Immunotherapies have changed how we treat the disease
By Philip Bonomi, MD
One of the things I learned early on in medical school is never to forget that it’s a privilege when a patient puts his or her trust in you to take care of them. I have never taken that privilege lightly. My goal has always been to prolong meaningful life and relieve suffering for my patients. That’s been my personal mission statement throughout my career.
And those goals are not always easy when it comes to treating lung cancer. When I started out in medicine, some of the treatments we tried for lung cancer were simply not effective. There were not a lot of options for our patients and often the prognosis was poor.
But through my long career, I have seen that perseverance, believing in an idea and not giving up on it can pay off.
Enter immunotherapies. When I was in medical school in the late 1960s, we had high hopes for immunotherapy. We thought it was going to be very important for treating patients with cancer. But then, we saw one failed study after another over the next few decades.
However, some basic scientists and clinicians didn’t give up on the idea. They were undeterred. They uncovered more insight into the mechanisms of immune checkpoint inhibitors, which are antibodies that allow a patient’s immune system to attack and kill cancer cells. In recent years, those breakthroughs have led to significant improvements for using immunotherapies — and a new hope for many patients who have lung cancer.
Timeline to success
In April 2015, immune checkpoint inhibitors were showing results as second line therapy for advanced lung cancer that had progressed on chemotherapy. The immunotherapy was more effective and had fewer side effects. Not only did it work, but it worked better than the chemo we had available. One study of patients who had all been treated before and had no hope for long-term survival, resulted in 15 percent of the patients being alive, and most are not on active anti-cancer treatment.
That was unheard of at the time. And it led many of us to think that maybe some subsets of patients just might be cured — never progressing — with immunotherapy. We needed more studies and more patients, but we started seeing the possibility of treating this as a chronic disease.
Then in November 2016, a study showed that if patients had a protein in the tumor called PDL-1, they would live longer if you gave them immunotherapy as the initial therapy by itself without chemotherapy vs. if you gave them chemotherapy. This study led to the FDA approval of pembrolizumab, a new immunotherapy drug for this group of patients.
Then in May 2017, we saw that if you gave a specific chemo (pemetrexed and carboplatin) in combination with pembrolizumab, patients with non-squamous lung cancer had a significantly higher response rate and delayed progression. After the FDA approved that, we started treating some of our patients at Rush with this combination — and our patients’ response rate was very impressive.
In April 2018, these findings were validated in a larger study looking at this combination of chemo and immunotherapy. The study found that this combination convincingly improves the survival rate in patients with stage IV, non-curable non-squamous cell lung cancer — reducing the risk of death by 50 percent.
Rush leading the way
Rush has been involved in these immunotherapy trials from the beginning. We remained cautiously optimistic that these immunotherapies would, in fact, live up to the potential we had hoped for decades ago.
In addition to immunotherapy studies, Rush was one of the first institutions in the world to study the benefits of concurrent chemotherapy and radiation therapy for people with locally advanced lung cancer — cancer that was too advanced for surgical treatment, but not spread all over the body. Eventually, larger studies validated that the combination of doing those two together was better than radiation alone and was better than chemo followed by radiation. It became the standard of care.
Further, a recent trial has found that treating this group of patients with immunotherapy after chemotherapy and radiation has significantly improved survival.
A new message for patients
We have seen so many major advancements for people with lung cancer. My hat goes off to all of the doctors, scientists, researchers and others who didn’t give up on this idea. There is now a lot of hope for many lung cancer patients.
A question I frequently hear from my patients is, “Doc, if we can keep it under control, some new treatments will come along, right?” Ten years ago, the chances of something new coming along that would help were slim.
In the past few years, my message to my patients has changed. It started out with, “We’re going to try to keep you alive longer.” Then, “We are going to try to convert this to a chronic disease that you can live with.” And now, I truly think there are some patients who may be cured with these immunotherapies. Even if the cancer is not all gone, it may be under control. That is a huge shift — and it is amazing. Of course, we need more time to study this and more studies validating these findings. But the potential is there.
I didn’t think the White Sox would ever win the World Series during my lifetime, and I never thought we’d be talking about people with late-stage lung cancer going into remission and staying in remission. It’s amazing. Being able to help my patients live longer, more meaningful lives with less suffering is what drives me every day — and these new treatments and advancements have given me and my patients a lot of hope.
Philip Bonomi, MD, is a medical oncologist at Rush who specializes in lung cancer. Bonomi recently was honored by the LUNGevity Foundation with its annual “Face of Hope Award,” which is awarded to an individual who recognizes the needs of those living with lung cancer and is actively making a difference. Last year, Bonomi and his team were also honored by the International Association for the Study of Lung Cancer as one of five worldwide recipients of the foundation’s inaugural Cancer Care Team Award, which recognizes programs that provide the highest quality of patient care.