Immunotherapy is a different approach to fighting cancer, and melanoma is one cancer type that this treatment is now approved for. As immunotherapy for melanoma has gained publicity, more patients are aware of it and are asking for more information about it.
What is Immunotherapy?
Immunotherapy boosts a patient’s own immune system to attack cancer. This approach is different than traditional strategies, such as chemotherapy and radiation, which attack both healthy cells and cancer cells equally.
According to Dr. Balch, “Health care professionals should understand that immunotherapy on its own does not treat cancer. Immunotherapy treats a deficient or abnormal immune system to treat the cancer. We want the patient’s immune system to recognize the cancer and attack it as a foreign invader.”
Since immunotherapy is engaging a person’s own immune system, it mostly leaves healthy cells alone, resulting in different side effects compared with chemotherapy. The side effects of immunotherapy are in a category of autoimmunity, because these checkpoint inhibitors may break tolerance to “self-antigens.” Not losing their hair and not suffering from intense nausea can make a difference to patients in terms of quality of life. This, along with the fact that many people are living longer after receiving this treatment, are big draws for people to try this treatment.
“There are many reasons to use immunotherapy,” says Dr. Kaufman, who served as President of SITC from 2014-2016. “In addition to the different side effect profile mentioned, we often see more durable responses with immunotherapy than with chemotherapy. Although chemotherapy often works quickly by directly killing tumor cells, immunotherapy responses may occur later because it takes time to activate the immune system and then target the cancer. What doctors and professionals need to realize is this may result in a more delayed response, but typically the patient may actually be looking better and feeling better.”
Dr. Balch emphasizes that the health care industry is still learning about and evaluating this treatment as its application is being incorporated into standard care practices.
“We are still learning how immunotherapy works. More research needs to be done. We are not yet sure if it can be used alone or if it’s best in combination with other therapies. We need more trials involving patients with earlier stage disease.”
As more immunotherapy success stories are promoted in the media, patients are beginning to ask about it, and health care professionals should be prepared.
“Patients frequently request immunotherapy now,” Dr. Kaufman says. “Many people seek me out for that. I even had a patient with breast cancer come to me seeking immunotherapy. I told her I specialize in melanoma. She said, ‘I know, but you’re the only one I can get immunotherapy from.’”
People need to understand that immunotherapy isn’t a blanket strategy for every type and stage of cancer right now, but more clinical trials are being conducted to expand the reach.
Managing Side Effects
Since immunotherapy works differently than other cancer treatments, health care professionals need to be aware of immunotherapy complications and monitor closely, because early intervention can reverse the symptoms after the immunotherapy is stopped and steroids begun.
“Monitoring is key with treating patients with immunotherapy,” Dr. Balch says. “In fact, immunotherapy requires more monitoring, assistance and follow-up than any other cancer treatment option. It is important for health care professionals to understand that and to educate patients that professionals are available 24/7 to call and discuss their problems.”
Both Dr. Kaufman and Dr. Balch agree that health care professionals need to monitor and assist patients more closely because of the side effects. Although the side effects with immunotherapy are typically less common than with chemotherapy or radiation therapy, some side effects, usually in the form of an autoimmunity, can be severe and may need immediate attention.
“Professionals must educate the patient on how to recognize the early warning signs of a potentially serious side effect,” says Dr. Balch. “Patients need to not be afraid to call the doctor at the earliest signs of symptoms. With autoimmune responses, if caught early, 90 percent of the time, an autoimmunity [caused by the immunotherapy] can be reversed with steroids and by temporarily taking the patient off of the immunotherapy. If the patient waits too long [to report symptoms], it can cause irreversible autoimmunity and possibly death. Colitis can progress to death, and an attack on the endocrine system can be permanent. Patients need to be told whom to call after normal office hours if they have side effects. Stress to them that they should not be afraid to call. If they experience any symptoms that are beyond what is normal for them, they should call their doctor’s office immediately.”
It’s also important to realize that side effects can be delayed with immunotherapy, sometimes occurring even months after going off the drugs.
“Professionals need to watch patients closely when they are on immunotherapy drugs,” says Dr. Kaufman. “Patients on immunotherapy need to be monitored more, even as long as three to four months after treatment stops since both therapeutic responses and side effects may occur late.”
Determining Candidates
In determining which patients are good candidates for this treatment, Dr. Kaufman offers several tips.
“We need to look at the tumor and cells as well as the patient and his or her condition and age. One thing we’ve found in a newly published study is that older patients who’ve used immunotherapy are showing better survival rates than expected. It was believed that elderly patients, or those over 65-70 years of age, were not good candidates for immunotherapy and it wasn’t safe for them because their immune systems may not work as well. We are finding that thinking is wrong. Age is not a good reason for preventing a patient from trying immunotherapy.
“Candidates with autoimmune or suppressed immune systems or chronic steroid use typically have not been considered good candidates because they were excluded from clinical trial participation. But we are finding now that some people with these conditions can benefit from immunotherapy with minimal increase in potential adverse events. They may just need more monitoring than other patients.”
Dr. Balch explains that in clinical trials, patients with later-stage melanoma are responding better to immunotherapy.
“It is amazing that even in patients with advanced disease who have failed other systemic treatments, we are getting a strong response,” Dr. Balch says. “We must systematically evaluate the benefits and risks of immunotherapy, including combinations of therapies in a progression of clinical trials, starting with patients with advanced cancer to assess the risk versus benefits, and then progressing to a goal of increasing survival rates in surgical patients in the form of adjuvant or neoadjuvant therapy.”