9 Things to Know About Immunotherapy and Lung Cancer

November 8, 2016
Jyoti Patel, MD, FASCO

Dr. Jyoti D. Patel is the Medical Director of Thoracic Oncology and Assistant Director for Clinical Research at the Lurie Cancer Center of Northwestern University. She also serves as Associate Vice Chair for Clinical Research in the Department of Medicine and is the Cancer.Net Associate Editor for lung cancer.

There has been a lot of exciting, recent news about immunotherapy in the treatment of lung cancer. In the past year, checkpoint inhibitors have become an important tool for treating advanced lung cancer. In March 2015, nivolumab (Opdivo) was approved by the U.S. Food and Drug Administration (FDA) for the treatment of squamous cell lung cancer after the first treatment had stopped working. Then, it was approved for the treatment of all types of non-small cell lung cancer (NSCLC) after the first treatment has stopped working. In October 2015, pembrolizumab (Keytruda) was approved for use in patients whose tumors express a protein called PD-L1 and who first received chemotherapy. In October 2016, pembrolizumab received FDA approval as a first treatment for some patients. And finally, atezolizumab (Tecentriq) was approved for all people with advanced NSCLC after chemotherapy in October 2016.

For decades, researchers have studied the role of the immune system in treating and preventing cancer. And now all of these recent FDA approvals have made immunotherapy a hot topic. Immunotherapy, also called biologic therapy, is a type of cancer treatment designed to boost the body's natural defenses to fight the cancer. There are types of immunotherapy beyond checkpoint inhibitors, including cancer vaccines, monoclonal antibodies, and chimeric antigen receptor (CAR) T cells.

The recent availability of these drugs has greatly changed how we treat patients. But what does the promise of immunotherapy really mean for patients? share on twitter  How do we know which treatment to choose, when to prescribe it, and for whom? Here is my list of 9 things to know about immunotherapy when you talk with your doctor:

  1. What is an immune checkpoint? Immune checkpoints are designed to suppress the immune system so healthy organs are not damaged. Cancer cells can take over these checkpoints so the immune system does not target them, thus letting cancer cells thrive and grow. PD-1 is 1 of many checkpoints that is used by cancer cells. Blocking the PD-1 checkpoint allows the immune system to recognize the cancer cells and attack them.

  2. How do they work? Nivolumab and pembrolizumab block the PD-1 checkpoint. Atezolizumab blocks PD-L1, which interacts with PD-1. All of these drugs are given by an infusion into the veins, or intravenously, in a doctor’s office.

  3. Not everyone benefits from immunotherapy. We are just scratching the surface of understanding what factors can be used to identify the patients who may benefit the most from immunotherapy. Researchers are studying what can help us better predict if a treatment will work in a certain person, such as the number of mutations or the number of inflammatory cells in a tumor.

  4. Who can receive nivolumab or atezolizumab? Both nivolumab and atezolizumab are approved for all patients with advanced NSCLC after first receiving chemotherapy, regardless of the levels of PD-L1 expression.

  5. Who benefits most from pembrolizumab? Patients with the highest levels of PD-L1 expression have a greater chance of having pembrolizumab work than chemotherapy. But only about 30% of patients with advanced NSCLC have very high levels of PD-L1 expression. We can measure PD-L1 expression with a tumor biopsy. It should be noted that if the biopsy shows no PD-L1 expression, this does not always mean that immunotherapy will not work.

  6. Who can receive pembrolizumab? Pembrolizumab is approved by the FDA for first treatment of patients with PD-L1 expression in over 50% of cells. It is also approved for treatment for patients with PD-L1 expression in more than 1% of cells.

  7. What about targeted therapy? Patients with a lung tumor with EGFR or ALK gene mutations should be treated with targeted therapy rather than immunotherapy initially. For these people, there is a higher chance that targeted therapy will shrink the tumor than that immunotherapy will work.

  8. What are the side effects of immunotherapy? Patients have fewer side effects from immunotherapy than from chemotherapy, but the side effects of immunotherapy can still be serious. Many side effects of immunotherapy are skin reactions similar to an allergic reaction, but there are also others that require prompt medical attention, such as inflammation of the gut and lungs or problems with the endocrine (hormone) system.

  9. What’s next in immunotherapy? Researchers are trying to combine approaches to increase the chances that an immunotherapy will work, such as pairing it with other immune checkpoint inhibitors, chemotherapy, or radiation therapy. Researchers are also studying whether using immunotherapy combined with surgery or radiation therapy can cure more people with early-stage disease.

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