Immunotherapy in older patients

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Published: 23 Nov 2018
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Dr Ellen Kapiteijn - Universiteit Leiden, Leiden, The Netherlands

Dr Ellen Kapiteijn speaks to ecancer at the International Society of Geriatric Oncology 2018 conference in Amsterdam about the efficacy of immunotherapy in older patients.

Dr Kapiteijn explains that immunotherapy with checkpoint inhibitors is as efficacious as it is with younger patients, so older patients should not be excluded from this treatment.

She also highlights that the immune function of older patients cannot be predicted by looking at immunosenescence alone - an area she hopes to present more on in the future.

This service has been kindly supported by an unrestricted grant from Janssen Oncology.

I talked about immunotherapy in older patients; I did a literature search and I talked about my own experience. What we see is that immunotherapy with checkpoint inhibitors is as efficacious as in younger patients and it does not have more toxicity than in younger patients, so in essence it’s a good treatment option for older patients. The main message is that we should not exclude older patients from that treatment.

Can you tell us a bit more about the literature search?

I looked at especially meta-analyses, so more studies analysed in one paper, and I looked at the checkpoint inhibitor studies. Mainly they were categorised into the tumour type – melanoma, lung cancer and other. We looked at the response rates, the progression free survival, overall survival of those papers. What we see is that they don’t differ if you look at older versus younger patients and the definition of older patients is mainly above 65 years old. We saw responses in all tumour types with the checkpoint inhibitors used as much as in younger patients.

Do you give combination immunotherapy?

The combination immunotherapy is not given a lot to older patients because of the toxicity. We know that it can be quite toxic and we use it especially in younger patients if you need a quick response, if you have a high tumour load and if you have a very fit patient. To be honest, in older patients we are afraid of the toxicity it might give. In the situation of a young patient you probably will take the risk more than in older patients because you don’t want to decrease the quality of life too much. We know that, for example, anti-PD-1 monotherapy can work quite as well as the combination therapy; it takes only some more time to work.

You found the inverse of what you expected for immunosenescence, tell us about that.

We know that the immune system decreases in function with aging, that’s the immunosenescence part but what we see in practice is that older patients have good responses as well. So we cannot predict exactly the immune function of older patients only looking at immunosenescence, it must be a complex thing and maybe the T-cell activation needed in immunotherapy with checkpoint inhibitors is just good enough to get a response. Another thing is that in aging you see inflammation coming up which can also give cancer or progression of cancer. We see that but we don’t see that the checkpoint inhibitors have a lesser effect. So we are doing quite some research in Leiden and we especially want to look at the immune system of patients over age with checkpoint inhibitors. So I hope to be able to present that in the future.

Are there any patients who should not be given checkpoint inhibitors?

I would say differently, I would say that any patient who is in a worse performance score, either two or more, you have to be in doubt to give it even if it’s a younger patient. If a patient has an autoimmune disease that’s also something you have to consider and it depends on the kind of autoimmune disease whether you can give checkpoint inhibitors or not but you always have to think about the metastasised disease which they have and balance that. So for any patients in a bad condition you would not treat, especially in older patients. Patients who are not able to walk or to take care of themselves or patients of whom you know they won’t call the hospital if they have diarrhoea or anything you should not treat or you should take care of a good system around them. So you have to ask about that if you see those patients.

How would you sum up your opinion on this topic?

It might be the conclusion of my presentation. I think age is not a reason in itself not to give checkpoint inhibitors because the efficacy and the toxicity are not less or more than a younger patient. I presented the case of Jimmy Carter, former President of the United States, who was diagnosed with metastasised melanoma three years ago, he even had brain metastases. He’s still alive now, 94, and he is in good condition. So you have to select, yes, but age in itself is not a reason not to give it.