Immunotherapy in lung cancer
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This presentation is a part of a debate on upcoming role of immunotherapy in lung cancer. The debate was held in 2016 at Dubai, UAE Cancer Congress.
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Immunotherapy in lung cancer
- 1. Is immunotherapy the best second line option in palliative setting in lung cancer patients? NO Dr Alok Gupta Consultant Medical Oncologist Max Super Specialty Hospital, New Delhi
- 5. CHEMOTHERAPY
- 6. Financial Issues should not be discussed in a Scientific Forum ????
- 7. YES - Financial Issues should be discussed in a Scientific Forum
- 8. Is immunotherapy really more effective than chemotherapy? Yes, but only in a fraction of patients
- 11. PFS as per PD-L1 Expression
- 12. OS as per PD-L1 Expression
- 14. Which is the best method to determine PD-L1 expression? PD-L1 IHC 28-8 pharmDx VENTANA PD-L1 (SP142) Assay
- 15. Selecting patients who might benefit from immunotherapy • All patients do not respond as well (PS<50 ). • Fraction of patients who might respond well (PS>50). • Which method/kit for PD-L1 staining is best?
- 16. Immunotherapy in first line metastatic NSCLC
- 17. Keynote 24 35% PS-0 65% PS-1 18%- Squamous 82%- Adeno
- 18. Keynote 24 15% in trial setting
- 19. Keynote 24
- 20. Keynote 24 Adverse Effects
- 21. Keynote 24 Adverse Effects
- 22. • Very highly selected patient population. • Results applicable to only 15% NSCLC. • Had a weaker chemotherapy arm. • Pembrolizumab associated with similar incidence of serious side effects. Keynote 24
- 23. CheckMate - 026
- 24. Immunotherapy cannot be considered the best second line option in palliative setting for ALL lung cancer patients
- 25. Reasons and conclusion • Not feasible to administer to majority of patients in real world. • Financial toxicity is a real world entity. • Only 15-20% patients have PD-L1>50%. • Best assay to assess PD-L1 expression on tumor cells remains to be established. • Limitations in the availability of PD-L1 testing. • Certainly not free of adverse-effects.
- 26. Thank You
Editor's Notes
- I will start by congratulating him for very conveniently having passed on the death sentence for chemotherapy in lung cancer. But I believe the jury is still out. In next few slides I will convince you that immunotherapy is not the best second line option in palliative setting in lung cancer patients, atleast not in majority of patients.
- Category 1 in NCCN really means something…Since I am Speaking against immunotherapy, Let me take the liberty to ask Dr Sajjan, in what % he is actually able to use Nivo or pembro as second line therapy… in more than 50% patients or less than 50%… Let me ask other oncologists… So, that means only ---% oncologists attending an International cancer congress follow one of the most reputed guidelines in oncology… Let us come out of the world of fiction and face the real world. How can it be the best option if only… What are the reasons behind not following the guidelines? Financial? Drug availability? Data not convincing enough with regards to who will benefit from the drug? Or Are we using our common sense? I think, a combination of all the above factors- cost, availability, unclear subgroups who will benefit?
- Actually we are not doing anything wrong by not following recommendations as guidelines themselves recommend..
- Nivolumab and Pembro are the best homes in the world. Guidelines recommend they are the best and there is category 1 recommendation that everyone should stay in them. But is that possible? NO These homes represent ideal world situation, what we see in clinical trials and come into guidelines..
- However, real life situation is very different… Having said that, a home is still a home, so what if its not nivo/pembro and is docetaxel, it gives same level of comfort. A treatment modality which is so unfeasible to administer that only ---% oncologists are using it, cannot ne considered best option
- Financial Difficulties are associated with poor QOL. Any Survival benefit derived from nivo/pembro would be nullified in real world due to financial toxicity of these drugs.
- Although approval is independent of PDL1 expression, response rates definitely correlate with PDL1>5%. For this reason, inclusion criteria in Checkmate 26 trial had PDL1>5% as one of the factors. For pembro, PS>50% For Nivo, PS>5%. Utter confusion…
- Existence and approval of more than 1 Assay for PD-L1 testing only adds to the confusion. Availability of these approved tests is also a concern.
- Hang ON!! You have excluded 85% of patients form your trial..pembro has been tested in 15% of very highly selected population.
- bevacizumab (0%), and maintenance therapy in the majority of them (60-70% in literature, only 39% in this trial). Masters GA, et al. JCO 2015 What happened to explain that they also receive only 4 cycles of their "light" chemotherapy ? This substandard attention lead to a very poor median survival in control arm (only 12 months with cross-over !) as compared with results of maintenance study (16-19 months) and progression-free survival (6 months in this trial and at least 8 months in first line cisplatin-based chemotherapy trial).