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Are Immune Checkpoint Inhibitors Sufficiently Tolerable to Recommend Them for Older or More Frail Patients?
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Drs. Ben Solomon, Leora Horn, & Jack West consider whether immunotherapy might prove to be more problematic when given to a broader population of older and frail patients with advanced lung cancer.

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Dr. West:  What about issues of the tolerability of these immune checkpoint inhibitors? What are your impressions of — are they really trivial toxicity, compared with conventional chemotherapy, are there issues with patients who would really not be great candidates for chemotherapy being treated with immune therapies, potentially with challenging consequences if they have any toxicities… Have you seen that, or are you hearing about that in patients being admitted with complications who you think might not have been great candidates?

Dr. Horn:  So, it doesn’t seem that the elder patients, or the poor performance status patients, are having worse toxicities. In fact, I do — in my experience, it’s easier than chemotherapy. You know, people leave and sometimes they come back, “are you sure you gave me something a few weeks ago?” If patients don’t have toxicities, these drugs are far superior to chemotherapy. They don’t leave people feeling tired or down for four to five days after treatment, but in those patients that develop pneumonitis or colitis, are the two really big toxicities that seem to have a big impact on quality of life, you know, if people’s thyroids stop working, it’s easily fixed, but those can really have in impact on how people do. The nice thing is, it’s less frequent than neuropathy from chemotherapy or febrile neutropenia, or some of the other things that we see as a result of chemotherapy.

Dr. West:  Your thoughts?

Dr. Solomon:  Yeah, I completely agree, and certainly the PD-1 and PD-L1 inhibitors are really well tolerated. They do have some different toxicities which Leora mentioned, that patients need to be aware of, in particular, pneumonitis, and I think those are important symptoms to bring to the attention of doctors, and they need to be investigated, and patients put on steroids if there is evidence of that — but certainly, compared with some of the other immunotherapies, such as ipilimumab, those toxicities are much less frequent, and the drugs, even in older, frailer patients, are tolerated really well.

Dr. West:  It’s important just to underscore that early identification of a toxicity and addressing that, whether by stopping the drug or initiating steroids, in some patients, is critical. So, I think the biggest challenge would be if patients don’t mention it, and doctors are oversubscribed and are not attending to it. But, hopefully, as everyone gets more experienced with them, we’ll know what to be looking for and asking about.

Dr. Solomon:  Exactly.

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