Cancer Immunotherapy Research Updates Panel at 2019 CRI Immunotherapy Patient Summit in Baltimore

Cancer Immunotherapy Research Updates Panel at 2019 CRI Immunotherapy Patient Summit in Baltimore


– Hi, my name is Ranee Mehra. I’m a medical oncologist. I am at the University of Maryland, Greenebaum Cancer Center, and I treat upper aerodigestive malignancy. So I started my career at Fox
Chase Cancer Center in 2006. And since then I’ve been
treating head and neck cancers and thoracic malignancies. So at the University
of Maryland I continue to treat both and I’m the Director of Head and Neck Medical Oncology. – Hi, my name is Marijo Bilusic, I’m a GO medical oncologist currently working at National Cancer Institute. I was trained as a fellow there, and I went to Fox Chase as GO medical oncologist for four years and then three and a half years ago I was recruited back to National Cancer Institute. So I have two hats there. I’m a program director for
fellowship training program. So I have 40 young hematology oncology trainees, who are going to be future hope of cancer research and care. And 50% of my added time
is doing immunotherapy mostly focused on prostate
cancer and geo malignancies. – I’m Suzanne Topalian, I’m the director of the melanoma program in
the Kimmel Cancer Center. I’m also one of the Associate Directors of the Bloomberg~Kimmel
Institute for Cancer Immunotherapy at Johns Hopkins. I’m trained as a surgical oncologist. I’m a physician scientists. So I study cancer immunology and work on drug development to develop
cancer immunotherapies. – Okay Suzanne, I’ll start with you, so what do you see is the most exciting advance in immunotherapy
and your specialty? – Well, in melanoma, this has dramatically changed the way that
we treat this disease. I would say that 10 to 15 years ago, the expected three years
survival for a patient with stage four metastatic melanoma was only 5% and now
with some of the modern immunotherapy trials, with anti-PD1, anti-CTLA4 combination therapy, we have 50% of patients
with durable survival after treatment. So that’s a tenfold
increase in the expected survival for patients with
very advanced melanoma. More recently, just two years ago, anti-PD1 therapies were
approved in the adjuvant or post surgical setting for patients with earlier stage of
melanoma, stage three, meaning that the melanoma had spread to local lymph nodes. And this also prolongs the time to relapse in these patients. And so this was approved by the Food and Drug Administration. And now we’re looking
at giving immunotherapy even earlier in the course of melanoma giving it before the patient receives surgery, and so it remains to be seen if that will be helpful to
this as in clinical trials now. – Very true. – So, GO world… It’s interesting there’s like usually we divide cancer
into hot and cold tumor, and the prostate cancer is one of the interesting cancer
that I’m focusing my research. Even though it was the first cancer we had the cancer vaccine
therapeutic approved for is sipuleucel-T in 2010. But it’s cold tumor and checkpoint inhibitors that don’t
work in Prostate cancer. So we are really trying to understand why is that and how we can make, how we can turn the cold
tumor to hot tumor using the vaccine and combination strategies. On the other hand, we
have a kidney cancer, and bladder cancer or
just having a checkpoint inhibitor, one after another approved, so we have now five checkpoint inhibitors approved for bladder cancer that sometimes makes it difficult, which one is selected to give it to a patient
with kidney cancer, which is interesting going more in towards combination with checkpoint inhibitor plus TKI, which was standard. So it’s moving from this
approach of using… With a kidney cancer was
a story that interleukin-2 was approved many years ago – – it’s a toxic treatment,
and there was a mortality in the clinical trials,
not many centers being comfortable and physician treating patient and that now, initially was super excitement checkpoint inhibitors, that we thought that’s
going to be the answer. And then we learned only 30% of patient will respond to a single
checkpoint inhibitors. So how we can make this
better and then transfer combination checkpoint inhibitor plus TKI? It seems that this is the way to go, and the response rates are much higher. And I think we’re making
dramatic progress. – Wonderful. And Ranee. – Well, I think patients have so many more options now than they
did even a decade ago, and in part because of the agents than the immunotherapy
drugs and treatments that we have to offer. And used to be, when I was in my training, we were just talking about chemotherapy, and that was the focal
point of a discussion when you’re trying to plan a new treatment for a patient. And then things shifted a little bit and you could say, well,
chemotherapy or maybe if you have a mutation, maybe you can get a targeted therapy, but that was still a minority of patients. And now, in one visit, we have a discussion
of the range of options from chemotherapy to immunotherapy to targeted therapy to
combinations to standard therapy to trials, and I think it puts a lot more burden on us to really be able to explain that well, very quickly and
to try to help determine what the best option is for a patient. But it’s a much more, I
think, rewarding experience for the physicians and
also for the patients to really have options to think through. – So Suzanne, melanomas had great progress with immunotherapy but
there’s still more to go. Can you talk about what
you see is the future in your disease? – Yeah, so in melanoma,
we’re helping about 50% of patients now, and we need to focus on the other 50%. Not everybody responds to immunotherapy. We do have other treatments that are effective and advanced melanoma, the class of drug called
kinase inhibitors. And so there are combination therapies, as you heard that, that we’re working on. Some of them involve combining different immunotherapies with each other, but some of them involve
combining immunotherapy with a completely different
form of cancer therapies such as kinase inhibitors
or radiation therapy. And so Dr. Jaffee
emphasized this in her talk, as one of the things for the future that we all need to concentrate on, and that’s what we’re doing in melanoma. – Great. So I’m going to open up to the panel. Whoever would like to
address this question. What are common questions from patients considering immunotherapy? Does someone want to take a shot at that? – Well, I think the first is, whether the chances
that it’s going to work, how do you know it’s going to work? What is it about my tumor that makes you think this will work? I think that’s probably first and foremost on everyone’s mind. There is a concern over side effects. I feel like I bring that up more, versus the questions
that are being directed to me, but I think
that’s an important part of the discussion that everyone
also has to be aware of. – Anything to add. – So, in my practice,
most commonly, people, they seek for immunotherapy, it is really a very popular word and they come and they want immunotherapy. So some of patients they
really have standard therapy approval, they really want to go on the immunotherapy
clinical trial and try and really trying to
educate patients like well, we have approved therapy, which works in 90% of
the patient, at least. And as a little reminder, some targeted therapy for prostate cancer. You want to try the vaccine
we’ve never tried before. And default is probably not going to work, but just because it’s so popular, everybody reads about immunotherapy, and it’s presently, I think it’s great Great to go on a trial,
but trying to understand that maybe it’s better to
try standard therapy first and then if they don’t
work trying something else. Or if this combination of
therapy plus standard therapy, all these different things. So just educating patient having more time understanding that even
[though] immunotherapy is super, super exciting, it’s not
always the right answer. And I think that’s the
challenge right now. – Did you want to add anything? – I think the approach
is going to be different for patients with
different types of cancer. I mean, a lot of what we’re talking about today does apply across
the board to all cancer types. But then you notice that
all of us sitting up here specialize in
different types of cancer. And so the background in
each of those cancer types, and in terms of what are
the standard therapies that are available, when should immunotherapy be used? Should it be the first treatment that you receive for metastatic cancer or should you receive chemotherapy first? Or a kinase inhibitor first and then only if that doesn’t work should you go on to immunotherapy? So there are a lot of individual considerations for different cancer types. In melanoma, immunotherapy
is considered to be a first option for our patients because this disease is
particularly responsive to immune-based therapies. But that might not always be the case. For instance, in prostate cancer, I think there would be a different path. – So I think that leads
me to another question that patients often wonder. So when will immunotherapy
and these other cancers become a first line therapy? Do you see this happening in your cancers? Do you first. – Yep. So in terms of kidney cancer, and bladder cancer, we are seeing the immunotherapy becoming… Kidney cancer, that’s
melanoma, it’s very receptive to immunotherapies so
I think it’s definitely going to be a frontline therapy. It’s already now approved combination nivolumab, two checkpoint
inhibitors given together. With prostate cancer, it’s a little bit different story because
it’s considered cold tumor so historically is not
responsive to a checkpoint. But I think there are lots of research going on trying to understand biology, why this is cold tumor,
or how we can make better. We still have very good responses with chemotherapy, normal
therapy with prostate cancer. So I don’t see being
frontline immunotherapy with prostate cancer. Soon but I think definitely
those studies are doing neoadjuvant treatment when we give the chemotherapy
before the surgery and then trying to understand with biopsies, and we’re
trying to biopsy more trying to understand
tumor microenvironment. Because sometimes we measure new cells in the blood it’s not the
same thing what we see in the tumor. So having biopsies technically challenging and you know, it’s not very exciting and occasionally, patients
don’t want to get, you know, needle stuck to my bone and drilled and we’re trying to definitely biopsy more sequence, or
trying to do molecular profiling, personalized approach, each patient is different so we don’t treat everybody the same, cookie cutter — everybody’s
a different patient. Trying to understand
biology of each patient. – So Ranee, what about you, because human papillomavirus is
associated with some head and neck cancers. Do you see immunotherapy is a first line in that? – So that’s an interesting question. So HPV related, oropharynx cancers is certainly a large proportion of the patients with head
and neck cancer, who we see. And that is a treatment that historically has been very responsive
to standard therapies with surgery or
chemotherapy and radiation. But those treatments also can have a lot of toxicity and side effects. And so I think as a field we’re sort of in this tug of war a
little bit between having very effective standard treatments, but that can also cause
late long term side effects to treatment, and these newer treatment options, which are very exciting and we don’t want to
compromise the good cure rates that we have now, and just go straight to immunotherapy, right. If somebody has an
early stage HPV related, oropharynx cancer and chemotherapy and radiation is appropriate for them and can have a very good
chance of curing them, I’m not going to not
offer that and instead do immunotherapy because
we don’t have data to support that. But we do need to incorporate immunotherapy into earlier stages of disease and that really
requires a much more coordinated effort with our colleagues, and surgery and radiation. It’s not just up to the medical oncologist in that setting and the
whole treatment team has to be comfortable with
doing those types of studies. So there are trials ongoing now. There are immunotherapy vaccines looking specifically at targeting HPV related disease, and those are being studied. Either immunotherapy is being studied after standard therapy. So we participate in
some of our cooperative group trials and ECOG-ACRIN has a trial right now looking at
immunotherapy checkpoint inhibitor after standard chemo radiation for HPV related disease. If somebody has high-risk features and their other driven
studies, looking more, incorporating some of the HPV vaccines, there are trials giving immunotherapy upfront before surgery. So I think this is just where
we really need the data, and that those are sometimes harder discussions because again, without immunotherapy, there still has be effective standard treatments and we don’t want to lose
those opportunities as well. – Okay, so, what do you
feel is the most common misperception regarding immunotherapy? I’ll open it up to the panel again. – So I think that because of excitement, the majority of patient may think that this is going to be
the answer, like I need to have some immunotherapy
that’s going to take care of. And the hope when patient come for at least in the
clinical trial at NCI, they feel like, okay,
we are going to provide the answer and hopefully
it’s going to work. So it’s a lot of disappointment. Majority of people will not respond to immunotherapy in the
clinical trial settings in at least the tumor type I’m treating. Like we see like 20% of patient responding that [is] super exciting. And then I think it is understanding how this
works, educating patient and then possible toxicity that we see that some patient they tend not to report and pay attention because it’s different than the toxicity from chemotherapy, and other treatment they’re receiving. So we can have the recently patient who was on checkpoint that
had like 15 diarrheas, and then he felt oh maybe
he ate something wrong. And it was very serious
toxicity from checkpoint inhibitors that require hospital stay, admission and then
treatment with steroids. And just sometimes I try to really educate patients like, well, if you have noticed something different, please let us know. Because, it could be sign of very serious toxicity that sometimes they think, oh, it’s nothing to worry about. So I think educating
patient and even though it’s some of the immunotherapy we’re giving them are very powerful, but then also they could
have different toxicity profile, and then not everybody may be recognizing that in the beginning. – Yes.
– Okay? – Oh no, I completely agree with that. The patients often come in and say, well, this will cure me and,
when I offer somebody a trial in immunotherapy,
it’s not with the goal of the cure. And so that ends up being a
very difficult discussion. And I keep having to remind myself that we have to also
talk about the reality of where a patient may
be in their disease. And sometimes I forget that as well, because we’re so excited
about the treatments that we have and the trials that we can offer. And I’ve also had patients tell me, well, I’m not going to
complain about the side effects because I don’t want you to stop this, and sometimes somebody
has a very mild side effects, like fatigue, but it’s making me worried enough that I said, “Maybe we should take a
break and figure things out.” I won’t complain of the fatigue, just keep giving it to me. That’s not what I want them to do either. So we really have to, I
think also take breaks when we need to take breaks and make sure we’re addressing quality
of life and side effects. – Suzanne do you have anything? – I agree with the
comment that many people don’t understand that immunotherapy is not right for everybody. Some patients just automatically, because they’ve heard so
much about immunotherapy in the news and everything, assume that it’s right for their cancer, and it may not be so
that’s where a conversation with your oncologist is very important. And actually I recommend
for anybody with a new cancer diagnosis to have
at least a consultation with an oncologist in
a major cancer center or academic center just
to hear about the full spectrum of options immunotherapy and all other options
before making decisions. – Great. So what do you all think
patients should think about when they’re considering
the clinical trial? In immunotherapy of course. What are the considerations for enrolling into a trial? – Well, there’s some practical issues. For instance, if you’re
going to have to travel to a medical center that’s far away to get your treatment, you have to think about how that fits into
the rest of your life. How many times a month would you have to be traveling? If you develop side effects? Is there a doctor close to home
who could help manage that? There are practical issues that we don’t think about
the first time we think about immunotherapy, but
I think that would be one of them is that… Especially if you’re in a clinical trial, that’s really a commitment for patients as well as physicians. Clinical trials are designed to address a medical question and the trial won’t be successful unless patients can stay on the trial and follow the
events that are supposed to occur on that trial. – I think in our case, so at the NCI, we are a federally funded agency so we don’t charge for
our services and we accept patients from all over United States, and we have quite a bit
of international patients. So in terms of what the problem is with our patient trial, is
many of them are traveling, they’re not local, they are
from all over United States, and then arranging their trips. And some clinical trials
are very time consuming because their frequent visits, frequent blood draws,
they have to be admitted in hospital for a couple of patients, for a couple of days. And it’s really impacting quality of life particularly to people, some people are still working and they have to take days off, and just adjusting their normal life with requirement of clinical trial. It can be a problem. And then, the other issue
is when patient goes, like I have quite a few patients in California or somewhere else and there is a toxicity and
how we then communicate. How I make sure patient has access to care immediately, if needed? I cannot fly patient across the country to come here to be treated. So establishing collaboration
with local oncologist, local primary care, making sure that the patient has access to care immediately, if needed. – And I’m sure there are
also cost considerations. The way clinical trials
are designed any aspect of it that’s experimental should be covered by
the class of the study. It should not be built to patients. But increasingly, I think as
we have combination therapies and one drug may be a standard
of care and another may be experimental and
some trials still cover everything and others try to have the insurance reimburse
for the standard of care. And then, sometimes
insurance companies may or may not agree to do that, and I’ve had patients who, the insurance companies have said, well, we’re not going to cover
this standard of care costs, because you’re combining it with other drugs on a clinical trial. And, that’s the other real challenges that we all face, and
we try to appeal that. But I think it puts a lot of stress, certainly on the patient. And then also, the entire team trying to figure out how to sort through that. So those should not be things that someone has to worry about when
they’re fighting a illness. But at the same time, I
think that’s the reality. – So one more question
before we open it up to the audience. So how has immunotherapy
changed how you treat patients in your practice? – Well, for melanoma, as I mentioned, it’s now a first line option and even for patients who
have particular mutations where they would be eligible to receive kinase inhibitors, most
oncologists and most patients want to try immunotherapy first. So that is a definite change compared to what we had, let’s say 10 years ago where the recommendation
of large cancer boards was that somebody with stage four melanoma should just go on to a clinical trial, like that should be the first option because we didn’t have any anything else that was really
effective at that time. – In GO tumors and bladder and kidney cancer definitely immunotherapy is becoming frontline therapy. So I think opportunities for patients are much more that, instead of having [just] The chemotherapy option Another option is a clinical trial because there’s no second line
therapy for bladder cancer that have five immunotherapy that are approved that they
are available for patients. They are discussing which
one we’re going to use. I think it’s something that we’re talking to our patients And kidney cancer is the same thing. So I think definitely the immunotherapy revolution, how I call it, there are so many new drugs approved in such a short period of
time, it’s really giving out a lot of opportunities for physicians and for patients to
offer better treatment. Now sometimes the challenge then comes in all the sequencing,
what do you use first? Which drug you use first? Because there’s no head to head comparison to tell us okay, this
is better than this one. So we are trying to work with the patient insurance company and
then figure out what’s the best next option. That’s definitely dramatically changing the way we practice
and giving patient more options, which is always good. The worst thing is, you
as oncologist have like when you have to tell patient, we have no more options. It would suddenly sound
like we have like five more approved drugs and it really gives hope which is very important. – I think definitely
we’re treating patients. The patients who do
well with immunotherapy, we’re treating them longer and they have a good quality
of life during that time. And so I think it’s been a rewarding time to be an oncologist
because you can actually have a relationship with
your patients that spans years, which is definitely been evolution in the field. – Great. So I’m going to open it up to
the audience for questions. One back there, you’ll be soon. – Can another immunotherapy be used when you have side effects to maybe prembol, bismol, whatever, or Keytruda can you use
another immunotherapy? – Who wants to address that? – I actually can’t see you. Yeah, there we go. So, sometimes depending
on how severe the side effects are, if the side effects are mild, sometimes we have… Just in a general comment
if the side effects are– – [Woman] Can you use
maybe some other ones? – Ok. – So the general approach is
if the side effects are mild, we can usually treat through
that with careful observation, if the side effects are quite severe, then we have to stop giving the anti-PD1 and treat the side effects. Depending on what the side effects are, sometimes we can try to start
the anti-PD1 therapy again. There’s some risk to that because the same side effects might come back. So it really all depends
on how threatening the side effects were that led to a pause in the treatment. – Okay, it’s also a question up here when you get a chance. – Can you discuss the association
between adverse events and the patient’s
response to immunotherapy. Thinking of your, Dr.
Topalian’s recent paper on the five-year follow up. It seemed to me you had positive responses in patients with grade three
and four adverse events. – Yeah, that’s absolutely right. We just published this several months ago and in the journal JAMA
Oncology we did a long term follow up where we took 270 patients with melanoma, kidney
cancer or lung cancer, who were treated on one
of the very earliest trials of anti-PD1 nivolumab. And we just asked the question, where are these patients now? And can we find some characteristics in these patients that
would have predicted that they would have prolonged survival? So, in fact, we found that the patients who had side effects related
to the therapy were more likely to be alive five years later. Now, this was maybe a
little bit unexpected, because you would think side
effects are undesirable. But actually there is a mechanistic link between the side effects that we see which are inflammation in
normal tissues as Dr. Jaffee described earlier, it’s
a spillover effect based on the mechanism of the drug. The drug is liberating immune responses. We want it to be directed against cancer cells, but sometimes there’s a spillover. So maybe these side effects just mean that the drug is very
active in that patient, but there is definitely a link
there because we showed it in hundreds of patients in that study. – Let me just ask one follow up to that. So for patients being treated for adverse events with long-term steroids or immunosuppressants,
do you see a turn off of the response at that point? – Yeah, so that’s a very
interesting question. So if we start the steroids
to treat a side effect that occurred on anti-PD1 therapy, that does not seem to interfere with the outcome. And we’ve published that in other studies. But if patients are on significant doses of steroids before they ever start getting anti-PD1, that will reduce the likelihood that they will have a good outcome. That’s been published by others. – There’s a gentlemen here. Right there. Ah, sorry. – Question is for Suzanne. I’ve been a caregiver
and in numerous cases. I’ve seen differences in treatments, outcomes effects on patients. I’m curious with melanoma, especially what the difference in the process is, and how
it affects the patients between the past process
and what you’re finding with immunotherapy. – I’m sorry that the
difference in melanoma between? – I’m looking at it from
a patient perspective. What they have to go through. What happens with the previous process, and what the process that’s
happening with immunotherapy? How does it affect the patient? – Sure, so with other kinds of therapy for melanoma, and each therapy has its own unique kinds of side effects. For instance, 15 years ago, there was one form of immunotherapy that was approved for melanoma that was high dose Interleukin 2. But this is a very toxic therapy. It only helped about 12% of patients with metastatic melanoma. Now the people who were helped survived for a very long time after
they received the drug, but many of them had to be
in the intensive care unit while they were on treatment to manage their side effects. So that was a very different
kind of immunotherapy. The immunotherapies that
we’re talking about here today, the anti-anti PD1 drugs, those are all outpatient treatments. So the patient comes to
the outpatient clinic, they’re there for a couple of hours to get their infusion, if all as well, they go home until the next time that they have to come back. We started giving these
drugs every two weeks intravenously, then it
was every three weeks, now it’s every four weeks. And for some of them, it
might even be extended to every six weeks. So that’s in clinical testing right now. So in terms of the time commitment, and the severity, the intensity of the treatment, that has
really been brought down a lot. So I think it’s much
more livable treatment now for patients. – Can you mention for lung cancer, which is another cancer that responds. What do you think? What’s the answer to that question? – So the, not that long
ago standard first line treatment for lung cancer involved a chemotherapy doublet
carboplatin and Taxol. That was the combination
that was used for many, many, many years and Taxol
can cause neuropathy. You lose your hair with Taxol. And I think that was the
picture of every newly diagnosed lung cancer patient, it’s a treatment that can have a lot of fatigue, risk of infections. And now we have even
options of in the first line setting, giving immunotherapy even without chemotherapy,
depending on the profile of the tumor. And, one of the patients at Fox Chase who I treated on a clinical trial with an immunotherapy
combination years ago, she didn’t, not that
I’m advocating for that, but she didn’t want her
social sphere to know that she even had the disease, and she didn’t have any
outward side effects. Her hair was still the same
style that she always had. That was how she chose to have her cancer journey but she had that choice right, where that was not something
that people had before. – Great. Have a question. – I have a question about prostate cancer. So where are you now into techniques is called cancer into the top cancer? The second question is,
do you know how instead of biopsy you can use the wet samples, where are you at it now? Because I know so we have some study done trying to look instead
of going into the bones just to use the blood samples. So where is it now? And also I know that now
do now is a proposition instead of using only one treatment, you use two kinds of treatments, so cancer doesn’t have a
chance just to get like, okay, I’m just… Is difficult for them to adjust, lets put this way. – Thank you for the question. So, the way how we divide cancer, it’s cold or hot, based
on the biopsy looking how many inflammatory T cells are there in the tumor biopsies. So when you do the prostate cancer, there are not many T cells there. So if they’re not T cells in the prostate and the tumor there, it’s not unlikely that they’re going to have immunotherapy [that] is going to work. So there are studies trying to learn how we can make this
inflammation happening there and how we can deliver T cells to a tumor and try to
turn it to a hot tumor. So vaccine is maybe one of the answer, adoptive T cell or some other approaches have been tested. In terms of combination therapy for prostate cancer is definitely the way how the field is moving. So initially, standard treatment for newly diagnosed metastatic disease
was hormonal therapy. For several years still cancer convert to hormone resistant disease and then additional
treatments were started. And in 2015, there was a
pivotal trial called CHAARTED that combined chemotherapy,
plus the hormonal therapy and showed significant improvement in survival of people who have high volume disease and that was
confirmed with European study called STAMPEDE. And then additional studies
were done since then like LATITUDE and TITAN showing that some second
generation hormone therapy in addition to standard LHRH agonist which suppresses the
secretion of testosterone can work and improve survival. So, definitely the treatment
paradigm in prostate cancer is shifting towards combination
therapy, as you indicated. And the third question
about liquid biopsies. We try to use the circulating tumor cells but it really does not stand up here yet. We don’t have strong validation. I think the research is going towards that direction that we can
identify but there still need to be that, work needs to be done that we can validate the markers, we can validate the approach, and I think I would
say the clinical trials still don’t apply to clinical practice. Some tumors it’s more advanced, like in breast cancer I think they’re more
than the prostate cancer. But I think [the] field is moving towards that direction trying
to do liquid biopsies, and try to learn anything in lung cancer. I think with a biopsy are more advanced than a prostate cancer, but I think that’s where field is going. Doing biopsies really is difficult and particularly prostate
cancer and everything is [in] the bones and
yield of those biopsies is very low. It’s like 30% of patient actually can have some tumor tissue. Otherwise it’s bad when you have to do decalcification of the bone, then you kill some tumor. So it’s really a lot of struggle with us and for the patients
as well trying to learn about molecular profiling
and genetic offerings. – Good morning. – Good morning. – Immunotherapy works with all cancers? – Good question. Who wants to address that? – So unfortunately, no. And even within a specific diagnosis type of cancer, it doesn’t work for all types. So for instance, for lung cancer, even though it’s FDA approved, and for lung cancer with multiple drugs and multiple time points
in someone’s disease, there are certain lung cancers that don’t really
respond to immunotherapy. And there’s a proportion of lung cancers that have specific mutations
that drive the cancer. And we know that those ones don’t respond as well to immunotherapy. And, that’s just one example. So it really is specific to diseases and even within a disease
specific to the features of the particular cancer. – So when someone come to you, and did I hear you say that you have a consultation therapy? Did I hear that? That there’s a part where you do consultation therapy with the person who comes to be interviewed for the trial? Well, my question is, once the person is selected for the treatment, do you find that a relationship between the medical field and
the person who is receiving the treatment works
better when the patient and the medical field, whoever is treating them, is positive and get along that helps with the treatment? – That helps no matter what treatment you’re on, right? – You say this helps with, no matter what treatment they are on? – You want to have confidence on who is treating you,
and you want to feel like you can talk to them. I think that’s a really great question you’re asking because it’s a partnership in this disease, as you’re
pointing out, I think. – Yes. – And that partnership means that you have to feel comfortable telling the healthcare team when you’re
not liking what’s happening. – Exactly.
– And the problems. And if you don’t feel comfortable, then that’s not good. That’s a great point. – Thank you. – We have one here, too. – Yes. For immunotherapy, if you have an immune-suppressive
disease like an immune IBD or something like that, Is
that contrary indicating to an immunotherapy? I’ve been told both ways. And does it automatically exclude that immunotherapy might be available? – Great question. Who wants to address that. Suzanne. – If the question about
autoimmune disease. – Yes. The baseline autoimmune. – Yeah. So it depends on how serious
the autoimmune disease is. But if it’s a disease
that requires high doses of steroids or other
immunosuppressive drugs, it may be too dangerous for those patients to receive immunotherapy. – What if they’re on maintenance therapy? – [Woman] Not active therapy, but you’re on maintenance therapy. – If patients are on low doses of steroids as a maintenance therapy,
sometimes it is possible to treat them with immunotherapy. But as I mentioned earlier, there have been publications recently showing that the response of the cancers in those patients might be at a lower rate than what we would expect in patients who don’t have to be on
those kinds of treatments. – What about non steroids, maintenance therapy. – Drugs that are more
powerful than steroids? – Non-steroids.
– Yeah. – The very old–
– [Man] Or something like that – [Woman] Very low dose (speaks faintly). – So I don’t think that
we have enough specific information on all of
those treatment types. Most of our patients
would come to us being on a maintenance dose of prednisone, for instance, I think
that would be most common. – [Woman] Would you find that out in the interview before the trial? – Absolutely very important to know that. – Question over there and then over here. – Hi! Sorry. Good morning. I’m a stage four lung cancer patient. I never smoked and I’ve been living with this for four years now. I’ve been on immunotherapy. March 2nd will be four years
of being on immunotherapy. So my question for you
is when March 2nd come, should I keep going? As long as the cancer’s still stable? Or when do you stop? – Yeah, that’s a really good question. Obviously–
– I feel blessed. I’m sorry. I’m so blessed. So I just wanted to know, should I keep going or do I stop? I’m sorry, I don’t want to cry. I’m sorry. – I think the fact that you I mean, that’s a good problem to have, right? That we have that question in front of us. And I think, that’s where we still are really trying to learn
like how long patients need to stay on it, I don’t know that we have the answer, and
some of it is probably specific patient to patient and so that’s where, back to the point of having a relationship with your care team. That’s some of the
difficult decisions right? That you have to have with your physician because that’s the person who probably knows best what’s been
going on with your– – I’m very blessed to have
a wonderful care team. And a wonderful oncologist. – So I think that’s something that it really is like a face
to face in depth discussion with risks and benefits. And then, deciding from there. And even if you go down one path, like you always have the
chance to relook at it, right? Depending on what’s going on? – Yes, because always look
for plan B just in case, I hold on to my faith
and four years strong. God is good. (crowd applauds) Thank you. – Can immunotherapy used
as a vaccine for cancer suspected to be in remission? So can you boost my
immune system to prevent the cancer from reoccurring? – Great question. – That’s the idea behind
what we’re trying to do by treating earlier stages of cancer. So, I mentioned before now in melanoma, anti-PD1, two different anti-PD1 drugs are approved to treat people who have had all of their
melanoma removed surgically but are at high risk for
relapse, meaning that somewhere in their bodies there
are microscopic deposits of melanoma that are too
small for us to detect on CT or PET scans. So we think that we’re going to surgery to remove all the cancer. But there are some microscopic deposits that were not able to
detect that at the time. So, yes, I mean, it’s been shown in large studies and now with FDA approvals that in melanoma, if
you give anti-PD1 drugs after surgery for patients
who are at high risk for relapse, that you can
prolong the time to relapse. And we’re now awaiting
the survival information from those studies. So these are fairly recent studies. – But I’ll add to that, because I think where you’re going is
if you’re at high risk, can we prevent the cancer at least I think that may be– – High risk of reoccurrence. – High risk, okay, so but even– – Or unknown if it’s
actually in remission. – Right, right, okay. So then I think that was a great answer, but we’re also thinking about, can we even predict who’s going to get cancer, and eventually prevent it. So with human papilloma virus. I don’t know how many of you had your kids vaccinated, but that prevents a lot of cervical cancers, and it prevents head and neck cancers, long term. That’s a situation where someone hasn’t been exposed to the agent
causing the cancer yet such as a virus. Even hepatitis B virus
vaccine prevents liver cancer. So we’re already preventing some infectious associated cancers. And the goal is to learn more about how would we prevent
cancers in high-risk families where we know that there
are genes involved as well. So that’s a longer goal. – Along with that, how can you sequence my tumor, if you can’t see my tumor now. – We can’t. So the goal would be to
sequence the original tumor, but again, it could
change when it comes back. So it would be better
to wait at this point. It’s very hard to consider a vaccine at this point, but if it was right after your treatment, let’s
say surgery, chemotherapy, we could use the recent
cancer to try to make an educated guess. But it would still be a guess and it needs to be done in a clinical trial. – Thank you. – I think last question,
we’re almost out of time. – Hi, I am a cancer… I’m a lung cancer stage four, I have tried different
type of immunotherapy Keytruda, Opdivo, and
nothing has worked for me, so I’m back to chemo. But I understood that a Divolumab that was for stage three before are they going to try to
create that with stage four? Is divolumab immunotherapy? – Right? Yeah, so Ddvolumab is an immunotherapy. It’s a similar class of
drugs as the Nivolumab and the Pembrolizumab. So there’s how the drugs
are different based on their properties, but then a lot of how we offer it to patients
really depends on how it was studied in the clinical trials. And so divolumab in the ICF, I think you’re referring
to the trial where it was looked at in patients who finished chemotherapy and radiation. And it was very successful
in that setting. Just because it was successful in that setting, in that
trial, doesn’t mean that it would work better than the
pembrolizumab or nivolumab in the setting of somebody
who has metastatic disease. Because the differences between
how those drugs are used are really more related to what population they were studied in, and the trials. I don’t know if that’s clear. And I’m probably not the answer. – The development for
nivolumab is stage four? – So there are trials, certainly, and looking at combinations. I think, pembrolizumab and the nivolumab are two good options
already in stage four. So rather than divolumab alone in stage four, probably
what’s of more interest is looking at combination studies for somebody who’s already
been on immunotherapy. – Which immunotherapy? I did Opdivo and nivolumab. At first it was Keytruda only. And then it worked, then
the old one goes down the new pops up. And then my doctor tried
optimal immunotherapy, the two immunotherapy. Ohdiva, Opdivo? I’m sorry, Opdivo and pembrolizumab. And some goes up some goes down. That’s why she put me back on chemo again. – Yeah. So with the area of probably research now and what we really need to focus on is what are the resistance,
why is it that it goes up and down, and understanding more about that resistance
that would help to develop the trials specifically in that setting. And there are trials out
there for lung cancer, for patients who’ve been on immunotherapy before who hasn’t worked,
but it still is an area that we need a lot of research on. (woman speaks faintly) – Absolutely. – Like targeted drugs?
– Again, it depends because it’s such a heterogeneous disease. It really depends on the specifics of your individual disease,
but there’s certainly for patients who’ve already been on immunotherapy combination studies, into some of the cellular based therapies, and anything incorporating chemotherapy and some of our more
traditional therapies. But now lung cancer is a disease where we traditionally
sequence, you want to know what mutations are there? You want to know what the
mutation burden of a tumor. – So a lot of factors come into play before deciding the next step, even, especially when somebody’s already been on immunotherapy. – You talked to me about patient one. None of the targeted drugs
works on me, just by itself. – We’re over time I’m sorry. So I think in the interest of time, there’s going to be plenty of time to ask additional questions at lunch or in the sessions that follow. So I think rather than delaying those additional sessions,
why don’t we stop here and I want to thank all
of you for participating and great questions. I want to thank our panelists for participating today. Thank you very much. (crowd applauds)