Can someone explain immunotherapy?

My brother had stage 3 melanoma and was treated with Keytruda at MD Anderson. The cancer is gone. Immunotherapy boosts your own immune system to locate and attack the cancer cells. Chemotherapy works by stopping or blocking cells from growing. Immunotherapy may or may not work, depending upon the specific cancer (and stage) that you have. 

Nancy

There are many types of immune-oncology compounds, some approved by FDA, many others in clinical trials.

Most known (that you will most likely hear of) are the so-called checkpoint inhibitors, which increase the immune response by stopping white blood cells (T cells) from being suppressed. There are different compounds (antibodies), classified based on the molecule it targets on the surface of the T cells: Some examples are ipilimumab (Yervoy) which targets CTLA-4. Other target a checkpoint protein called PD-1 or one of its ligands, PD-L1 For example, nivolumab (Opdivo), pembrolizumab (Keytruda), atezolizumab (Tecentriq). The issue right now is that only around 20% of treated patients respond (in which case it is obtained partial or complete remission); the exact reason for that is not known. There are many clinical trials that study the blood and tissue biomarkers, to determine what can be used to predict the answer. These check point inhibitors are even used in combination, like anti CTLA-4 plus a PD-(L)1 inhibitor, most likely to succeed. These are well tolerated, the most common side effects are immune mediated reactions that can be easily recognized and treated (in large, specialized centers).
As well as checkpoint inhibitors, two other immunotherapy approaches have produced exciting clinical trials results (that unfortunately are not used now for H&N cancers, but their use will extend to other cancer types): CAR-modified T cell therapy (used for hematological cancers) and TILs (tumor infiltrating lymphocytes) (used for malignant melanoma). Both rely on reprogramming the patient’s own white blood cells.

Also included in this large basket of immunotherapies are cancer treatment vaccines – treatments that increase the “visibility” of the patient’s cancer cells to their immune system.

accordiongirl said:

Thank you!!

Corleone - yours was a very detailed, yet relatively easy to follow explanation.  i'm wondering how these therapies are determined (which one works for which patient, etc) and also how they're administered - is it a pill, a shot, an IV drip, etc.   Do patients typically stay on it for weeks, months, years?  Is it something that causes awful side effects?  Sorry for all the questions - just trying to understand and looking at it online overwhelms me.  i appreciate your straightforward explanations.

Thank you!

~ accordiongirl

Generally, these are administered over a 30 min – 1 hour infusion, every 3 weeks. The side effects are manageable and consists of stimulation of the immune system: any organ inflammation you can think of, ending with “-itis”, like enterocolitis, hepatitis, pneumonitis, etc. Sometimes some anti-inflammatory agents are given prophylactically, just before the infusion. Patients are staying on treatment for as long as they benefit from the treatment. Cautionary tale: sometimes a so-called “pseudo” progression may happen, when a CT scan shows an increase in the tumor volume (which would be considered progression, based on some measuring algorithms, in the case of chemo treatment). It is called pseudo, when the volume is increased temporarily - because the tumor is infiltrated with white blood cells, which is a good thing, showing that the immune cells are attacking the tumor. A second CT scan (done usually between 4-8 weeks) will show if it’s either pseudo, (when the volume will decrease significantly), or confirmed progression (when the tumor volume has not changed from the first one or it’s even larger).

Unfortunately there is a big problem, it is not (yet) known if the treatment will work or not, before trying. It’s a kind of hit or miss situation. But considering the lower toxicity (by comparing with classical chemo) it is worth trying. More and more this is given as a first line of treatment (which makes sense, because the immune system is still OK), versus what has been tested in clinical trials at the early stages of development, when these were given as a last resort, in patients who had multiple lines of treatment, after there was no alternative treatment left.

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