The Case of the Immunotherapy Inquiry
Jay is a 62-year-old man with newly diagnosed, stage IIIA (T3, N1), unresectable, non-small cell lung cancer (http://voice.ons.org/topic/lung-cancer) (NSCLC) that tested negative for ALK, EGFR, and KRAS mutations. Additionally, PD-L1 (programed death receptor ligand) expression was less than 30%. Jay is symptomatic with a persistent cough, unintentional weight loss, and fatigue.
Jay presents to the medical oncology office to discuss treatment options. Jay tells Jessica, the intake nurse, that he is not interested in chemotherapy or radiation. He says that he read about new ways to treat cancer by using the body’s immune system and insists this is the only therapy he is willing to try. Is Jay a good candidate for immunotherapy (http://voice.ons.org/topic/immunotherapy)? Why or why not?
Immunotherapy in Cancer Care
The excitement over immunotherapy as a new approach to treat cancer can be confusing to patients. Treatments such as monoclonal antibodies (e.g., rituximab, trastuzumab), oncolytic virus therapy (e.g., talimogene laherparepvec), adoptive T-cell therapy, cancer vaccines (e.g., sipuleucel-T, human papillomavirus, hepatitis B), and checkpoint inhibitors (e.g., PD-1 or CTLA4 inhibitors) are all considered immunotherapy: therapies that harness the power of the immune system. The general public may not be aware of the many factors affecting the human immune response to pathogens and cancer’s ability to evade immune system recognition.
Another fact, not always evident in advertising and word-of-mouth information, is that not all types of cancers respond to immunotherapy. Additionally, immunomodulating drugs as a first-line cancer therapy are approved only for specific situations (http://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-016-0623-5); nearly all indications are as second-line treatment after chemotherapy. In Jay’s case, standard-of-care recommendations (https://www.nccn.org/professionals/physician_gls/pdf/nscl.pdf) are concurrent platinum-based chemotherapy and radiation therapy.
Jessica explains the standard-of-care guidelines and clarifies that one of the main reasons for chemotherapy and radiation therapy as first-line treatment is because chemotherapy is typically more effective than immunotherapy at rapidly killing cancer cells. Notable effects from immunotherapy can often take multiple treatments, and although results can be long lasting in some people (http://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-016-0623-5), other people realize little or no effect overall.
As Jessica further explores Jay’s understanding of the side effects associated with chemotherapy and radiation treatment, she realizes that Jay believes there are few, if any, side effects related to immunotherapy. Jessica informs Jay that although immunotherapy is generally well tolerated, the drugs are associated with immune-related reactions (http://www.onclive.com/web-exclusives/fda-approves-pembrolizumab-for-frontline-pdl1-nsclc?p=2), such as colitis, pneumonitis, and hepatitis. These symptoms occur when the immune system stays active (http://dx.doi.org/10.1188/11.CJON.E58-E65) and T cells specifically stay in overdrive.
She gives him printed information on NSCLC and a patient resource guide (http://www.patientresource.com/Immunotherapy_Guide.aspx) explaining how immunotherapy works and its approved indications and recommends reviewing the National Comprehensive Cancer Network (https://www.nccn.org/professionals/physician_gls/pdf/nscl.pdf) patient guidelines for NSCLC.