COMMENTARY

Finding the 'Sweet Spot' With Corticosteroids in Cancer Care

Mark G. Kris, MD

Disclosures

April 18, 2019

This transcript has been edited for clarity.

This is Mark Kris from Memorial Sloan Kettering, speaking again about the use of corticosteroids in oncology. Clearly, they're one of our go-to agents, part of our standard antiemetic regimens, a cornerstone of the management of neurologic complications, and part of the management of many side effects, including dyspnea and anorexia.

It's very important to use corticosteroids judiciously, but at the same time, never be afraid to give the right dose and the right schedule to treat the problem that a patient is facing at that moment. I don't think any of us would give a lower dose of corticosteroids in the face of spinal cord compression for fear of steroid side effects or lessening the effect of an immunotherapeutic agent. That should be the same for any important side effect.

I think there's absolute agreement that you want to give the lowest dose of corticosteroids possible that will do the job. The acute and late side effects of steroids are substantial and can be lethal; therefore, giving the right dose to get the job done only for as long as needed is absolutely essential. That said, just as in that example I gave you about spinal cord compression, you really have to give the dose that's necessary to treat the imminent risk to the person.

An interesting effect of this is the issues we have raised for our patients. Today I was speaking to a patient who has suffered some pneumonitis following radiation, is receiving an immune checkpoint inhibitor, and his dyspnea only can be controlled by steroids. It was very humbling to hear the difficulties that we put our patient in because we constantly want to put people on the lowest dose of steroids, push that taper, and do the taper as quickly as possible.

Our patients, however, know in their souls that eventually they get to a dose where they feel less well, where a dose of steroid is such that they cannot live their life normally and they cannot live the life that they choose.

In this world of immunotherapeutics, in addition to the fear of steroid-induced side effects which, again, can be very serious and even life-threatening, there is now the fear that if patients don't lower steroids enough, they are going to be hampering or lessening the effects of the immunotherapeutics we are giving them that they are hoping will preserve and extend their lives.

We need to know and be cognizant of the effects we have on our patients and the additional burden that they feel by this issue of being on steroids, being tapered, and not just tapering for side effects, but now somehow lessening the effects of the immune drugs.

I would caution the medical oncologist listening that we really have no absolute evidence that a steroid dose during the course of therapy lessens the effect or duration of effect of the immunotherapeutic drugs. Obviously, we want to give the lowest dose of steroid necessary. There are theoretical reasons why it would lessen the effect of immunotherapeutics, but [to date], there is no randomized trial [demonstrating this].

In fact, some patients who have the most serious side effects received the most immunosuppressive therapy, steroids, and anti-TNF agents. Those are the patients who sometimes have the best outcomes.

We need to be judicious with steroids. Don't be afraid to use them for the right indication. Pay attention to this extra dilemma and burden we've put on our patients.

We need to work with our patients to find that sweet spot of the lowest possible dose of steroids that will give them the benefits they need to maintain their lives and that will be the lowest dose to prevent side effects and any possible effects on the immunotherapeutic agents we are administering.

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