Published May 21, 2021
Use of the cancer immunotherapy treatment atezolizumab after surgery and chemotherapy lowers the risk of tumor recurrence in people with early-stage non-small cell lung cancer (NSCLC), according to new research.
The findings represent one of the biggest breakthroughs in NSCLC treatment in many years. NSCLC makes up about 84% of lung cancers, according to the American Cancer Society.
“This could be an important advance in our understanding of immunotherapy and a step forward for many patients with lung cancer,” says American Society of Clinical Oncologists (ASCO) Chief Medical Officer Dr. Julie R. Gralow.
Immunotherapies have proven their effectiveness in improving survival among individuals with advanced-stage NSCLC, but this study was the first phase III study to demonstrate that immunotherapy can extend disease-free survival (DFS) in patients who have had surgery for early stages of NSCLC (stage II to IIIA).
Atezolizumab appears to be especially effective among people who are positive for the immune checkpoint protein PD-L1. Your oncologist can test for PD-L1 status using a “simple test” that involves staining a sample of the tumor with a marker for PD-L1. The lab gives the tumor a percent expression score ranging from from zero where none of the cells have PD-L1 expression and up to 100 percent where all of the cells have PD-L1 expression.
Immune checkpoint proteins are normal parts of the immune system. They bind with other proteins to prevent an immune response that is so strong it attacks healthy cells. About half of the people diagnosed with early-stage NSCLC have PD-L1 on the surface of their tumors. However, when PD-L1 binds with another protein—PD-1—the immune system has a more difficult time knocking out cancer cells. Atezolizumab is a type of immunotherapy called a checkpoint inhibitor, which means it blocks PD-L1 from binding with PD-1.
“Non-small cell lung cancer remains very challenging to treat,” says the study’s lead author, thoracic specialist Dr. Heather Wakelee, chief of the Division of Oncology at Stanford University Medical Center. “With screening we are finding more cancer at earlier stages of disease where surgery can lead to cure. However the risk of recurrence is high for lung cancer after surgery.”
She adds that if a tumor is removed and it has spread to lymph nodes in the lung (stage II), the risk of the cancer coming back is about 40 to 50 percent. If the cancer has grown to be very large, or has spread to more central lymph nodes (stage III), the majority of patients will have the cancer return. But the findings of her study suggest that immunotherapy may help keep cancer at bay.
In the study, researchers found that patients with stage II to IIIA and levels of PD-L1 of 1 percent or greater who received atezolizumab had a 34 percent reduction in the risk of cancer recurrence or death compared to similar patients who received best supportive care.
Among all patients with stage II-IIIA NSCLC, regardless of PD-L1 status, the reduction in the risk of tumor recurrence or death versus best supportive care was 21 percent.
Best supportive care means patients receive no specific cancer therapy, but are treated for symptoms related to the surgery and prior radiation or chemotherapy. The median DFS (the point when 50 percent of the patients in the study have died or had their cancer return) for patients receiving best supportive care was 35.3 months. At the time data collection was halted prior to presenting the study’s findings, the group of patients who received atezolizumab still had not reached a median DFS, meaning that more than 50 percent of those individuals were still alive and cancer free.
Dr. Wakelee says she expects that in time, the atezolizumab group will reach median DFS, but she is encouraged that this immunotherapy will boost life expectancy for people with lung cancer. “We are very hopeful that the DFS benefit will actually lead to an increase in the number of patients where the cancer never comes back and thus an increase in the cure from cancer in this setting,” she says. “We do not yet know that information, as it will take more time in follow-up before we can tell if we are actually changing the total number of people who have the cancer come back or if we are just postponing the recurrence of the cancer.”
Progress in lung cancer treatment has largely focused on advanced-stage disease, but this study produced encouraging signs that personalized medicine with atezolizumab in early-stage NSCLC may make a big difference in quality of life and life expectancy for people dealing with lung cancer.
But Dr. Wakelee says there is still much to learn.
“There are other studies looking at giving immune therapy before surgery and looking at other types of immune therapy being added to the checkpoint inhibitors like atezolizumab,” she says.
There are several types of lung cancer surgery, and the decision about which is best is based largely on the location of your cancer, its size and whether it has started to spread.
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