Immunotherapy in Lung Cancer: 'The Sky Is the Limit'

Recent years have brought many advancements in the use of immunotherapy to treat non-small cell lung cancer. However, there is still a long way to go, according to Naiyer A. Rizvi, M.D., director of thoracic oncology and the director of immunotherapeutics for the Division of Hematology and Oncology at Columbia University Medical Center.

Rizvi sat down with OncLive, a sister publication of CURE, to discuss the current immunotherapy landscape, and where it is headed.

How has the rise of immunotherapy impacted the prognosis for patients with lung cancer?

Rizvi: I think immunotherapy has really transformed patients with lung cancer's lives. The caveat to that is that it's transforming a relatively small proportion of patients' lives. To me, though, that's our foot in the door for trying to help more patients through our research and work that we do and develop newer immunotherapies and understand why people respond and why they don't respond. The research that's ongoing has been explosive, so I'm confident that we'll be able to help more and more patients every day.

What are your thoughts on PD-L1 as a biomarker? Are we at a point where we can say it is effective, or do we still need more work?

PD-L1 as a biomarker is effective. I think it works best in concert with tumor mutational burden. Both biomarkers identify somewhat different patient populations and there is some overlap. But I think the two biomarkers together probably give us the most robust information about who is going to respond to these therapies.

For patients with driver mutations, does immunotherapy have a role there, perhaps in combination with a targeted agent?

For patients who have EGFR mutations or ALK rearrangements, they still do best with targeted therapy and they still get targeted therapy first. We still haven't really been able to figure out how we can help those patients with immunotherapy. I think there is some benefit in some of the recent phase 3 trials giving chemotherapy and immunotherapy combinations in patients with EGFR mutations, for example, who progressed on their targeted therapy. So, I think we're making some progress, but we need to do more work around immunotherapy for those patients.

Is the future of immunotherapy going to be in combinations or systemic therapy?

The future of immunotherapy will be combinations. I don't know that it will only be with immune checkpoint blockade. It could be with biospecifics or other novel approaches that many people are working on.

It could be with CAR-T cell therapy for all we know. There is work really in every avenue of immunotherapy. There's research in lung cancer that's still going on, so the sky is the limit.

We're just starting to understand how to manage the side effects that come along with immunotherapy. What would be your word of advice on this topic?

In terms of side effects, one just has to be vigilant about any new symptoms that the patient has. Make sure they communicate with the doctor in his or her office about any issues that they may have.

A lot of it is patient education and vigilance.

In other cancer types, physicians and researchers express the goal of making cancer a chronic disease. Are we there yet in lung cancer?

I think it's the whole spectrum. We have patients who we treated with immunotherapy 10 years ago where their cancer hasn't come back, and you can say that they're in remission or whatever you want to call it.

Yes, they may be kind of stable and some may live with it as a chronic disease, but there are other people who we can hardly help at all. So, I think it's really a range of outcomes that are possible. We need to improve those people who aren't benefitting at all to at least making their cancer a chronic disease. And we need to turn our "chronic disease" to something more than that, so I think there's room for improvement.