Immunotherapy to Treat Cancer

By Dr Krishna Prasad
Dr Krishna Prasad is the chief medical oncologist at Mangalore Institute of Oncology (MIO). He is the first medical oncologist of Mangaluru and has vast expertise in the area of cancer chemotherapy, hormone therapy, immunotherapy, and newer biological therapies in treating solid and hematological cancers.
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Jun 26, 2019

In humans, the immune system is a very important as it defends the body against infecting and other foreign agents by distinguishing our body´s own cells (self) from foreign elements (non-self). The principal immunologic cells are called leukocytes or white blood cells, and some examples include macrophages and lymphocytes (natural killer cells, T-cells and B-cells). Any new substance that the immune system doesn’t recognize raises an alarm, causing the immune system to attack it and eliminate it from the body. For example, when any microbes contain substances such as proteins that are not normally found in the human body, the immune system sees these as “foreign” and attacks them. In fact it is because of the immune system that humans are in a position to fight the various infections caused by bacteria, viruses and fungi and live a healthy life.

The immune system is also effective in protecting us against tumor cells. In fact most incipient cancers are eliminated by a process called immune surveillance or immunoediting. However unlike with microbes, the effectiveness is always not constant because the immune system has a tougher time targeting cancer cells. This is because cancer starts when cells become altered in the individual’s body and start to grow out of control. The major drawback here with is that many people with healthy immune systems still develop cancer and because the cells are not different enough from normal cells and the immune system doesn’t always recognize cancer cells as foreign. To worsen at times the immune system recognizes the cancer cells, but the response might not be strong enough to destroy the cancer. Also cancer cells themselves can also give off substances that keep the immune system in check.

To overcome this, in the recent past efforts are being made at harnessing the immune system to act against the initiation, development and progression of cancer. Meticulous research in the past two decades has led to the development of ways to help the immune system recognize cancer cells and strengthen its response to eliminate the cancer cells. For these observations, Dr James P Allison and Tasuku Honjo were awarded the Nobel Prize in Physiology or Medicine for the year 2018. The treatment is now being termed as immunotherapy and is gaining wide use in the developed countries. In colloquial terms immunotherapy is treatment that uses certain parts of a person’s immune system to fight diseases such as cancer.

From a mechanistic overview the basis for immunotherapy involves utilizing the body's immune system to induce anti-tumor response to suppress or eliminate the cancer cells. In this one of the most useful methods is to stimulate the patient’s own immune system to work harder or smarter to attack cancer cells. The other methods are to give man-made immune system proteins. Today, among the different therapeutic options for treating cancer, immunotherapy is a potential attractive strategy especially to prevent relapse of disease resulting from residual malignant cells and/or tumor metastases.

Here with the use of immunotherapy for cancers common in Kerala are discussed:

Immunotherapy for lung cancer

Recent reports from around the world indicate that lung cancer is one of the most common cancer and that it affects approximately 2.1 million people—and causes an estimated 1.7 million deaths. Among cancers, lung cancer is the leading cause of cancer-related deaths for both men and women in the world and claims more lives every year than do breast, prostate, and colon cancer combined. Conventionally depending on the stage and general health of the individual, surgery, radiation and chemotherapy is used. Since the majority of lung cancer patients are diagnosed with advanced disease (stage IIIb/IV), conventional treatment options are unlikely to result in complete cures, though they may significantly improve survival and provide symptom relief. However in the recent past immunologicals, tezolizumab (Tecentriq), durvalumab (Imfinzi), nivolumab (opdivo) and pembrolizumab (keytruda) are being used for effective tumor control.

Immunotherapy for Head and neck cancer (HNC)

Head and neck cancer, a collective term for cancers arising in the head and neck region is the most common cancer in India. The treatment for HNC depends on individual factors, including the exact location of the tumor, stage of the tumor, and the affect individual’s general health. These conventional treatments for head and neck cancer (surgery, radiation, and chemotherapy) may be used alone or in combination, depending on stage and location. Head and neck cancer is highly curable—often with single-modality therapy (surgery or radiation) if detected early. More advanced head and neck cancers are generally treated with various combinations of surgery, radiation, and chemotherapy. With any treatment plan, the goal is not only to remove the cancer, but also to preserve the functions of the structures involved in speaking, swallowing, and expression. In the treatment of HNC with immunotherapy, nivolumab (opdivo) and pembrolizumab (keytruda) is used.

Immunotherapy for lymphoma

Lymphoma is a type of cancer that arises in the infection-fighting cells of the immune system called lymphocytes (a type of white blood cell made in the bone marrow). Lymphocytes circulate the body via blood and the lymphatic system. Lymph nodes, a key structure of the lymphatic system, are found throughout the body and filter lymph fluid to remove foreign particles. When bacteria and other invaders are found in the lymph fluid, lymphocytes multiply within the lymph nodes, including natural killer (NK) cells, T cells, and B cells. Lymphoma is one of the primary cancers that affect children and young adults. The two main types are: Hodgkin lymphoma, affecting only about 10% of patients diagnosed and non-Hodgkin lymphoma (NHL), accounting for the vast majority (90%) of lymphoma diagnoses.

The treatment for lymphoma depends on type of lymphoma diagnosed (e.g., Hodgkin lymphoma vs non-Hodgkin lymphoma) and disease stage. Chemotherapy, radiation, or combinations of the two are typically used to treat both types of lymphoma. Stem cell treatment is an option when initial courses of treatments are ineffective. Radiotherapy is used less often and typically when the disease is localized to a single site in the body. Recently Immunotherapy with nivolumab (opdivo), pembrolizumab (keytruda), interferon alfa-2b (intron a) and adoptive cell therapy like with axicabtagene ciloleucel (yescarta) and tisagenlecleucel (kyrmriah®) is being used.

Immunotherapy for breast cancer

Globally breast cancer is one of the most commonly diagnosed cancer types among women globally. Reports indicate that there were an estimated 2.1 million new cases of breast cancer and 630,000 deaths due to breast cancer in the world in the year 2018. Thus, the need for effective, lasting breast cancer treatment is urgent. Current methods for breast cancer treatment typically involve surgery if the disease is diagnosed early. Depending on the stage and molecular characteristics of the cancer when diagnosed, breast cancer surgery may be followed by additional chemotherapy, radiation, or targeted therapies, including hormone therapy. With regard to immunotherapy, recent studies have shown that atezolizumab, (tecentriq), in combination with chemotherapy, was effective in the treatment of triple-negative, metastatic breast cancer in patients whose tumors express the PD-L1 protein.

Immunotherapy for liver cancer

The liver performs many vital functions involved in detoxification, drug processing, and metabolism of fat and sugars. Liver cancer is one of the most common and is globally the sixth most common cancer and the second leading cause of cancer deaths around the world. Globally, in 2018, there were an estimated 840,000 new cases of liver cancer along with 780,000 deaths. Depending on the stage of the cancer when diagnosed, liver cancer may be treated with surgery and chemotherapy. With regard to immunotherapy, recent studies have shown that nivolumab and pembrolizumab (keytruda) are shown to be effective.

Immunotherapy for gastric cancer

Globally stomach cancer, or gastric cancer, is the fifth most common cancer and the third most deadly. Recent reports suggest that worldwide, every year nearly one million new cases are diagnosed and 780,000 succumb to the disease. Treatment of stomach cancer depends on where the disease initiated and the extent of its spread throughout the body. If diagnosed early, surgery is the first-line treatment for stomach cancer, sometimes in combination with chemotherapy and/or radiation treatment. For advanced stomach cancer, chemotherapy is the treatment of choice. With regard to immunotherapy for gastric cancer, pembrolizumab (keytruda) has been approved and are in use.

Clinical studies from around the world are encouraging, and that immunotherapy alone or in combination with conventional treatments can significantly improve patient outcomes. Reports from the US, where most of the studies have been conducted suggest that immunotherapy in some cancers are effective in long-term disease control. Immunotherapy has been introduced at MIO and the results are very encouraging.

Comment on this article

  • Lissy, Mangalore

    Fri, Jul 12 2019

    Article is very informative. Thank you Doctor

    Agree

  • Loraine, Udupi

    Tue, Jul 9 2019

    Dear Dr,
    Read your article.It is very informative. However would like to know c the costs of each of the therapies so, as to give an estimate of the cost of the treatment.

    Agree

  • Dr Felcy D'Souza, Mangalore

    Thu, Jul 4 2019

    Very informative article Doctor. Thank you for sharing. Keep up the good work.

    Agree

  • Kavyashree, Mangalore

    Wed, Jul 3 2019

    Thanks sir ... Good article

    Agree

  • Kavyashree, Mangalore

    Wed, Jul 3 2019

    Thanks sir ... Good article

    Agree [1]

  • jd, mangalore

    Wed, Jul 3 2019

    Dear Dr. Prasad, thank you for the article. When one is affected, neither the patient nor the near ones are in the frame of mind, to read and understand with equanimity. Reading this article, gave an understanding of what it is, how bad and how to handle with out being emotional.

    This kind of information, for any majorly affecting and destroying disease should be shared and explained at school college level, so that some among the young take keen interest and read up more on that and stand as pillars when calamity strikes.

    Agree [1]

  • Dr Jitendra Pratap, Mangalore

    Wed, Jul 3 2019

    Thank u sir,
    For writing about immunotherapy in cancer treatment
    Its very informative for general public in common..

    Agree [2]

  • Vince, Mangalore

    Tue, Jul 2 2019

    @Rama...... I think Elcent has a point....

    Newer treatments are great but like u mentioned if they cost a kidney and cornea in India then it’s best to know what really works ....... or at least what makes the most sense

    I also visited the website given and thanks a lot..... it’s very informative
    I also saw there though that no other product has lung cancer approval except Pembrolizumab....... So if a govt agency in UK can restrict drugs to be used why should we use all of them vs something that makes more sense

    I agree that RnD needs improvement in India. It sucks

    Agree [2]

  • Anita Britto, Mangalore/Auckland

    Mon, Jul 1 2019

    Thanks, Dr Prasad for this very well-written succinct and self-explanatory article which will be immensely useful to practically every person – as there’s not a single one of us who have been immune to the tentacles of Cancer – either personally or through a close family member of friend.

    While it can be extremely tiring and exhausting to scour through a plethora of articles on the internet for relevant information, it is nice to come across articles like this which are so informative and patient –focussed.

    May God bless you for reaching out to people and giving them realistic hope despite your busy schedule.

    Agree [6]

  • Rekha, Mangalore

    Sun, Jun 30 2019

    Very Informative and this doctors treatment is very effective as for my mother in law he informed its stage 4 and would live for a maximum of one year or 2. But now his treatment is working 100% for her and the chemotherapy is now from every month to once in 3 months now.

    Agree [3]

  • Rama, USA

    Sun, Jun 30 2019

    @Elcent,
    These are very new drugs and I don’t think there is enough data. But this is ray of hope for cancer patients. I think the Doctor is trying to draw attention to new treatment modalities . The article is for us mortals and not a presentation to the medical community. Keep up the good work Dr. Krishnaprasad!

    @Elcent you can refer this website for more info.

    https://www.nice.org.uk/guidance/ta531

    Agree [2]

  • rama, USA

    Sun, Jun 30 2019

    Very informative article.

    How is the cost of these medications in India. In the USA most insurances cover the treatment after a certain protocol has been met. It would be very beneficial if India is able to spend some money on R&D in ducing indigenous Immunotherapy agents.

    Agree [3]

  • catholicwomenworldwide.com, canada

    Sat, Jun 29 2019

    Well written and informative.

    Agree [1]

  • Charllote, Mangalore/Muscat

    Sat, Jun 29 2019

    Well written article with simple language. These are immune checkpoint inhibitors and not all cancer patients can benefit from such therapy. It depends on their PDL-1/PD-1, CTLA4 staus.
    I am very pleased to know it has been in practice at MIO since it is a very expensive treatment. Hope our government plans cancer funds for people with low income, so they too can afford such treatment.

    Agree

  • HENRY MISQUITH, Bahrain

    Fri, Jun 28 2019

    Excellent Doctor and I am sure it will motivate not only people fighting from cancer but also their families.. God bless everyone!!

    Agree [3]

  • Sandy, Udupi

    Fri, Jun 28 2019

    But what is the average costs of immunotherapy,doctor? If there is no subsidy from the government, will the average Indian be able to afford them. I hope with time, the costs will come down.

    Agree [3]

  • Miya, Sydney

    Fri, Jun 28 2019

    Very good article

    Agree [2]

  • Elcent, Mangalore

    Thu, Jun 27 2019

    Well written sir

    But just playing devils advocate It’s surprising to see that you chose to put tecentriq, Opdivo and Keytruda in the same basket because while reading through literature it clearly shows that Keytruda has been demolishing competition with superior data at every congress and analysts reports

    So pardon the nativity but I believe Keytruda is only drug in the 1L HN space and also 1L lung space and there is no other product approved at FDA and EMA in this 1L setting for these 2 cancers. Would be great to see Scientific data if any for these 2 high risk cancers in India where mortality is very high....

    By the way I guess These therapies are used for bladder cancer too???

    Agree [5]

  • Reva, Mangalore

    Wed, Jun 26 2019

    Very informative article Sir...

    Agree [3]


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