In the past decade, immune checkpoint inhibitors have emerged as transformative treatments for stage 4 non-small cell lung cancer (NSCLC). Recent research, published in February, highlighted the extended survival of many patients who underwent immunotherapy, a treatment method that activates the body’s immune system to detect and eliminate cancer cells.
Traditionally, a maximum of two years of immunotherapy has been the standard treatment for NSCLC patients. However, a new study conducted by scientists at Penn Medicine suggests that discounting immunotherapy after two years is a reasonable approach, provided the cancer has not progressed. The findings, published on June 4 in JAMA Oncology and presented at the 2023 American Society of Clinical Oncology (ASCO) Annual Meeting, reveal that there was no statistically significant difference in overall survival between patients who ceased therapy at two years and those who continued indefinitely.
Senior study author, Charu Aggarwal, MD, an oncologist who specializes in lung cancer at Penn Medicine’s Abramson Cancer Center, said, “These results reinforce what clinical trials have shown us: that two years of immunotherapy may be enough. We have the data today to be able to say that physicians and patients should feel comfortable stopping immunotherapy at this point.”
Comparable Lung Cancer Survival Rates with Immunotherapy Limited to 2 Years or Extended Indefinitely
To conduct this analysis, Dr. Aggarwal and her team examined a national electronic health database encompassing patients with advanced NSCLC from various academic and community healthcare settings. Among the 1,091 patients who received an immune checkpoint inhibitor as their initial treatment, either as a standalone therapy or in combination with chemotherapy, none exhibited continued cancer growth.
The average age of study participants was 69, with approximately half being female and nearly 7 out of 10 being white. At the two-year mark, only about one in five patients discontinued immunotherapy, while the remainder continued treatment indefinitely.
Notably, survival rates indicated no significant disparity between the two groups, with a 79 percent probability of survival for those who stopped at two years and 80 percent for those who continued indefinitely, four years after treatment initiation.
If Outcomes Are the Same, Why Stop at 2 Years?
Dr. Aggarwal says, “A lot of immunotherapy patients say, ‘I’m tolerating this. This is going well. My cancer hasn’t come back. Why would I stop?’ But we must keep in mind that there are financial issues and physical toxicities related to it.”
Dr. Aggarwal also shares that immunology can cost anywhere between $10,000 and $20,000 per month, of which insurance doesn’t necessarily cover all of the expenses either. This makes the financial burden heavy for any patient that needs to consider this type of treatment.
Additionally, while immunotherapy activates the immune system against cancer, it may also trigger immune responses against healthy cells and tissues, warns the Cancer Research Institute. Patients might experience flu-like symptoms, fatigue, chills, fever, nausea, muscle aches, and breathing difficulties, alongside other side effects like sinus congestion, diarrhea, heart palpitations, and organ inflammation. Immunotherapy can also lead to rash, arthritis, hypopituitarism (insufficient pituitary gland hormone production, explains Johns Hopkins Medicine), and hypothyroidism (inadequate thyroid hormone production).
A spokesperson for the American Lung Association and chief radiation oncology at the Lahey Hospital and Medical Center, Dr. Andrea McKee, anticipates that many immunotherapy patients will find comfort in the news that survival benefits seem to persist beyond the two-year mark. This is particularly significant considering that lung cancer is the leading cause of cancer-related deaths among adults in the United States, with non-small cell lung cancer accounting for 80 to 85 percent of cases.
“These patients come once a month to an oncology clinic, infusion center, or hospital, so you can imagine after two years of doing this people are wiped out and have had enough. This study goes a long way to reassuring them that they can stop treatment after two years,” says Dr. McKee, who was not involved in the study.
A Groundbreaking Approach to Addressing a Leading Cause of Cancer Mortality
According to the Centers for Disease Control and Prevention, more adults in the United States die from lung cancer compared to other types of cancer. Around 80 to 85 percent of lung cancers are NSCLC, says the American Cancer Society.
Despite the promise immunotherapy holds for this patient population, it’s essential to acknowledge that it may not be effective for everyone. Research from Johns Hopkins University suggests that only 15 to 20 percent of patients achieve long-lasting results with immunotherapy, with response rates ranging from 20 to 40 percent in research published in Nature journal.
Nevertheless, for those who do respond positively, immunotherapy can be a lifeline, potentially resulting in remission and the absence of active disease.
Dr. McKee says, “We always hate to use the word ‘cure,’ but some of these patients are being cured. It’s a select group of patients who actually have this phenomenal response, and when you do get it, it can be a home run. You can see no cancer growth — no active disease.”
Notably immunotherapies for NSCLC include the following:
Tecentriq (atezolizumab), Imfinzi (durvalumab), Libtayo (cemiplimab-rwlc), Opdivo (nivolumab), Keytruda (pembrolizumab), and Yervoy (ipilimumab).
The study authors also observed that 11 patients who discontinued therapy at two years later experienced cancer progression. Of these, eight patients resumed immunotherapy and achieved a median progression-free survival of 8.1 months, a “pretty good response” in their treatment journey.
“Immunotherapy is still in its infancy. We’re learning so much every few months as to how to use the treatment to better care for our patients and elongate their survival,” she adds.
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