Background:
Development of immune checkpoint inhibitors represents a major breakthrough in cancer therapy. There are an increasing number of patients receiving these novel agents regionally. We hereby present the real-world data and challenges of providing immunotherapy at GVH.
Methods:
Patients who were commenced on anti-PD-1/anti-PD-L1 monotherapy or in combination with anti- CTLA-4 from July 2015-June 2017 were identified. Ethics approval was obtained. Patient and disease characteristics, treatment response and immune-related adverse events (irAEs) were collected. Progression-free survival was analysed using Kaplan-Meier analysis.
Results:
Thirty-four patients were identified (15 pembrolizumab, 14 nivolumab, 4 nivolumab/ipilumumab, 1 avelumab). Cancer types include melanoma (n=20), non-small cell lung cancer (NSCLC) (8 adenocarcinoma, 5 squamous cell carcinoma) and merkel cell carcinoma (n=1). The median ECOG status was 1 (range 0-2). The median progression-free survival of NSCLC patients on nivolumab was 3.8 months (95% CI, 2.2 to 5.4) and not reached in melanoma patients on pembrolizumab. Fourteen patients (41%) developed irAEs (5 [36%] grade 1, 4 [29%] grade 2, 5 [36%] grade 3), the most common being dermatological followed by gastrointestinal, endocrine, hepatic, pulmonary and renal. Most irAEs were managed as outpatient, only 1 of 5 (20%) patients with grade 3 irAEs required hospitalisation and intravenous steroid. There was no treatment-related death. Immunotherapy was ceased in 17 patients- 6 adverse events, 5 progressive diseases and 6 deaths.
Discussion:
Regional hospitals are capable of delivering immunotherapy to patients safely with comparable outcomes, however not without challenges. A significant number of our patients experienced irAEs. Their management warrants a multidisciplinary approach, which unfortunately is often not achievable. A higher index of suspicion, access to medical oncologist on-call, and local guidelines are required for early recognition and timely management of irAEs. The short shelf life of these agents also poses a challenge to their delivery and storage at regional sites.