Lung Cancer Patients Live Longer with Immune Therapy | Hacker News Reader

Lung Cancer Patients Live Longer with Immune Therapy

nytimes.com

111 pointsadumbledore77 comments

I’m now 5.5 years post-treatment with immunotherapy for Stage IV melanoma and have had no evidence of disease for over four years. When immunotherapy works, it can be impressive.

For me, my treatment (adoptive cell therapy using tumor infiltrating lymphocytes) used my own white blood cells (130 billion in lab-selected and expanded form) to overwhelm the mutated cancer cells.

It was a one-time treatment (over 3-4 weeks in the hospital) with no further meds or other treatments required.

Immunotherapy has become an important tool in the future of fighting cancer, for sure.

That’s great news both for you and for all of us.

I hope all patients that would benefit from this treatment will have access to it, to save their lives and to validate and improve the therapy for all those to come

Yes, harnessing the patient's immune system to fight their cancer is a very promising technology and is saving the lives of many patients, even more as the processes and meds get further refined.

What was the treatment like? I've heard it's similar to having the worst flu of your life * 1000.

He has a life. Melanoma is insanely deadly and painful.

Yes, the treatment was obviously totally worth it. And, I'm extremely grateful for being in the lucky 30% of patients who response completely to it.

Yes, for the two days of high dose IL-2 every 8 hours, it was pretty bad. My experience was limited to nausea, fever, sweating, and bed-shaking rigors. I've heard that some patients experience hallucinations.

Note: IL-2 was administered after I received my lab-grown white blood cells. It acts as signal to one's immune system to activate. It was used to jumpstart my immune system after it had been replaced.

Was there an option to be sedated? I wouldn't handle fever and shaking that bad, I'd panic.

Also I don't think I'd be eligible, I have ulcerative colitis which is autoimmune.

I wonder how a combination of aggressive immunotherapy and "sickness" counteracting effects of cannabis (for the nausea, fever, sweating) would do in making the immunothrerapy more effective and tolerable.

Since the treatment was performed on site at the National Institutes of Health using Federal research dollars, this wouldn't have been an option. So, I have no idea.

I'm a radiation oncologist specializing in lung cancer. Here's my take:

Immunotherapy is really revolutionizing the treatment of locally advanced and metastatic lung cancer. However, a "revolution" in our world is improving 5-year survival by 10-15% in absolute value. It's not outstanding, but when your baseline is around 10%, improving it by 10% means doubling it. That's why immunotherapy is being adopted so quickly despite its price.

A poster mentioned $100 000 is not a lot if it adds 10 years. It's not as simple. Right now we don't really know if we can stop the treatment. So people often receive the treatment until they progress. If it's 4 years, we're looking at $400k... The cost on society in general will have to be dealt with (and debated) at some point. I doubt insurance companies will continue paying for those treatments "forever", especially considering how prevalent lung cancer is.

Immunotherapy benefits from a great "romantic" story, which helps with its marketing like no other drug. It's your own immune system, your army, waking up and attacking the greatest villain of all; cancer. The alternative, chemotherapy, is often seen as poison. Granted, it has fewer side effects, but it has some, and they can be nasty. Basically, the immune system is in a constant state of equilibrium. You stimulate it too much and it starts attacking your own body. We're seeing some cases of thyroid problems, lung inflammation (pneumonitis), skin problems... Generally speaking though, it's better than most chemos.

Overall, it’s a great treatment but obviously not perfect, crazy expensive to a point that it’s likely not sustainable in the long run. Despite all of the drawbacks, it’s a really exciting time for oncologists as we can finally offer more hope to our lung cancer patients.

This is truly exciting and only just the beginning.

There is a host of bio-tech startups following this initial wave - with two main goals:

1., Improve the treatments to become 100% cures

2., Lower the price

This is very similar to tech and, say, the storage space. Went from 100k for a few GBs to peanuts for TBs on AWS pretty quickly. That's what momentum in a crowded space will do.

Healthcare systems around the globe will have to figure out the effects of this, similar to autonomous driving. And it is not just simple cost of treatment.

What if cancer becomes curable? What to do with all the cancer wards? Specialists in Oncology? Chemo/Radio/Surgery? The spider-web effect here is gigantic.

Sticker price for the drug vs. long term treatment (multiple chemo rounds, surgery, palliative care) if its 100k is NOTHING.

From an economic perspective, cures (or, even, long-term durable remissions) are definitely disruptive to the current models of care.

Yes, this news is exciting. But right now we're a very long way from curing cancer.

In 50% of the full range of cancer types treated so far by the drug in question, immunotherapy does absolutely nothing. And for another 25% it helps only a little. Only about 25% see a game-changing response. Even then, among high responders, most are not cured. They do live longer than if treated only with chemo. (In this study announcement, there's a 51% better survival rate after one year. That's great for those who are near death. But it offers them additional months of life, not decades.)

As of today, the fraction of patients who are fully cured of cancer by immunotherapy is unhappily small. It's also important to remember that these therapies are too new for us to know how long the positive effects will last. Will the lucky ones add months or years to their lives? We don't know. As of today it's just too soon to tell.

I do agree that the potential of treating cancer using the immune system is exciting. Certainly. But right now we're nowhere near able to declare victory or start worrying about the implications of ending cancer. That's not fair to the unlucky majority of cancer patients.

But it offers them additional months of life

Personally, I always wonder why people go through the pain and expenses to add a few more months. Years/cure - yes, go for it. A few months? I'll take the painkillers and anti anxiety drugs, thanks - it was a good run.

absolutely, but also a chicken and egg problem.

a lot of immuno-onco is currently only approved for late-stage cancer patients. basically once you're near death and chemo/radio is done, you get the new stuff. and even within those groups you get people that are cancer-free within weeks. astonishing.

long term survival is unknown - sure. no one has been treated ten years ago with this stuff. besides a time machine there is no way of knowing, just waiting.

watching companies like https://www.modernatx.com/ building whole platforms is super exciting though. as someone who has lost family and young colleagues to cancer, this shit cannot come soon enough.

> After a median follow-up of 10.5 months, the estimated rate of overall survival at 12 months was 69.2% in the pembrolizumab-combination group versus 49.4% in the placebo-combination group.

Seriously groundbreaking. This is a once-in-a-decade paper. [1]

[1] http://www.nejm.org/doi/full/10.1056/NEJMoa1801005?query=fea...

There have been lots of similar 'groundbreaking' data from the various anti-PD1/-PDL1s over the pest few years. This is great, but not greater than lots of others.

complaints about study funding aside, checkpoint inhibitors really are stunningly effective for some cancers.

it’s the first major advance we’ve had in oncology in maybe 25 years.

Haven't there been fairly significant advances in using specialized chemotherapies for specific forms of cancer? This at least has been my impression from a few books I've read.

More or less correct, the parent comment is nonsense. There are multiple special types of cancer that can be specifically targeted now (for example CML), though few of those are chemotherapies aside some improved targeting mechanisms via antibodies. Also, prognosis accuracy has and is improving dramatically. And there are HPV vaccinations now, targetted virus treatments comming up and so much more. Immunotherapies are great but not the first and only thing in 25 years.

AACR meeting in Chicago is the real event. If you're a science junkie, http://webcast.aacr.org/s/2018annual/PL01

Also from AACR: Google Augmented Reality Microscope: https://www.youtube.com/watch?v=9Mz84cwVmS0

My Father is currently on a trial in Australia which combines Immune Therapy with traditional chemo treatment. The results can only be described as a miracle. He has gone from being inoperable stage IV melanoma (with the disease first being spotted in his lung, not his skin) to showing next to no evidence of the disease.

When I read many medical studies in the media, they often sound too good to be true. In this instance it is the real deal.

I hope access to this treatment becomes readily available for the rest of the public.

Not to be dismissive, but those other media stories often had someone incredibly improve their condition too and that someone would have had children to go around saying "this is the real deal" but it's still only an anecdote and it still only works on some patients. Even quack therapies have people recovering naturally sometimes. Not so say immunotherapy is quackery.

This is a really significant public health advance.

In the US, cancer is the second leading cause of death, and lung cancer is one of the largest causes of cancer death. Curing this disease, even in a subset of patients, is really amazing

https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm

https://jamanetwork.com/journals/jama/fullarticle/2678018

Thanks for sharing. I wish that instead of building destructive weapons, there was more focus was on building cures for the many diseases and fighting hunger and poverty..

I remember reading this recent Financial Times article[0] about how China is innovating in the area of providing immunotherapy and other breakthrough treatments.

[0]: https://outline.com/tdDNdd

[1 non-outlined link]: https://www.ft.com/content/30b5a944-3b57-11e8-b9f9-de94fa33a...

Right now China is playing fast-follower in general with this work, but rapidly becoming more innovative.

There are quite a few Chinese companies developing their own PD 1, PD L1 and CTLA4 inhibitors (these are the first gen immunotherapy treatments), and a lot of innovation in CAR-T cell therapy (first approved products of this type were US and European, Novartis and KITE pharma). There is less regulation of cell therapy in China, so potential for some breakthroughs.

A company called Legend Biotech in China surprised the biopharma world at a major confreence last year with breakthrough work with a cell therapy targeting BCMA.

However, the amount of US and EU investmnet in immuno-oncology is still greater than in China

Someone close passed away from lung cancer last year. He received immune therapy (keytruda), and while it may work wonders for others, it comes with drawbacks; My main issue was that it takes 4 to 5 treatments (with weeks between each treatment) before you even really know if it worked or not. This is valuable time that could be used to treat the cancer with chemo (which admittedly has way worse side effects than keytruda, but still).

Are there numbers that say what the success rate of immuni therapy is?

It sort of depends on what you define as success. The goal was never to "cure" the cancer, rather, to shrink the tumor.

I hesitate to assign an exact percentage to the effectiveness since there are so many factors to consider, but I remember Keytruda being reported to shrink tumors in less than a third of patients who took it.

The goal is to cure, from the article, quoting the head of lung at Yale:

> “Chemotherapy has limitations. Immunotherapy has the ability to cure. I lead the Yale lung team. We have patients on these immunotherapies alive more than eight years.”

I am sorry, that wasn't clear; That was the goal in the specific case of my family-member. The tumors would never fully disappear, and he would likely need more treatments later on.

Went to a talk about immunotherapy last year, toxicity of these class of therapeutics was way better than the best other available treatment. Sadly still too nascent, but don't forget to ask for it if you can.

Bad reporting - fails to explain what Immunotherapy actually is, jargons all over. Can anyone explain in simple terms?

Check out the cancer.gov page[1], which does a decent job of giving an overview. The drug in question, pembrolizumab, is a monoclonal antibody (you can tell because the name ends with '-mab'), and you can read more about how those work on this page[2].

[1] https://www.cancer.org/treatment/treatments-and-side-effects...

[2] https://www.cancer.org/treatment/treatments-and-side-effects...

Immunotherapy is not new. My mom went to Greece in 1980’s and received it. It was illegal in the US then. She would go to Mexico for booster shots. I believe it really extended her life w quality. She passed in 1990 but looked good... not a bag of bones like chemo patients.

Odd they don't mention the cuban work on this field.

"Researchers with Cuba’s Center for Molecular Immunology have developed and approved an immunologic cancer therapy that improves survivability for certain types of cancers in some cases; as of January 2017, the drug has begun clinical trials for the treatment in the United States."

https://www.usatoday.com/story/news/world/2018/01/09/cuba-ha...

Vaxira / Racotumomab

https://www.ncbi.nlm.nih.gov/pubmed/25420897

https://www.frontiersin.org/articles/10.3389/fonc.2012.00150...

This drug has completed a limited Phase II study in 2014 (71 patients), adding about 5 months of life over the control group (11 mo vs 6 mo). Then it began a large international phase III NSCLC (lung) study which apparently hasn't ended yet.

It's approved for use in Cuba and Argentina, probably only for lung cancer.

Thanks! Weird I got down voted for my comment..

Cuba has a lung cancer vaccine for $2. Peer reviewed. You don't hear about it. Edit: I don't even know why I go here if this site is so toxic I get downvoted for pointing out something. Enjoy your guys toxic conformation bias

The "vaccine" you refer to here is racotumomab. It's not a vaccine in the common-parlance sense ("prevents disease"), but a different immunotherapy treatment which is only approved for use in Cuba and Argentina. I'm mildly curious why it doesn't exist in the US. All of the clinical trials in the USA which I can find on that drug are either incomplete[1] or completed-but-without-results[2][3][4]. For all of those trials, "Laboratorio Elea" is the sponsor or a collaborator, so I presume they have the rights to the drug in the USA. That's apparently a company out of Argentina[5]. I don't know why they seem to have given up on getting the drug approved in USA, but wikipedia says "[a study] is underway in Argentina, Brazil, Cuba, Indonesia, Philippines, Singapore, Thailand and Uruguay", though the citation for that seems incredibly suspect[6].

[1] https://clinicaltrials.gov/ct2/show/NCT02998983

[2] https://clinicaltrials.gov/ct2/show/NCT01460472

[3] https://clinicaltrials.gov/ct2/show/NCT01598454

[4] https://clinicaltrials.gov/ct2/show/NCT01240447

[5] http://www.elea.com/

[6] https://en.wikipedia.org/wiki/Racotumomab#Clinical_trials

The prohibitively expensive nature of any immunotherapy leaves me profoundly skeptical of its practical usefulness. $100,000/year? That's more than twice the median income in this country.

Is it simply that expensive to get mabs from animals, is drug development disgustingly expensive, or is there unbounded greed in pharmaceutical companies?

It's all 3.

It's way more than $100,000 a year too. My treatment alone (Keytruda, every 3 weeks) is around $300,000 a year; about double the price the company will quote you if you ask, because they don't estimate the cost it takes to get blood work, get seen by an oncologist, and then get the treatment administrated to you safely by a trained nurse ready to respond to any adverse events that may spontaneously occur during infusion. However, thanks to current health care law in the US there are caps on the amount of out-of-pocket expenses your insurance can charge you. I have run of the mill bigco health insurance and my personal max out-of-pocket cost (after premiums, deductibles, etc.) is at least two orders of magnitude less than the cost to insurance.

More then last 2 than the first one. Getting money from investors is much harder than getting MAbs from animals. Probably more gruesome, too. Also greed is not just the Pharma. Some Hospitals/physicians use Clinical Trials as a profit center, and see Pharma as a bottomless pit of cash-- its a bit of a vicious circle.

PhDs that have dedicated their lives to specializing in specific cancers, failed drugs, research that leads nowhere, failed clinical trials because of XYZ. It's all highly specialized. And if done with a rigorous protocol, it's all expensive.

You're not doing a lifetime of cancer research in hopes that you earn an average salary.

For the company, if you finally get somewhere with a drug that is affective, you have to try and recoup your investment. How else do you fund future research?

Most US medical research is highly dependent of public funding. Company's are only interested once the risks drop enough and the rewards are very near.

Looking at just research and eliminating patent dogging efforts, Drug companies don't pay for nearly as much research as you might think.

>One study assessed both capitalized and out-of-pocket costs as about US$1.8 billion and $870 million, respectively.

https://en.wikipedia.org/wiki/Cost_of_drug_development

These numbers certainly aren't risk-free. Even if the company has 10 billion in cash, how many potential research leads can they bring to market? Not many.

I agree that pubic funding is an essential foundation for this industry, but disagree that the risk drops before industry gets a hold of technology. Large clinical studies are crazy expensive for many good and many bad reasons, and many of them will fail giving zero ROI. I agree that much of Pharma, (especially, but not only, some very bad actors) spend more on IP Attys and Commercial efforts than R&D, and that hurts me to watch. Academia doesn't do the research that is required to get drugs to people--who does PK and ADME studies on hundreds of animals? No one excpet industry does the detailed manufacturing process development and critical parameter work required to support approvals, especially in biologics. Yes, many drug companies need to be fixed (and some outright eliminated), but the industry does serve a purpose.

Company's are only interested once the risks drop enough and the rewards are very near.

Clearly not true. Less than 5% of molecules that drug companies pick up make it to market. Huge failure rate.

1:20 is relatively good odds. A random molecule is something like 0.000000001%.

> How else do you fund future research?

Taxes?

That's kind-of what happens... only in the US, it's a huge tax on ill people, rather than a smaller tax on healthy people.

You have it exactly backwards. The healthy people are in fact paying for the ill people (who typically don't come even remotely close to ever paying for the cost of their treatment/care). The real cost to cover healthy people is extremely low, they pay artificially inflated prices for their insurance that subsidizes care & coverage for other sick people.

In the US, 5% of patients represent over 50% of the cost of healthcare. 1% of patients are 20% of all expenses. The healthiest 50% represent just 3% of the healthcare system's costs - they're the financial offset group.

For downvoters that find facts uncomfortable: that's why the ACA needed to force all people to have insurance, it's a financial necessity to get as many paying healthy people in the system as possible to financially offset the cost of sick people if you want to try to make it work. This is healthcare system 101.

> You have it exactly backwards. The healthy people are in fact paying for the ill people (who typically don't come even remotely close to ever paying for the cost of their treatment/care). The real cost to cover healthy people is extremely low, they pay artificially inflated prices for their insurance that subsidizes care & coverage for other sick people.

Agree - that's indeed how insurance works. :)

I was referring to high co-pays on vastly expensive new drugs, and was also being slightly facetious.

nothing is “prohibitively expensive” in healthcare unless you can’t afford your out of pocket costs, which is perhaps increasingly the case for a lot of people, but even conventional cancer treatment is still way over out of pocket costs, so I don’t see how the cost of this treatment really makes much of a difference.

if you don’t have health insurance, your floor for “prohibitively expensive” is probably way lower than this already.

I've been in and out of the hospital a bit lately (broken back). That seems downright cheap. I average about $4,000 an hour when I'm in. The most recent "study" took an hour with one low paid tech using one ultrasound machine and it cost over $2,000. CT Scan? 15 minutes $7K. Heck, they charged nearly $800 to "start an IV" when they didn't even start it, it was the ambulance EMT that put it in (billed separately) they just injected morphine into it. If you don't have good insurance you are one small slip away from bankruptcy.

Have you tried shopping around?

https://www.healthcarebluebook.com and a bunch of others are trying to provide price transparency. Sometimes 30 min drive means thousands in savings.

CT scan is less than 100$ in most places in India. It could go up to 200$ in some hospitals and is considered expensive by the patients.

And ultrasound is 10-20$. I find it seriously expensive in US. One thing is the health insurance or public backed healthcare is not widely adopted and patients still pay from their own pockets in India so charging exorbitant amounts is a big no-no.

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