Immunotherapy May Improve Lung Cancer Outcomes, Reduce Side Effects

Immunotherapy has drastically changed the treatment of lung cancer.

In recent years, immunotherapy has become an effective treatment option for patients with lung cancer and utilizes a patient’s own immune system to attack cancer cells, an expert said.

There are even more advancements on the horizon that may further the use of immunotherapy in different stages of the disease, Emily Touloukian, president of Coastal Cancer Center in Myrtle Beach, South Carolina and a medical cochair of the COA Patient Advocacy Network, said in an email with CURE®.

Touloukian discussed how immunotherapy has different — but manageable — side effects as compared with chemotherapy, which patients may be better suited for the treatment and what may be expected of this therapy in the future.

How can immunotherapy be an effective treatment option for patients with lung cancer?

It's important that we make sure we understand the difference between chemotherapy and immunotherapy. Chemotherapies are drugs typically given through the IV, sometimes by mouth, that attack rapidly dividing cancer cells. And that's how a patient may get the side effects from it because not only are cancer cells rapidly dividing, but other cells in the body are dividing as well that line the stomach and (gastrointestinal [GI]) tract. Patients can get nausea, some diarrhea and hair loss that way.

Immunotherapy works differently, as it really revs up the body's immune system to wake up and attack the cancer cells. So a completely different mechanism of action, which, a lot of times, can be a little gentler on the body.

Can you explain how immunotherapy is gentler on the body?

The potential side effects of immunotherapy are much less than the side effects from chemotherapy typically. Side effects from chemotherapy can be nausea, vomiting, hair loss, fatigue. Side effects from immunotherapy are really immune-related. So the body can attack other things in the body aside from those cancer cells, so things that we more commonly see if we do see a problem are things like skin rash or thyroid problems. Those are two very common ones that are easy to monitor for by checking the thyroid’s function and if a patient has a rash. Other times, it can cause inflammation of other places in the body like the lungs, liver, colon, those sorts of areas. And so typically, when a patient is on immunotherapy, they get a list of questions that they’re asked every time they are in so that we can try to identify those things if they do start to occur.

Are potential side effects easily managed?

Every patient is different. But more often than not, the side effects can be managed relatively well with steroid treatments. Steroids help to calm down the immune system from attacking the organ that's causing that side effect, and that usually works.

There are a few other immune-modulating medications that we can use for certain specific side effects. Like if they attack the colon, there are some other medicines we can use there.

More often than not, it is steroid treatment. And it does calm the immune system down relatively quickly and address that side effect.

What immunotherapy options are available for patients with lung cancer?

There are actually quite a few immunotherapy options available for patients with non-small cell lung cancer. It really depends on the features of the cancer itself, what other mutations may be present, what other options that patient may have and the patient themselves. There are immune checkpoint inhibitors, there's PD-L1 inhibitors, and sometimes those are given on their own or often they're combined with chemotherapy as well.

Can all patients with lung cancer be treated with immunotherapy despite what type it is?

It's absolutely better suited for patients who have different features on their lung cancer. There's a marker called PD-L1 that we check in patients with non-small cell lung cancer. And if that's expressed very highly in the patient with metastatic cancer — meaning that it's moved outside of the lungs to other places in the body — then we can use immunotherapy by itself. But if that marker is expressed to a lower degree, we can combine it with chemotherapy in the setting of lung cancer that has moved to other places in the body.

Are there certain questions that patients should ask their care team when discussing immunotherapy as a potential treatment option?

If immunotherapy is being considered as a treatment option, it's very important that the patient lets the care team know if they have any autoimmune diseases, because that's something that can definitely be affected by immunotherapy. Those diseases can be exacerbated by the use of immunotherapy. So if the patient had a disease that causes significant life-threatening issues right before they were diagnosed with it, that may be something the care team really would want to know so that we didn't exacerbate that same issue again.

That's really important that a patient tells their care team about any autoimmune diseases. Sometimes, we hear a patient say, ‘I had an autoimmune disease back then and now it's controlled.’ And the patient doesn’t mention it at their visit, they don't put it on their paperwork.

We see that sometimes patients go on medicines for rheumatoid arthritis or an autoimmune condition and they get an injection at their rheumatologist’s office. They don't think to put that on their medicine list. That's really important to me to make sure that I always ask my patients three or four times to make sure there's nothing there that's going to harm them.

Are there additional immunotherapies on the horizon that may expand patient’s treatment options?

Immunotherapy for all cancers has just been rapidly developing. Every time I turn around, there's some new indication for immunotherapy in cancer, which is really exciting because we can treat more people with fewer side effects.

But more recently — just earlier this month — there was a new indication for immunotherapy in lung cancer to be given before surgery for curative intent in stage 3 lung cancer. That was a really exciting new trial that was released at one of our meetings earlier this year.

As we learn more about how to utilize immunotherapy, there's all kinds of trials going on right now to see is it more is it effective in earlier-stage lung cancers instead of stage 4 lung cancers, where we can treat and manage cancer but aren't necessarily going to cure the cancer. Immunotherapy is moving slowly into earlier lines of cancer treatment. So combining with other chemotherapies perhaps for earlier stage lung cancers or before surgery for lung cancer to give us better results, higher rates of cure and patients living longer.

This transcription has been edited for clarity and conciseness.

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