What’s in the web for family physicians – Cancer immunotherapy

Wilbert WB Wong 王維斌，Alfred KY Tang 鄧權恩

HK Pract 2020;42:43-44

In Hong Kong, the 5 leading cancers are colorectal cancer, breast cancer, lung cancer, prostate cancer and liver cancer. ¹ A number of therapeutic approaches are available for cancer treatment, including surgery, chemotherapy and radiation therapy. The Nobel Committee has awarded Nobel Prize in Physiology or Medicine to two immunologists to commend their breakthroughs in treating cancers with immunotherapy. ² Immunotherapy has been proven to be effective in treating cancers, and has brought a ray of hope to quite a number of cancer patients. It would be good for family physicians to keep themselves updated on this topic.

Overview of Immunotherapy for Cancer treatment

As the principal agency for cancer research of the federal government of United States, their website provides a comprehensive overview on immunotherapy. It outlines how immunotherapy works against cancer, the different types of immunotherapy, and the types of cancers that can be treated with immunotherapy. Side effects, route of administration of immunotherapy, the frequency of treatment and the expected results of treatments are also included.

In brief, the immune system detects and destroys abnormal cells in preventing the growth of many cancers, however, cancer cells have ways to avoid destruction by the immune system. People whose tumours contain tumour-infiltrating lymphocytes often do better than people those without. The more popular types of immunotherapy to treat cancer include immune checkpoint inhibitors, T-cell transfer therapy, monoclonal antibodies, treatment vaccines and immune system modulators.

Immunotherapy of cancer review for family physician

This review at the website of Australian Family Physician outlines the theoretical framework behind immunotherapy, and recent advances in immunotherapy. At least two immunotherapeutic approaches, checkpoint inhibition and cellular therapy with autologous (‘self’) chimeric antigen receptor T cells (CAR T cells), show indisputable evidence of efficacy in several cancer types.

Immune checkpoints targeting the PD-1 pathway have generated a lot of interest. This has been proven to be of great clinical implications in cases of melanoma, non-small-cell lung cancer, small-cell lung cancer, kidney cancer, Hodgkin lymphoma, hepatocellular cancer, bladder cancer and breast cancer.

Many cancers are shown to express ligands for CTLA-4 at high levels, thus creating a strong negative signal. Therapeutic ‘checkpoint inhibitor’ antibodies such as anti-CTLA-4 (epilumumab, ‘Yervoy’) block this interaction, to disinhibit and amplify a pre-existing immune response to cancer cells.

Cost-effectiveness analysis of pembrolizumab compared to standard of care as first line treatment for patients with advanced melanoma in Hong Kong

This article, published by The Chinese University of Hong Kong in 2020, demonstrated Pembrolizumab being cost-effective relative to chemotherapy (dacarbazine (DTIC), temozolomide (TMZ), and the paclitaxel-carboplatin combination (PC)), and highlycost-effective compared to ipilimumab, for the first-line treatment of advanced melanoma in Hong Kong.

According to the media release in Legislative council meeting record in 2018 ³ , there are three immunotherapy drugs listed as self-financed items (SFIs) on the HA Drug Formulary (HADF) for treating four types of cancers, namely skin cancer, renal cell cancer, lung cancer as well as head and neck cancer. Nivolumab, a type of immunotherapy drug for treating skin cancer, has been covered by the Community Care Fund Medical Assistance Programme since August 2018.

According to the latest release of Hospital Authority Drug Formulary in Feb 2020 ⁴ , pembrolizumab is classified as self-financed items without being included in the safety net. The article demonstrated pembrolizumab as cost-effective in advanced melanoma and that this drug could hopefully be included in the safety net in future.

The Society for Immunotherapy of Cancer (SITC) cancer immunotherapy guidelines

The Society for Immunotherapy of Cancer (SITC) of United States issued a collection of updated consensus guidelines and recommendations developed by a panel of expert physicians, nurses, and scientists, regularly communicated to review existing new data to be incorporated into updated consensus management guidelines.

The cancer immunotherapy guidelines are reviewed on an ongoing basis to account for newly available clinical trial data and FDA approvals. Published guidelines at the website include immunotherapy for bladder carcinoma, cutaneous melanoma, head and neck carcinoma, non small cell lung cancer, prostate cancer and renal cell carcinoma.

Immuno - Oncology Agent Immune -Related Adverse Event Clinical Guideline - Side effects of Immunotherapy and management

The guideline is developed by Oxford University Hospital of the United Kingdom. Clinical guidelines are developed for the recognition and management of immune related adverse events secondary to immuno-oncology agents. While immuno-oncology agents are being increasingly used in the treatment of cancers including melanoma, lung cancer and bladder cancer,early recognition of symptoms and treatment of potential immune-related adverse events is critical in ensuring appropriate management and in some cases may require the use of immunosuppressants.

Immune-related adverse events can occur a number of months after initiation of immunotherapy agents, even after discontinuation. The guidelines cover the management of adverse events like fever, fatigue or poor appetite to severe conditions like shortness of breath or shock.

Harvard Medical School: Immunotherapy: An answer to cancer?

A webinar delivered at Harvard Medical School on advances in immunotherapy for cancer. Immunotherapy involves new treatments that trigger the immune system to attack the tumour, delivering dramatic benefits to some patients with advanced cancers. The speakers shared insight from decades of research into pathways that may lead to a cure. This presentation outlined the scientific background on how the treatment works and gives an insight for future development.

Advances in cancer immunotherapy 2019 – latest trends

Immunotherapy of cancer is a rapidly evolving field, and has established itself as a new mode of cancer treatment improving the prognosis of many patients, ranging from haematological to solid malignancies. The two main discoveries behind this success are checkpoint inhibitors (CPIs) and chimeric antigen receptor (CAR) T cells. Results of currently ongoing studies on checkpoint blockade will most likely expand the use of CPIs to additional patient populations (e.g. new tumour entities, perioperative use, use in special patient populations) and might identify new combination partners for CPI.