Comment: The success of immunotherapy means we have to change our mindset as we treat patients

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Published: 1 Jun 2019
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Dr David Graham and Dr Edward B. Garon

Dr David Graham and Dr Edward B. Garon comment on data, during a press conference at the 2019 American Society of Clinical Oncology (ASCO) Annual Meeting, from the KEYNOTE-001 trial.

This was a phase Ib randomised trial studying the use of pembrolizumab in aNSCLC patients who had not been previously treated and also those who had received prior treatment.

Watch Dr Garon's interview here, and press conference here.

Dr Richard Schilsky

I’d like to ask Dr David Graham, one of our ASCO experts, to provide some additional context and some insights.

Dr David Graham

Thank you Dr Schilsky and Dr Garon. We have seen over the last couple of years at the ASCO annual meeting a lot of impressive data with immunotherapy. This report from Dr Garon and his colleagues actually highlights two very important things that we need to think about. The first is that with the use of immunotherapy in appropriate patients we have to start thinking of how we deal with our patients in different ways than we used to. In previous years we would see a person with metastatic non-small cell lung cancer and unfortunately have to paint a pretty gloomy picture. Their chances of being alive five years down the road would be 5% or sometimes even less. Now as we look at these data with the patients appropriately treated with pembrolizumab one in four of them or more are going to be around five years from now and that completely changes our mind-set as we treat patients.

The other very important thing that this report highlights is the importance of appropriately funded studies to gather these data. Working just in practice patterns in the community we would have never learned this from our patients. Without an appropriately funded study to gather these data over time we would never find out that there is this group of people who are around that is way more than we could have ever expected. So we continue to highlight in ASCO the importance of appropriately funded clinical trials and this is just another highlight of our theme of this meeting. We’re learning from our patients every day.

Dr Richard Schilsky

Thanks. And I want to ask you one quick follow-up question. So, as I understand it, although response rates were fairly high in the patients who stayed on pembrolizumab for at least a couple of years the majority of those responses were not complete responses if I am correct. So presumably then that means that these are patients who were living longer in the presence of their disease. So does this suggest that somehow there’s now some symbiosis between the immune system and the patient and the tumour that the patient is able to just continue to survive presumably without progression of their cancer but without its complete regression either?

Dr Edward B Garon

An excellent question. There’s been a great deal of literature, particularly in the melanoma world, about the importance of complete response and that association with long-term outcomes in lung cancer. I think that the question as to what is going on in these lesions that have improved but have not completely gone away is somewhat unclear. We have in some occasions at our own institution we have a very active translational research effort and we have been in situations where we have biopsied these. Sometimes we find them to have active cancer, sometimes we find they do not, that there’s scar or sometimes granuloma. We have found multiple different things and so it’s very hard to know to what extent what we’re seeing on the scans at this point is not malignant disease versus this idea that you’re bringing up that somehow the immune system and the cancer have fought each other and worked themselves to a draw and that the cancer is being appropriately maintained. I think that that’s going to be an area that will be an interesting one for our future research.