Immuno-therapy as First Line Cancer Treatment Nepal - CME at KCC

• The immunotherapy CME at Kathmandu Cancer Center was highly successful. Experts from diverse fields participated in the event. Medical, radiation, and surgical oncologists ,gastrointestinal and head-neck onco-surgeons as well as nursing professionals were among the attendees. The program explored immunotherapy’s role in treating cancer. It focused on bladder, kidney, and stomach cancers. Lung, head-neck, and hepato-biliary cancers were also highlighted. Dr. Rajani Jha, clinical oncologist, led the session. She shared insights on latest clinical data and its potential in Nepal.

Participants engaged in detailed discussions about the latest immunotherapy agents, including checkpoint inhibitors like pembrolizumab, nivolumab, durvalumab and atezolizumab. Of particular interest was the emerging data on combination approaches, including chemo-immunotherapy and dual immunotherapy strategies.

Some key trials on immunotherapy as first line setting.

• • The KEYNOTE-426 trial demonstrated that the combination of pembrolizumab and axitinib significantly improves overall survival, progression-free survival, and objective response rates compared to sunitinib in patients with previously untreated advanced clear cell renal cell carcinoma, with a median follow-up of 67.2 months showing a 60-month overall survival rate of 70.7% for the combination therapy

• • The IMbrave150 trial demonstrated that the combination of atezolizumab and bevacizumab significantly improves overall survival and progression-free survival compared to sorafenib in patients with unresectable hepatocellular carcinoma.

• • The TOPAZ-1 trial demonstrated that the combination of durvalumab with gemcitabine and cisplatin significantly improves overall survival and progression-free survival compared to chemotherapy alone in patients with advanced biliary tract cancer.

• • The KEYNOTE-966 trial demonstrated that the combination of pembrolizumab with gemcitabine and cisplatin significantly improves overall survival (12.7 months vs. 10.9 months) and progression-free survival compared to chemotherapy alone in patients with locally advanced unresectable or metastatic biliary tract cancer.

• • The KEYNOTE-826 trial demonstrated that the combination of pembrolizumab with platinum-based chemotherapy, with or without bevacizumab, significantly improves overall survival and progression-free survival compared to chemotherapy alone in patients with persistent, recurrent, or metastatic cervical cancer.

• • The KEYNOTE-177 trial demonstrated that pembrolizumab significantly improves overall survival and progression-free survival compared to standard chemotherapy in patients with untreated microsatellite instability-high or mismatch repair-deficient metastatic colorectal cancer.

• • The CHECKMATE-649 trial demonstrated that the combination of nivolumab with chemotherapy significantly improves overall survival and progression-free survival compared to chemotherapy alone in patients with advanced gastric, gastroesophageal junction, or esophageal adenocarcinoma.

• • The KEYNOTE-811 trial demonstrated that adding pembrolizumab to trastuzumab and chemotherapy significantly improves overall survival (20.0 months vs. 16.8 months) and progression-free survival in treatment-naive patients with unresectable, HER2-positive metastatic gastric or gastroesophageal junction adenocarcinoma

• • The CHECKMATE-648 trial demonstrated that first-line treatment with nivolumab combined with either chemotherapy or ipilimumab significantly improves overall survival compared to chemotherapy alone in patients with advanced esophageal squamous cell carcinoma.

• • The KEYNOTE-048 study demonstrated that pembrolizumab alone or in combination with chemotherapy significantly improves overall survival compared to cetuximab plus chemotherapy in patients with untreated recurrent or metastatic head and neck squamous cell carcinoma, particularly in those with high PD-L1 expression.

• • The KEYNOTE-355 trial demonstrated that the combination of pembrolizumab with chemotherapy significantly improves overall survival (23.0 months vs. 16.1 months) and progression-free survival in patients with metastatic triple-negative breast cancer whose tumors express PD-L1 with a combined positive score (CPS) of at least 10.

• • The IMpassion130 trial demonstrated that the combination of atezolizumab and nab-paclitaxel significantly improves progression-free survival compared to placebo plus nab-paclitaxel in patients with metastatic triple-negative breast cancer whose tumors express PD-L1. (>1%)

• • The KEYNOTE-522 trial demonstrated that neoadjuvant treatment with pembrolizumab plus chemotherapy, followed by adjuvant pembrolizumab, significantly improves overall survival in patients with high-risk early-stage triple-negative breast cancer compared to chemotherapy alone.

The importance of appropriate patient selection through molecular biomarker testing was extensively discussed. Participants emphasized the critical role of PD-L1 testing, mismatch repair (MMR) status, and Combined Positive Score (CPS) in various cancer types. These biomarkers serve as crucial tools for identifying patients most likely to benefit from immunotherapy. Thereby optimizing treatment outcomes and managing healthcare resources effectively.

Immunotherapy in an established treatment in Lung Cancer . These are key trials  in first line setting.

• CHECKMATE-227 trial
• KEYNOTE-189 trial
• KEYNOTE-407 trial
• IPSOS trial
• EMPOWER-Lung
• IMpower 133 trial (small cell)
• CASPIAN trial (Small cell)

Dr. Jha discussed how immunotherapy, which harnesses the patient’s immune system to identify and destroy cancer cells, has brought remarkable improvements in survival and quality of life of cancer patients. However, she emphasized that the implementation of such advanced treatments in Nepal comes with unique challenges, particularly regarding accessibility and affordability. Given that Nepal’s healthcare system is still developing resources and infrastructure for cutting-edge cancer treatments, Dr. Jha highlighted the need for multi-level support systems, including healthcare training, patient awareness programs, and institutional support, to make immunotherapy a viable option for Nepali cancer patients. 

 

A significant portion of the CME was dedicated to the practical aspects of implementing immunotherapy in Nepal. The participants noted the trend of decreasing costs of immunotherapy drugs over recent years. This is making treatments increasingly accessible to Nepali patients. Discussions was done about acessability and affordability, and also about potential solutions and support systems.

The cost of immunotherapy remains a big barrier for many Nepali patients, leading to what is often termed “financial toxicity”—the economic strain experienced due to high treatment expenses. Given the high costs of immunotherapy drugs and the extended duration of treatment required, managing these expenses is crucial. During the CME, participants discussed strategies to mitigate financial toxicity, such as local and international funding assistance, insurance options, and KCC’s efforts to provide financial counseling and support to patients. KCC has actively worked to enhance accessibility to such treatments and is continually advocating for affordable solutions to support patients in need. By fostering collaborations, raising awareness, and advocating for policy changes, KCC is making strides in offering advanced treatments like immunotherapy while aiming to reduce the financial burden on patients.

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Frequently Asked Questions (FAQ)

What is immunotherapy?

Immunotherapy is an innovative cancer treatment that harnesses your body’s immune system to fight cancer cells. Unlike traditional methods, which directly target cancer, immunotherapy stimulates your immune system to identify and attack cancer cells more effectively. This treatment approach offers promising results with potentially fewer side effects. By boosting your body’s natural defenses, immunotherapy assists in slowing or stopping cancer growth, and in some cases, even leads to complete remission. It’s a personalized treatment avenue that holds great potential for transforming the way we combat cancer, offering new hope and improved quality of life for patients on their cancer journey.

Where does it work?

Immunotherapy works by helping your body’s own defenses fight cancer. It teaches your immune system to recognize and attack cancer cells as if they were invaders. This is done through special molecules or cells that are designed to trigger an immune response against the cancer. Immunotherapy can be effective for various types of cancer, including melanoma, lung, kidney, and bladder cancers. It’s like giving your immune system a boost to battle the cancer cells more effectively, offering a targeted and potentially less harsh treatment option.

How is immunotherapy given?

Immunotherapy is administered through injections or infusions. It could be given intravenously or under the skin. The treatment schedule varies depending on the type and stage of cancer. While immunotherapy generally has fewer side effects than traditional treatments, some common ones include fatigue, mild fever, and flu-like symptoms. Skin reactions and digestive issues might also occur. Serious side effects are rare but can involve the immune system attacking healthy organs. It’s essential to communicate any changes to your medical team. Overall, immunotherapy’s potential benefits in fighting cancer often outweigh its manageable side effects.