COMMENTARY

ASCO 2021: Best Lung Cancer Immunotherapy Data

Mark G. Kris, MD

Disclosures

July 21, 2021

This transcript has been edited for clarity.

This is Mark Kris from Memorial Sloan Kettering Cancer Center, with the second of three discussions about presentations on lung cancer from the 2021 American Society of Clinical Oncology (ASCO) meeting. I've divided the discussions into three areas: Part 1 was on improvements in treatment of locally advanced disease; immunotherapeutics is the topic of today's discussion; and part 3 will be about targeted therapies.

I'm not going to talk about the various updates on immunotherapeutics that were presented. I'll leave those for folks to look at on their own. Instead, I want to focus on three specific presentations.

The first is by Oladimeji Akinboro, MD, and investigators at the US Food and Drug Administration, who pooled data from clinical trials that compared immunotherapeutic agents alone with the combination of chemotherapy and immunotherapeutic agents. In particular, they looked at the benefits of those therapies in patients with PD-L1 scores of 1%-49% — not zero and not greater than 50% — and they found a clear benefit for people who received chemotherapy plus an immunotherapeutic. This was not a randomized trial but a compilation of multiple randomized trials that, again, shows that people with PD-L1 scores of 1%-49% are likely to have greater benefit when they receive an immunotherapeutic along with chemotherapy. Intuitively, that makes sense, and these data support it.

Remember that you can still add an immunotherapeutic in patients with PD-L1 scores greater than 50%, particularly patients who are very symptomatic or who have a critical need for a response. There's likely to be more benefit and perhaps a deeper benefit by giving chemo plus an immunotherapeutic, even with a high PD-L1.

The second presentation — and I have a conflict of interest here — is from Jia Luo, MD, and colleagues from Memorial Sloan Kettering. This group looked at patients who had an immune-related adverse event and were treated with corticosteroids but didn't get better. The investigators collected information on all patients who received an additional immunosuppressant and found that these additional drugs worked well for many patients, particularly infliximab and mycophenolate. They also noted that people who received high-dose steroids often suffered steroid-related adverse effects. Many patients who ultimately died [from] a serious toxicity with an immunotherapeutic agent died from steroid-induced complications, particularly infections.

Going forward, I believe we're going to see more study of the reasons for adverse effects related to immunotherapeutic agents, and efforts to give a specific drug for a specific type of adverse effect or a specific mechanism of that adverse effect. I believe that will be the strategy with research.

An important message from this study is that these immunosuppressant drugs are helpful, and in my opinion they need to be given first. If someone developed immune-related colitis, I would give them infliximab first. If someone developed immune hepatitis, I would give them mycophenolate first. And then use steroids as a backup. I've been very impressed by the severe adverse effects of steroids and I would urge you to use these other drugs sooner rather than later. Be careful of steroids. They're not benign treatments. I believe all of us probably know examples when the steroids were an issue.

The last presentation is about the use of the artificial intelligence to analyze pathologic specimens from patients who had resections after receiving an immunotherapeutic agent — in this case, atezolizumab. This was presented at a special session about the use of machine learning and artificial intelligence in oncology.

This presentation points to the huge potential for using artificial intelligence and machine learning for the analysis of pathologic specimens. It showed clearly that the analysis of these specimens using machine learning techniques led to an even better prediction of long-term outcomes than using the pathologic evaluation alone. This will become a complementary technique. I believe that, more and more, we're going to see digital pathology entering our clinical trials and care.

Mark G. Kris, MD, is chief of the thoracic oncology service and the William and Joy Ruane Chair in Thoracic Oncology at Memorial Sloan Kettering Cancer Center in New York City. His research interests include targeted therapies for lung cancer, multimodality therapy, the development of new anticancer drugs, and symptom management, with a focus on preventing emesis.

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