The evidence supporting this protocol is provided by three trials, CheckMate 067, CheckMate 069 and ABC. In the phase 3 double-blinded, multicentre, international, randomised trial CheckMate 067. In this trial, 945 eligible patients with previously untreated unresectable stage III or IV melanoma were randomised in a 1:1:1 ratio to receive either nivolumab alone, nivolumab plus ipilimumab, or ipilimumab alone.1
From July 2013 through to March 2014, a total of 1296 patients were enrolled at 137 centres worldwide. A total of 945 eligible patients underwent randomisation: 316 patients were assigned to the nivolumab group and received 3 mg/kg of nivolumab every 2 weeks (plus ipilimumab-matched placebo), 314 patients in the nivolumab plus ipilimumab group received 1 mg/kg of nivolumab every 3 weeks plus 3 mg/kg of ipilimumab every 3 weeks for 4 doses, followed by 3 mg/kg of nivolumab every 2 weeks as maintenance treatment, and 315 patients in the ipilimumab group received 3 mg/kg of ipilimumab every 3 weeks for 4 doses (plus nivolumab-matched placebo).1 Baseline characteristics were balanced across the three groups. Treatment was continued until disease progression or unacceptable toxicity.
The co-primary end points were progression-free survival (PFS) and overall survival (OS). Secondary end points were objective response rate (ORR), tumour PD-L1 expression as a predictive biomarker for efficacy outcomes, and safety. This study was not powered to compare nivolumab monotherapy with nivolumab plus ipilimumab.1
CheckMate 069 is a double-blind phase 2 study involving 142 patients with previously untreated stage III or IV melanoma. In this study patients were randomly assigned in a 2:1 ratio to receive ipilimumab (3 mg/kg) combined with either nivolumab (1 mg/kg) or placebo once every 3 weeks for four doses, followed by nivolumab (3 mg/kg ) or placebo every 2 weeks until the occurrence of disease progression or unacceptable toxic effects. Randomisation was stratified according to BRAF mutation status (V600 wild type vs mutation-positive).3
The primary end point was the rate of investigator-assessed, confirmed ORR among patients with BRAF V600 wild-type tumours. Secondary end points included investigator-assessed PFS in patients with BRAF wild-type tumours, the ORR and PFS among patients with BRAF V600 mutation–positive tumours, and safety.3
Patients with active brain metastases or leptomeningeal disease were previously excluded from clinical trials. The ABC (Anti-PD1 Brain Collaboration) trial provides data on activity of immunotherapy in brain metastasis. Immunotherapy-naïve patients with at least one brain metastasis between 5 and 40 mm with no prior local brain therapy were randomized to nivolumab or combination nivolumab-ipilimumab. Patients with brain metastases in whom local therapy had failed, or who had neurological symptoms, or leptomeningeal disease were enrolled in a third non-randomised cohort receiving nivolumab alone. The primary endpoint was intracranial response from week 12.4
Efficacy
CheckMate 067
After a median follow-up ranging from 18.6 to 38.0 months across the three groups, the median PFS was 11.5 months (95% CI 8.7-19.3) in the nivolumab+ipilimumab group and 6.9 months (95% CI 5.1-9.7) in the nivolumab group, as compared with 2.9 months (95% CI 2.8-3.2) in the ipilimumab group. The hazard ratio for progression or death was 0.43 (95% CI 0.35-0.52) with nivolumab+ipilimumab vs ipilimumab (p<0.001) and was 0.55 (95% CI 0.45-0.66) with nivolumab vs ipilimumab (p<0.001). The rate of PFS at 3 years was 39% in the nivolumab+ipilimumab group and 32% in the nivolumab group as compared with 10% in the ipilimumab group5
At a minimum follow-up of 60 months, the median OS had not been reached (NR) in the nivolumab+ipilimumab group and was 36.9 months in the nivolumab group, compared with 19.9 months in the ipilimumab group (HR=0.52; 95% CI 0.42-0.64; p<0.001 with nivolumab+ipilimumab vs ipilimumab; HR=0.63, 95% CI 0.52-0.76; p<0.001 with nivolumab vs ipilimumab). The OS rate at 5 years was 52% in the nivolumab+ipilimumab group and 44% in the nivolumab group, compared with 26% in the ipilimumab group.6
At a minimum follow-up of 77 months, the median OS was 72.1 months (95% CI 38.2-NR) in the combination therapy arm as compared with 36.9 months (95% CI 28.2-58.7) and 19.9 months (95% CI 16.8-24.6) in the nivolumab and ipilimumab arms, respectively (HR=0.52; 95% CI 0.43-0.64; p<0.0001 for combination therapy vs ipilimumab alone, HR=0.84; 95% CI 0.67-1.04 for combination therapy vs nivolumab alone and HR=0.63; 95% CI 0.52-0.76; p<0.0001 for nivolumab vs ipilimumab). 6.5-year OS rates were 49%, 42% and 23% in the nivolumab+ipilimumab, nivolumab and ipilimumab groups, respectively. PFS was 11.5 months (95% CI 8.7-19.3), 6.9 months (95% CI 5.1-10.2) and 2.9 months (95% CI 2.8-3.2) in the three groups, respectively.7
The phase II CheckMate 069 study showed similar efficacy and toxicity for patients receiving combination ipilumumab/nivolumab and ipilimumab monotherapy respectively.3
Response to treatment7 |
Nivolumab
(n=316)
|
Nivolumab
+
ipilimumab
(n=314)
|
Ipilimumab
(n=315)
|
Complete response (%) |
19 |
23 |
6 |
Partial response (%) |
26 |
36 |
13 |
Stable disease (%) |
9 |
12 |
22 |
Progressive disease (%) |
38 |
24 |
50 |
Unknown (%) |
8 |
6 |
9 |
ORR (%, 95% CI) |
45 (39−51) |
58 (53−64) |
19 (15−24) |
Median duration of response (months, 95% CI) |
NR (45.7-NR) |
NR (61.9-NR) |
19.2 (8.8-47.4) |
NR= Not reached
Kaplan Meier curves for (A) overall survival and (B) progression-free survival7
© J Clin Oncol 2022
ABC study
With a median follow up of 17 months, intracranial responses were achieved by 16 (46%) of 35 patients treated with combined nivolumab + ipilimumab, five (20%) of 25 patients treated with nivolumab monotherapy and one (6%) of 16 patients with poor prognostic features (neurological symptoms, progression after previous local brain treatment or leptomeningeal disease) treated with nivolumab monotherapy.4
Toxicity
CheckMate 067
Treatment-related adverse events were reported in 96% of the patients treated with combination therapy, 86% of those treated with nivolumab, and 86% of those treated with ipilimumab. Grade 3 or 4 adverse events occurred in 59%, 21%, and 28%, respectively. Treatment-related adverse events of any grade that led to the discontinuation of therapy occurred more frequently with combination therapy (39%) than with either monotherapy (12% nivolumab, 16% ipilimumab).5
The most common select adverse events of grade 3 or 4 were gastrointestinal events, which occurred in 15% of the patients who received combination therapy, in 4% of those who received nivolumab monotherapy, and in 12% of those who received ipilimumab monotherapy (specifically, diarrhoea in 9%, 3%, and 6% of patients respectively).5
There were two deaths related to a study drug within 100 days of the last dose: one death due to neutropenia (nivolumab group) and one due to colon perforation (ipilimumab group). There were two deaths considered to be related to a study drug (>100 days after the last dose) in the combination therapy group: one due to autoimmune myocarditis (approximately 2 months after receiving a single dose of anti-PD1 outside the context of the trial) and one due to liver necrosis.5
At the time of 6.5-year analysis, grade 3/4 treatment-related adverse events were reported in 59% of patients treated with combination therapy as compared with 24%, and 28% in the nivolumab and ipilimumab groups, respectively. No new safety signals were detected.7
Adverse events5

© N Engl J Med 2017