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Roy S. Herbst MD, Ensign Professor of Medicine and Chief of Medical Oncology at Yale Cancer
Center and Smilow Cancer Hospital at Yale-New Haven, Connecticut, discusses the impact
of immunotherapy on thoracic cancer with PracticeUpdate’s Dr Farzanna Haffizulla.
Dr Haffizulla:
During the poster discussion session,
Dr Naiyer Rizvi presented data on the use of immuno-
therapy for many thoracic malignancies. What’s your
opinion on these data?
Dr Herbst:
Immunotherapy has changed the way we
look at thoracic cancer. I lead the thoracic oncology
program at the Smilow Cancer Hospital at Yale; I used
to lead the program at MDAnderson for many years. I
can tell you that – aside from targeted therapy, in which
you know there’s a genetic defect, you have a target,
you give an EGFR inhibitor, an ALK inhibitor – I’ve
never seen anything as impressive as immunotherapy
for many of these diseases. Now, the caveat is, as well
as it works, it still only works in about 1 in 5 people;
but, if you look at immunotherapy in lung cancer, mes-
othelioma, patients are coming in who have no genetic
drivers, who would have gotten chemotherapy, and had
a survival of 6 months to a year, and now we are seeing
people live longer.
That’s important, I think, for your audience. Everyone
else who sees these patients – the pulmonologist, the
cardiologist, the internist – now needs to realise that
there’s a whole new breed of patients with lung cancer,
who are, maybe not cured of their disease, because it’s
too soon to say that immunotherapy is curative, but
who are living with the cancer. But, as you activate
the immune system against a cancer, you do activate
it against the thyroid; so you’re going to see a great
deal of thyroid issues. Against the colon, you might
see colitis. Against the lung, pneumonitis. Something
to really keep an eye on, skin rash, other issues. But it
really is a huge advance.
Dr Haffizulla:
ASCO named immunotherapy as the
clinical cancer advance of the year for 2016, and you
said it perfectly when you mentioned that this is now
a whole new arena. Not just for oncologists, for all
healthcare providers involved in caring for that par-
ticular patient. How do you propose we translate some
of that information, and this new thought process,
throughout the medical community? To increase the
collaborative spirit, as it were, as we’re seeing immu-
notherapy on the horizon with such success?
Dr Herbst:
I lead a SPORE, which stands for Special-
ized Programs of Research Excellence. It’s a large grant
for lung cancer; we’re one of four sites in the United
States that has one, and through the grant we’re actual-
ly studying this very carefully. In science, in medicine,
the fact that we’re seeing activity, proof of concept, is
huge. Everyone is so excited about it at ASCO, and they
should be, because 20% response in a disease that kills
200,000 Americans a year and 1.5 to 2 million people
in the world a year is a huge advance; but we still have
to figure out why it works in some and not others.
One of the things we’re very focused on in our research,
and we’re presenting some data here and at other meet-
ings this year, is what is it about those patients who
respond and then become resistant? So, we’re doing
biopsies at our centre at the start of treatment and after
the patients become resistant to ask what’s different,
and if there is any way that we can then stimulate them
to respond again. Or what is it about those patients
who never benefit, those primary resistant patients?
That’s where combinations of drugs are going to come
in, and as I walk through the halls of ASCO, that’s what
the posters are about. In fact, I’m presenting one myself
on a combination of pembrolizumab and ramucirumab,
an angiogenesis inhibitor, and, while the results are
early, we’re showing a safe combination and potentially
a combination that could be more active than one drug
alone, and that now needs to go to further study.
Dr Haffizulla:
I think that you mentioned something
extraordinarily vital, in studying the tumour and then
the changes that happen in that particular tumour,
not only after treatment, but as it metastasises. You
know, understanding the proteins that are translated
and expressed in those particular tumours and then
using targeted therapy, individualising the treatment
and maximising use of the immune system.
Dr Herbst:
Exactly. One of the biggest papers here
at ASCO basically shows that, in profiling tumours
and by knowing what’s going on, you are able to treat
them better; and that makes sense. If a car comes in
to your shop, and it’s not running, you wouldn’t just
start throwing stuff at the car; you’d figure out what’s
exactly wrong. It’s much more important in a human.
Farzanna Haffizulla MD, FACP,
FAMWA, practices general
internal medicine in Florida. She
was the national president of
the American Medical Women’s
Association (AMWA) 2014–2015.
Dr Roy Herbst on practical aspects of
immunotherapy for thoracic cancers
AMERICAN SOCIETY OF CLINICAL ONCOLOGY 2016 ANNUAL MEETING
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