhengda Tianqing Pharmaceutical company Co., Ltd), once a day, two weeks and then stop for a week, three weeks for a course of treatment. Adjust dosage according to adverse reactions, and continue current dosage treatment if no obvious adverse reactions occur. If grade 2, 3 and 4 adverse reactions are intolerable, the doctor should base on patient's tolerance and decided to whether or not to take a drug reduction or discontinued, and the reduction is 10 mg or 8 mg, until the disease progresses. In the course of treatment, according to the results of relevant examinations and adverse reactions of patients, the best treatment measures can be taken to ensure the implementation of the treatment plan.

Post-treatment evaluation criteria
Chest and abdominal Computer Tomography (CT), bone scan and craniocerebral nuclear magnetic resonance (MRI) were reexamined after two cycles or when clinical symptoms worsened of anlotinib treatment. The therapeutic effect was evaluated according to the Response Evaluation Criteria in Solid Tumors 1.1(RECIST1.1) established by the International Union against Cancer (UICC). It can be divided into complete response (CR), partial response(PR), stable disease(SD) and progressive disease(PD). The clinical bene t is that the curative effect is maintained for more than 4 weeks. Objective remission rate (ORR)= (CR + PR)/ total cases * 100%, Disease control rate(DCR) = (CR + PR + SD) / total cases * 100%. PFS was calculated from the start time of taking anlotinib to the date of disease progression or death from any cause. OS was calculated from the start time of taken anlotinib to the date of death or latest follow-up time. Adverse reactions were evaluated according to the Common Toxicity Criteria (CTC) 3.0 issued by the National Cancer Institute(NCI) in 2006.

Statistical methods
Patients were classi ed into two groups according to their PS and were compared using the chi-squared test or Fisher's exact test for qualitative variables. The Kaplan-Meier method was used to calculate survival rates, univariate and multivariate prognostic analysis was used to Cox regression model and calculate the hazard ratio (HR) and 95% con dence interval (CI), to nd the independent prognostic factor. Statistical analysis was performed by using SPSS 22.0 software package(SPSS Inc., Chicago, IL, USA), statistical results P < 0.05 was considered signi cantly. Review Manager 5.3 was applied to forest gure with univariate signi cant factors.

Baseline patient characteristics
We retrospectively collected the medical data of advanced NSCLC patients between June 2018 and April 2019, the follow-up time of cut-off date was 30 June 2020, and by the end of follow-up time with a median of 15 months. There were 134 patients with NSCLC who were treated with anlotinib, while a total of 91 NSCLC patients were enrolled. Intolerance of adverse reactions and was not oral anlotinib in fteen patients, seven patients PS was 3, twenty-one previous have brain metastases, so those patients were exclusion. At the end of the follow-up, the patients were still in oral anlotinib and the disease was not progress, and the patients could not be contacted during oral anlotinib, those of patients as a censored case. (Fig. 1). According to pathological type, there were 43 patients in adenocarcinoma and 48 in squamous. The previous EGFR mutations(n = 22), ALK mutations(n = 2) and KRAS mutations(n = 2) were detected. Twenty patients received the EGFR-TKIs treatment(Ge tinib, Erlotinib, Eritinib), and sixty-ve received the platinum containing chemotherapy, two patients recived ALK inhibitors(Crizotinib), and four patients recived the gemcitabine or pemetrexed monotherapy. The characteristics of the study population are shown in Table 1.

Univariate and Multivariate Survival Analyses in All Patients
The median PFS was 4.7 months, the mediate OS was 6.4 months for received anlotinib. Univariate and multivariate analyses were performed to evaluate the predictive impact of anlotinib and other clinicopathological factors on OS and PFS. The results of univariate analyses showed that ECOG PS 2 (P = 0.000, Fig. 2A), liver metastasis (P = 0.032), metastasis sites more than 3 (P = 0.019) were the poor prognostic factors for PFS. ECOG PS (P = 0.000, Fig. 2B); smoking (P = 0.02), treatment of base line (P = 0.013), liver metastasis (P = 0.017) and metastasis site (P = 0.011) were signi cantly associated with OS. Neither pathological type nor previous EGFR mutation was found to be associated with PFS or OS. (Table 3)    II grade III-IV grade I-II grade III-IV grade Hand-foot syndrome 16(17) 9(10) 4(4) 2(2) 1(2) Abbreviations: ALT, alanine aminotransferase; PLT, Platelet

Subgroups analysis of PFS and OS in ECOG PS
Subgroup analyses were performed pathological type and ECOG PS for anlotinib treatment (Table 3). In squamous + ECOG PS of Subgroup, PS 0-1 group has signi cantly longer PFS(6.7 vs 2.95 months, P < 0.05, Fig. 2C) as well as OS(8.1 vs 3.2 months, P < 0.0001, Fig. 2D) than PS 2 group. Moreover, in adenocarcinoma + ECOG PS of subgroup, the result of PS 0-1 had signi cantly longer PFS than PS 2(4.1 vs 2.2 months, P < 0.05, Fig. 1E); although the OS was no signi cantly difference between two groups(6.6 vs 4.4 months, P = 0.0599, Fig. 2F), the PS 0-1 of OS was nearly two months longer than PS 2.

Discussion
Most advanced NSCLC patients inevitably have disease progression after rst-line and second-line treatment, and need further treatment. A Phase III clinical study (ALTER-0303) [15] showed that The median OS(9.63 vs 6.3 months,P = 0.0018), PFS 5.37vs1.4 months P < 0.0001 , DCR 81.0% vs 37.1% P < 0.0001 and ORR 9% vs 1% P < 0.0001 of anlotinib were signi cantly better than those of placebo group, and the adverse reactions were generally tolerable, similar to those reported in previous studies.
In the present study, the result of patients who received anlotinib showed that the median PFS was 4.7 months, and the median OS was 6.4 month. In addition, the ORR and DCR were 9.9% and 51.6%. Although the survival time was shorter than that of ALTER-0303, one of the result was considered that there were 28 patients with PS 2 in this study, this may be an important reason for the difference in survival time. According to Di Maio et al [18] showed that physical condition has a greater impact on the choice of treatment options and drug tolerance, and is also an important indicator re ecting the severity of patients' condition for advance NSCLC treatment. Furthermore, if we exclude patients with PS 2, the median PFS, OS were 5.5 and 9.2 months, which was similar to the ALTER-0303. And also the same study showed that bevacizumab combined with chemotherapy was an effective and tolerable treatment for NSCLC patients with low PS score [20] . For patients with PS 2, the median PFS, OS were only 2.7 and 4.3 months. Furthermore, according to analysis of short-term therapeutic effect of anlotinib with PS, the PS 0-1 of ORR(ORR, 45.1% vs 6.6%), DCR(8.8% vs 1.1%) was signi canly more than PS 2. On the other hand, the adverse reactions of anlotinib on PS, our result also shows that the PS 0-1 group of I-II adverse reactions was high than PS 2 group(52.3% vs 32.1%), but the III-IV adverse reactions were less than PS 2 group(9.5% vs 10.7%). which may indicated that PS was an important factor affecting the treatment of advanced NSCLC by anlotinib, and high PS may lead to patients' di culty in bene ted from anlotinib treatment.
Previous studies have showed that the growth characteristics of lung squamous cell carcinoma(LUSC) are mainly central type, slow growth, local invasion and low regional lymph node metastasis rate [2,21−23] . The tumor tissues have relatively rich blood supply, and the main cause of death is that the tumor lesions in the chest are not effectively controlled or local recurrence occurs after treatment [2,24] . The anti-angiogenic drug bevacizumab combined with paclitaxel and carboplatin has only been approved rst-line treatment for advanced non-squamous NSCLC without EGFR mutations [25][26] . And a multi-center phase II clinical trial of apatinib in third-and further-line for advanced NSCLC showed that apatinib can signi cantly improved the survival time of advanced non-squamous NSCLC, with PFS 4.7 months, DCR 12.2%, and ORR 68.9% [2,27] .
The characteristics of LUSC is characterized by central type and more cavitives, which maybe the result that antiangiogenic drugs bevacizumab and apatinib are prohibited for the treatment of advanced LUSC due to the high risk of bleeding. So what is the e cacy and safety of anlotinib third-and further-line in the treatment of advanced LUSC. We divided the pathological type into adenocarcinoma group(n = 43) and squamous group(n = 48) with unselected PS patients, the result shows that there were not signi canly differences between in two groups with OS(7.4 vs 6.1 months, P > 0.05) and PFS(5.2 vs 3.8 months, P > 0.05). Furthermore, in subgroups analysis the pathological type and ECOG PS for anlotinib treatment, the combination of squamous and PS 0-1 has signi cantly longer PFS(6.7 vs 2.95 months, P = 0.001) as well as OS(8.1 vs 3.2 months, P < 0.0001) than PS 2. Moreover, in Adenocarcinoma + ECOG PS of Subgroup, the result of PS 0-1 had signi cantly longer PFS than PS 2(4.1 vs 2.2 months, P = 0.0049); although the OS was no signi cantly difference between two groups(6.6 vs 4.4 months, P = 0.068), the PS 0-1 of OS was nearly two months longer than PS 2. This study may shows that the advanced LUSC recived anlotinib treatment with the same e cacy which is comparable to adenocarcinoma, advanced LUSC patients with PS 0-1 and recived anlotinib treatment may bene t the most than PS 2, no matter in mPFS or mOS.
The number of metastasis organs in advanced lung cancer is an important factor for survival and prognosis of patients, the more metastasis organs, the worse prognosis [28][29] . Patients with liver metastases are associated with poor outcomes and the worst prognosis (median PFS 1.15 vs 3.24months, median OS 3-4 vs 5-8months) than non-liver metastases in the advanced NSCLC [30][31][32] . Therefore, a study of bevacizumab in the treatment of advanced non-squamous of NSCLC patients with liver metastasis shows that bevacizumab regimens subgroup was associated with signi cantly longer PFS(4.2 vs 2.6 months, P < 0 .01) and OS(7.1 vs 4.4 months, P < 0 .01) than non-bevacizumab regimens subgroups in patients with baseline liver metastases [33] . So what is the effect of anlotinib in the treatment of advanced NSCLC with liver metastasis?. In our study, the patients was divided into two groups according to the number of metastatic sites in advanced NSCLC. The ≥ 3 metastatic sites of mPFS(3.2 vs 5.4months, P = 0.021) and mOS(4.6 vs 9.2months, P = 0.013) in patients with anlotinib was signi cantly shorter than < 3 metastatic sites, and also was an independent risk factor for PFS(HR = 1.632, 95%CI: 1.004-2.656,P < 0.05).
Furthermore, we made a subgroup univariate analysis of liver metastasis, the patients oraled the anlotinib showed that non-liver metastases of median OS(8.4 vs 4.4months, P < 0.05) and PFS(5.4 vs 3.2 months, P < 0.05) was longer than liver metastases, the liver metastases patients with higher costs and health care resource. Our study may be considered most similar to that of research [31][32][33][34] , which examined the prognostic effect of liver metastases had a signi cantly shorter OS.
The clinical studies of anlotinib in the treatment of advanced NSCLC have shown better e cacy and survival bene ts. However, the current study has several limitations. Firstly, because the study was a retrospective analysis, the small sample size, the results are easy to be affected by many other factors, and also lack of information regarding quality-of-life bene ts. Secondly, most patients take anlotinib outside the hospital, many syndromes were not found in the course of treatment, and the related syndromes were not given timely intervention, which made the later related syndromes more serious. Although the data of patients for analysis was retrospective, the patients recived anlotinib treatment were bene t and adverse reactions can be tolerate.
In conclusion, the present study showed that the single drug of anlotinib has de nite e cacy and mild adverse reactions in the treatment of advanced NSCLC. Furthermore, the patients in advanced NSCLC with an ECOG PS 0-1 get better PFS and OS than PS2 followed by anlotinib treatment. And the results of univariate and multivariate analyses shows that the patients with PS score of 0-1, no liver metastasis, squamous cell carcinoma, third-line treatment and non-smoking may get better curative effect.
In adverse reactions, the PS 0-1 of patients were more tolerance than PS 2. All of that may shows us that the important of PS scores for advanced NSCLC recived anlotinib treatment.