Glucagon-like peptide-1 receptor agonism is associated with improved lung cancer outcomes and tumor growth control

Emerging evidence indicates a reduced incidence of multiple cancers in users of Glucagon-like peptide-1 receptor agonists (GLP-1RAs), drugs widely used for glycemic control and weight reduction that modulate several key regulators of metabolism. We sought to examine their association with non-small cell lung cancer (NSCLC) outcomes in overweight and obese patients and gain mechanistic insights from mouse models. Two clinical cohorts of overweight and obese NSCLC patients—one undergoing surgical resection (n=1,177, 71 GLP-1RA users) and another receiving immune checkpoint inhibitors (ICIs; n=300, 10 GLP-1RA users), were propensity score matched for relevant covariates and analyzed for clinical outcomes. GLP-1RA use was associated with increased recurrence-free survival in overweight and obese patients (HR=0.41 [95%CI=0.16-1.04], p=0.026) after lobectomy. Further, GLP-1RA treatment reduced tumor burden in obese but not normal-weight mice and altered the frequency and phenotypes of leukocyte populations and gene expression patterns in obese tumors, crucial to cancer progression and anti-tumor immunity. Concurrent GLP-1RA and immunotherapy was associated with improved overall (0.41 [0.16-1.01], 0.027) and progression-free survival (HR=0.31, [0.10-0.94], 0.019) for patients with advanced NSCLC. GLP-1RAs may enhance lung cancer-specific clinical outcomes and augment immunotherapy efficacy. Preclinical evidence suggests this effect is obesity-restricted and mediated by immune modulation of the tumor microenvironment. RNA sequencing was performed on excised, subcutaneous KPN1.1 tumors from obese mice treated with GLP-1RA. At the time of mouse tumor harvest, a fragment was flash frozen and was later used for RNA isolation using the miRNeasy mini kit (Qiagen). The sequencing libraries were prepared with the RNA HyperPrep Kit with RiboErase (HMR) kit (Roche Sequencing Solutions), from 500ng total RNA. Following the manufacturer’s instructions, the first step depletes rRNA from total RNA. After ribosomal depletion, the remaining RNA is DNase-digested to remove any gDNA contamination. Samples are then purified, fragmented, and primed for cDNA synthesis. Fragmented RNA is then reverse-transcribed into first-strand cDNA using random primers. The next step removes the RNA template and synthesizes a replacement strand, incorporating dUTP in place of dTTP to generate ds cDNA. Pure Beads (KAPA BIOSYSTEMS) are used to separate the ds cDNA from the second-strand reaction mix, resulting in blunt-ended cDNA. A single ‘A’ nucleotide is then added to the 3’ ends of the blunt fragments. Multiple indexing adapters, containing a single ‘T’ nucleotide on the 3’ end of the adapter, are ligated to the ends of the ds cDNA, preparing them for hybridization onto a flow cell. Adapter-ligated libraries are amplified by PCR, purified using Pure Beads, and validated for appropriate size on a 4200 TapeStation D1000 Screentape (Agilent Technologies, Inc.). The DNA libraries are quantified using KAPA Biosystems qPCR kit, and are pooled together in an equimolar fashion, following experimental design criteria. Each pool is denatured and diluted to 350pM with 1% PhiX control library added. The resulting pool is then loaded into the appropriate NovaSeq Reagent cartridge for 100 paired-end sequencing and sequenced on a NovaSeq6000 following the manufacturer’s recommended protocol (Illumina Inc.).