Optimizing immunotherapy, biomarker testing vital to progress in lung cancer treatment
Click Here to Manage Email Alerts
Most oncologists treating non-small cell lung cancer reported more research into immunotherapy treatments, patients with comorbidities and biomarker testing will be vital to improving care, according to results of a nationwide survey.
Treatment of NSCLC has advanced significantly in recent years, but oncologists identified several needs to continue that growth.
“We’re oncologists. We’re typically glass half-full people faced with some of the hardest things to go through in patients’ lives,” Julie Brahmer, MD, MSc, director of thoracic oncology at the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, told Healio. “Clearly, therapies don’t work for everybody, even if you have the biomarker for that therapy in your cancer.”
The Cancer Research Institute commissioned The Harris Poll to conduct the study, which included responses from 250 oncologists treating advanced NSCLC from 37 states.
“It’s treating physicians really telling us what they want or what they need,” Brahmer said.
Immunotherapy
Most oncologists indicated they wanted more research into new treatment combinations involving immunotherapy (71%) and how to treat patients improving on immunotherapies (64%).
Additionally, many oncologists identified treatment sequencing strategies (49%) and additional immunotherapy options (30%) as areas to focus on.
“Immunotherapy treatments are great, but they don’t benefit everyone,” Brahmer said. “That can be a significant disappointment for our patients as well as ourselves,” she added. “Now that immunotherapy is part of almost every stage of lung cancer treatment, if that doesn’t work, we don’t have great treatment options yet outside of chemotherapy.”
More treatments lead to more questions though.
“For single-agent immunotherapy, most everyone’s getting comfortable with this type of treatment. But when you start combining immunotherapies, that gets a little bit harder because [the] side effects increase, and the side effects to immunotherapy can be very complicated, particularly in [patients with] lung cancer who have other health issues that also can mimic some of these side effects,” Brahmer said.
Brahmer had three questions she would like to see answered in immunotherapy research in the next few years.
“One is figuring out who can get away with single-agent immunotherapy upfront versus having to do it with chemo,” she said. “Then, how to combat resistance to immunotherapy.”
Determining the best treatment course beyond chemotherapy is an important issue to address for those whose cancer is initially controlled by immunotherapy but then starts progressing, Brahmer said.
The third question involves approaches to patients who have completed a typical course of immunotherapy lasting up to 2 years.
“Are there ways that we can test to see if you go to a maintenance, that you get this treatment maybe four times a year and your cancer never comes back? Can you go [down] to once a year?
“[For] 30% of patients, their cancer doesn't come back after immunotherapy,” she continued. “In those three different questions, I'm hoping we could raise the bar and increase that by 20% to 30%.”
Patients with comorbidities
Most oncologists (88%) confirmed patients with comorbidities need to be studied further.
“As we get older, we tend to have other health issues that can complicate care,” Brahmer said. “We have to tailor therapy based on that, and sometimes — particularly folks that have multiple issues — their tolerance of therapy or the side effects to therapy are not that great.”
Brahmer noted more than half of patients are older (above the age of 75 years), yet they are often excluded from clinical trials, limiting information on how newer therapies relate to their comorbidities, particularly heart disease and poor kidney function.
“How do these patients really do?” she asked. “What can be done to mitigate the side effects to these treatments and make it easier for these patients to tolerate?”
Metastases
Most oncologists (86%) raised concerns about treating patients whose cancer metastasized to the brain. Drugs treating lung cancer do not absorb well in the brain, Brahmer explained.
“We typically have to also use radiation therapy to treat the spots in the brain. That can be a challenge,” Brahmer said.
“There’s something called leptomeningeal disease — that’s when cancers spread to the surface or the fluid around the brain,” she added. “That is extremely hard to treat because most of our drugs don’t get into that space.
Some research suggests that immunotherapy can treat brain metastases, as well as some targeted oral therapies, according to Brahmer.
“Probably half of the oral therapies that we have do get in the brain, but not all of them,” she said.
Optimism does exist, however, as improvements continue to be made, Brahmer explained.
Most oncologists (75%) also noted patients whose cancer metastasized to their bones can be difficult to treat as well.
“That causes a lot of morbidity because of pain, and potentially loss of function,” Brahmer said. “If patients are in pain, they’re not going to get up and around, and then the patients just tend to deteriorate more quickly.”
Research and funding are critical in these areas.
“Research gives us hope that things can change, and we can figure out why these areas are harder to treat, and why the treatments we have don’t work [well],” Brahmer said.
Biomarker testing
Nearly all oncologists (94%) agreed biomarker testing is necessary for making treatment decisions, but the same percentage also responded that more work is needed to improve care for patients with known biomarkers.
“If patients are on the right therapy up front, they have a chance to do well for a long period of time,” Brahmer said. “The problem is, if their cancer is growing through that initial treatment, or they have too many side effects to the initial treatment, they may not get to the right treatment afterward.”
Further development of blood-based biomarker testing could alleviate some issues.
“It’s just easier,” Brahmer said. “You get the results quickly — typically within a week — compared with tissue, where it could take 2 up to even 4 weeks. If you don’t have enough tissue to do the test, the test is inconclusive, and you’ve got to go back and biopsy.”
Biomarker testing has been used more in recent years, but accessibility continues to be a problem.
“There is data out there that says that not all these patients are getting it,” Brahmer said. “Sometimes patients because of their illness, their symptoms from lung cancer are so great, their oncologist and even the patients don’t feel like they can wait for these results, so they just get started on chemotherapy, and that may not be best.”
Brahmer added that high costs can prevent patients from getting necessary treatments, even if they get biomarker testing.
She said educating patients and primary care physicians could benefit a substantial amount of people.
“As soon as a patient is diagnosed with lung cancer, they should understand that you’re running these tests,” Brahmer said.
“We have to make sure that the primary care doc is part of that conversation because some of these tests could be started or ordered by them, so that when [patients] end up in the oncologist’s office, the oncologist has all the information that they need,” she added. “And then also making sure patients are their best advocates and making it easy for them to understand what needs to be done.”
For more information:
Julie Brahmer, MD, MSc, can be reached at brahmju@jhmi.edu.
Collapse
Read more about
Click Here to Manage Email Alerts