Immunotherapy for Early-Stage Lung Cancer
- The Food and Drug Administration recently approved immunotherapy for use with chemotherapy in treating non-small cell lung cancer (NSCLC) prior to surgery.
- Checkpoint inhibitors are a type of immunotherapy that turn on the immune system to attack the cancer.
- PDL-1 testing can confirm whether you’re a good candidate for immunotherapy.
- This treatment may prevent you from needing total lung removal surgery or chemotherapy.
Surgery has been the main treatment for early-stage lung cancer, sometimes combined with chemotherapy before or after surgery. But immunotherapy is starting to play a bigger role in lung cancer treatment.Read More
“You don’t buy the first wedding dress you see,” she tells SurvivorNet. “ You may come back to it, but you go and look more. So, that’s what we do. We need to do sequencing, PDL1 testing, and a full pathology report. And a PET scan and a brain MRI. And that way you have all the information to pick your best wedding dress/cancer treatment.”
Dr. Raja Flores, chairman of the Department of Thoracic Surgery at The Mt. Sinai Medical Center, agrees that more information is power. “When I first meet a patient, I don’t right away rush them off to the OR (operating room). I give them all the data. I give them my opinion based on the data for their specific case. And I let them marinate. I tell them, come back and see me in a week or two. It’s important that they get second opinions.”
Typical Early-Stage Lung Cancer Treatments
Having an early-stage lung cancer means that the cancer is confined only to one lung and sometimes the lymph nodes on that same side of the chest. Once cancer has spread beyond one side of the chest, surgery to remove the cancer completely is no longer possible.
Because lung cancer has a chance to return even after the best surgery, chemotherapy, radiation, or both are often added to take out any stray cancer cells that might have been left behind. These treatments kill cancer with strong medicine and high doses of radiation.
What happens when you’ve been newly-diagnosed with lung cancer?
Immunotherapy is different from chemotherapy. It harnesses the power of your own immune system to target your cancer. When doctors recommend immunotherapy for early-stage lung cancer, they’re usually talking about checkpoint inhibitors.
Here’s how this treatment works:
- Checkpoints are proteins on the surface of T cells, a type of immune cell. T cells attack harmful substances such as bacteria, viruses, and cancer cells. PD-1 is an example of a checkpoint.
- Lung cancer cells have their own protein, PD-L1, that activates PD-1 and tells the T cell to ignore them. You can think of PD-L1 as a cloak that hides the cancer cell from the immune system.
- The interaction between PD-1 and PD-L1 is like a switch that shuts off the immune response.
- Immunotherapy drugs called PD-1 and PD-L1 inhibitors flip the switch. They block these proteins to switch the immune response back on so that your immune system can kill the cancer cells.
When Would You Get Immunotherapy?
Immunotherapy is an adjuvant or neoadjuvant treatment for early-stage lung cancer. Adjuvant means additional and refers to treatments given after an initial surgery. Neoadjuvant refers to treatments given before surgery.
A few immunotherapy drugs have been approved for lung cancer treatment in different circumstances:
- Nivolumab (Opdivo) can be combined with chemotherapy to shrink the cancer before surgery.
- Atezolizumab (Tecentriq) may be used after surgery and with chemotherapy to destroy any cancer cells left behind.
- Pembrolizumab (Keytruda) or cemiplimab (Libtayo) might be the first treatment you get if you aren’t a good candidate for surgery, radiation, or chemotherapy, or if the cancer has spread.
- Durvalumab (Imfinzi) can control the cancer’s growth after you’ve had chemotherapy plus radiation.
Immunotherapy comes as an infusion that you get into a vein over a period of about 30 minutes. You’ll get a dose once every two to three weeks.
How Immunotherapy Could Change Your Treatment Plan
In the past, it was common for people with early-stage lung cancer to go straight into surgery. Now you might start treatment with three cycles of chemo plus immunotherapy. In a clinical trial, this treatment shrunk tumors more than chemotherapy alone. Dr. Duma calls the advancement “life changing.”
The treatment could shrink your tumor enough to change the type of surgery you need. Rather than getting pneumonectomy, which removes an entire lung, you might only need a lobectomy, which removes just a section of the lung. That could lead to a very different outcome.
“When you do a whole pneumonectomy…that patient’s life is never going to be the same. It doesn’t matter how much pulmonary rehabilitation you enroll in. You are missing an entire lung,” Dr. Duma says. “My patients with pneumonectomies, their quality of life significantly changes. But the patients with lobectomy recover in three months.”
Dr. Flores expresses caution on the potential impact of chemo plus immunotherapy prior to lung surgery: “The only potential cure for lung cancer so far is surgery when the cancer is caught early. The other treatments may prolong survival, but they don’t result in a cure.”
Revisions to the National Comprehensive Cancer Network guidelines for 2022 include a recommendation for use of nivolumab plus chemotherapy prior to surgery for eligible NSCLC patients. The panel added that if an immune checkpoint inhibitor is used prior to surgery, then a checkpoint inhibitor should not be used after surgery.
Are You a Good Candidate?
You’ll have tests to find out whether you’re a good candidate for immunotherapy combined with surgery and chemotherapy. One test checks your cancer’s genes for mutations.
Some people with non-small cell lung cancer have a gene mutation such as EGFR, or ALK. If you test positive for one of these mutations, there are pills which target these specific mutations and work better than chemotherapy and immunotherapy.
If you get chemo as part of your treatment, you may have to deal with issues like hair loss, nausea, bruising, and appetite loss. Immunotherapy comes with its own set of side effects, which include:
- Skin rash
- Loss of appetite
Because these drugs take the brakes off of your immune system, they can cause an autoimmune reaction. That’s when your immune system misfires and attacks your own organs. This kind of reaction isn’t common, but it can be serious.
One worry about having immunotherapy before surgery is that the side effects might be severe enough to make you put off surgery, which could give the cancer extra time to grow. But studies haven’t shown this happening, Dr. Duma says. “The side effects didn’t delay surgery. Surgeries became faster and were better types for the patient,” she adds.
Could Immunotherapy Help You Live Longer?
Early studies on immunotherapy for early-stage lung cancer have shown promising results. Having this treatment before surgery might make the surgery you need a smaller operation and reduce the odds of your cancer coming back.
A study called CheckMate 816 compared chemotherapy alone with a combination of Opdivo and chemotherapy before surgery. It found that Opdivo plus chemotherapy improved event-free survival, which is the amount of time that passes after surgery without the cancer coming back or spreading.
The treatment also improved the number of patients who had a pathological complete response (pCR), which means there were no signs of cancer in tissue removed during surgery. Studies have linked higher rates of pCR with better survival.
What to Ask Your Doctor
- Should I have genetic or molecular testing?
- Am I eligible for immunotherapy? Am I more, or less, likely to respond to this treatment?
- What side effects might I expect from immunotherapy?
Current and former smokers should get screened for lung cancer