Immunotherapy - the new treatment for cancer.

welcome to the Cancer Council Western Australia's cancer update series this is the last lecture for our 2016 series my name is Melissa Leger I manage one of the teams in the education and research division at the Cancer Council Western Australia today professor Michael Norwood is going to talk about a very new tool in cancer in the treatment of cancer immunotherapy and I think the crowd here today shows the interest in this new and interesting treatment we are really fortunate to have Professor Millwood here today sometimes when we look for experts to present the cancer update lectures we don't need to look too far we're very privileged to have an expert such as Professor Michael Millwood here in Western Australia professor Melwood is the foundation chair of clinical cancer research at the University of Western Australia and a consultant medical oncologist at Sir Charles guard in the hospital since 2003 professor Millwood has a strong track record in delivering clinical trials outcomes he is an international expert in thoracic cancers and melanoma he has published more than 170 original papers and over 270 abstracts at international meetings but without any further housekeeping announcements please join me in welcoming professor Michael mill wish thanks very much Melissa and it's great to see so many people here I hope you find this interesting and for coming inside on what is the first nice Pleasant spring day we've had for a long long time probably since last spring so in terms of disclosures I do provide advice to pharmaceutical companies on the development of drugs including immune targeted therapies so I've listed there the companies that I do provide advice and consultation for so the themes that I want to get through today firstly what is our immune system why is it potentially important for a disease like cancer how can we use drugs to change the immune system what where are we at at the moment particularly with melanoma and lung cancer but I'll touch on some other cancers as well and where we where will we be in the years to come and I'll we won't go through this in the exact order that's written there but that's what I hope we'll get through so what is our immune system our immune system is a complex network it contains different cells it contains different proteins and all of these function together in a coordinated way to provide what we call the immune response and our immune system is there primarily to recognize foreign proteins and foreign cells that get into our body in other words to help us fight off infections infections with bacteria with viruses with parasites and this is something that we have evolved with over the millions of years that we've been evolving to what we are today as has our environment and as have the microbes in that environment so we can exist in the complex of the world when an example about terrier gets inside our body and threatens to cause an infection our immune system can recognize this through multiple steps then activate cells of the immune system to fight and destroy the invading bacteria and in some circumstances the immune system will then retain a memory of that infection which is why for some infections you only get it once and why you can immunize people against it so the immune system has a recognition it has a what we call effector or a killing function to get rid of invaders and it has in some circumstances a memory the immune system can go wrong and I'm sure you're aware of what we call immune deficiency diseases where the immune system does not work and where the immune system doesn't work the patient is at risk of getting infections that will prove fatal and you probably remember the kids the so called babies in bubbles that have to live in this protected environment because they don't have a functioning immune system and any infection that our immune system would deal with very easily can be fatal to them and some of those immune deficiency diseases can be treated with various drugs or with transplantations of bone marrow or other things but if your immune system is really deficient then your health is very poor conversely the immune system can develop what's called autoimmune diseases and autoimmune diseases where the immune system goes a bit wrong and starts recognizing non foreign cells in the body in other words our normal body cells but thinks they are foreign so starts attacking them and this can cause serious and chronic diseases like rheumatoid arthritis or SLE or the neurologic disease gala and ballet barre syndrome and a number of other diseases that are less serious such as Bittle ago where you lose the pigmentation in your skin and as you know our immune system does not permit us to have cells and organs from other people living in our body so if we want to receive an organ transplant from a donor it has to be carefully matched so the immune systems of the donor and the recipient are very close and even in those circumstances the person who receives the organ has to go on powerful drugs to suppress the immune system to allow the transplant to continue to function so our immune system is important in protecting us against infection and if it goes wrong either by not working well or working too well we can get very ill indeed and it prevents us doing some of the things that modern medicine wants to do like transplanting organs from one person to another but our immune system is not there because of cancer cancer is not part of our evolutionary process our body is not evolved to recognize and attack cancer cancer is a recent illness as we know cancer is a disease predominantly associated with older age and we are not evolved to live to the lifespan that we now can our bodies are evolved to live to maybe thirty forty years of age and our environment now has changed so quickly that our bodies have not evolved in the way that we have evolved to recognize and fight infections from bacteria and other organisms so our immune system is not there to recognize and fight cancers cancer's obviously and not foreign in the sense that they arise from our own bodies cancers are diseases of our own body cells and the immune system does not therefore have to see a cancer cell as a foreign cell but cancers do arise because of mutations in various genes that cause the cancer cell to become malignant and divide in an uncontrolled way and because of these mutations abnormal proteins can be produced on the surface of cancer cells and the immune system recognizes foreign cells and foreign proteins by detecting the shape and the configuration of these proteins so if there is a sufficiently abnormal protein on the surface of your own body cell then yes your immune system could recognize it so yes the immune system could recognize the presence of cancer cells in the body so does it actually do so does the immune system recognize activate and destroy cancer cells in the body yes it does we notice now in fact changes to our body cells as a result of the damage to the DNA is happening all the time we are probably always producing abnormal cells with abnormal protein and probably our immune systems all the time are looking at our own body cells and recognizing those that are sufficiently different however clearly it doesn't always work because if it did we wouldn't get cancers and cancers are a very common problem so the immune system yes potentially can recognize cancers probably does and a lot of the time but frequently it doesn't and the cancers grow and become clinically apparent and people get cancer so the question is why why does this occur why does the immune system sometimes not recognize and get rid of a cancer cell and allow the cancer to grow and spread we've known for quite some time that there is a complex link between cancer and our body's immune system remember I said there are diseases where the immune system doesn't work and that our people with those diseases have a high rate of developing fatal infections however some diseases where the immune system doesn't work are also characterized by a high risk of developing cancer particularly at a young age so there's something about having an immune system that doesn't work that also put you at risk of cancer if you need drugs to suppress your immune system because you have an autoimmune disease or because you have a transplant that also increases your risk of cancer and if you get cancer then your outcome is likely to be worse than if you didn't have immunity pressive treatment so again if we have to suppress the immune system it makes the risk of cancer worse we also know that some people who do very well with cancer treatments will develop autoimmune type phenomenon so it seems that there's something about having a good response to cancer treatment that is also associated with the immune system becoming active and we know that very rarely cancers can shrink without any treatment being given it's very unusual but it does occur and for that to occur there must be some other way that cancer cells have got rid of and that must involve the immune system so here's here's a patient I treated a long time ago and you'll see so you can see this patient has developed vitiligo he's losing the pigmented silk cells in his skin and this is an autoimmune condition this is a sort of thing that Michael Jackson had so why lost all this pigmentation and you can see this happening here and across here and this was associated with their very good response to okay to treatment and happening up here as well and I like showing this picture because patient gave me permission to but you can see how long ago it was by the sort of computers that we were using in the clinic at that time so what happened a few years ago that really gave this a boost what what's happened to change what we've known about the link between cancer and the immune system to the point where we now are developing effective treatment for cancer based on the immune system this was a front page in a science magazine a couple of years ago announcing this as the the breakthrough of the year now I showed this slide at this talk last year which was on another topic so those of you who are here will have seen it before but just to remind you that when we talk about a cancer a cancer is not just a collection of cancer cells a cancer is more similar to an organ in the body and if you take out a cancer from anybody and you look at it under the microscope which we do all the time you don't just see cancer cells there you see other cells that are normal cells in the body that you would get if you removed any diseased organ so you see fat cells you see supporting structural cells you see blood vessel cells and you see immune cells and here's a little cartoon of a cancer and all the blue cells are cancer cells but intermixed with them and particularly surrounding them are other cells from normal tissues blood vessel cells supporting structural cells and cells derived from the immune system are neutrophils macrophages and in particular lymphocytes and lymphocytes are the cells of the immune system that contain the so called killing function there are other cells that can do this as well but the T lymphocytes are the most important ones and they can be present in and around cancers so why are they there and if they're there why aren't they getting rid of the cancer cells well about the turn of the century maybe a little before maybe 1997 the actual reasons why this occurred started to be worked out so don't do this is a melanoma cell here it could be any sort of cancer cell and near it is an immune cell a T lymphocyte which has the potential to get rid of it and surrounding it is another immune cell whose job it is is to tell the lymphocyte that this is a foreign cell get active and get rid of it and these cells have to talk to each other and cells talk to each other by expressing on their surface various different proteins that bind to other proteins on the cell they want to communicate with and depending on exactly which proteins are there it signals to the next cell to do something or not do something so one of the things that will have happened here is this cell will the figured out on this cell that there's a foreign protein called an antigen it will then have said to this cell here's an antigen you could recognize this therefore get busy and destroy this cell okay oh here it is here's the antigen I can recognize you now we're going to get rid of it however there are other proteins involved in this talking between cells that have a so-called negative regulatory function which means they act as brakes they say hang on don't do this our immune system is in a very delicate state of balance between recognizing and destroying cells and saying we'll hang on no no this looks a bit like a normal cell let's not get rid of it remember you don't want your immune system to get too active otherwise it might start attacking your normal cells so we have breaks so-called checkpoints on the immune system that function in this environment and cancer cells turn these brakes on and that was the discovery that was made there are breaks that can damp down the immune response and these breaks are certain molecules that around cancers around cancer cells become much more active so cancers cells turn on a break in the immune response and so even though there are cells there the message they're getting is hang on don't get rid of this guy let it live and grow so we now know what is stopping the immune system the so called checkpoints or brakes once we know what's happening we can try and disrupt that we can design and make drugs that will block these breaks what we call checkpoint inhibitors that will release the brake and turn on the immune response around the cancer cell now to do this you have to make drugs which are currently antibody drugs because antibodies will bind to proteins and they will bind to proteins that we now know are the essential core of these negative brakes so if I go back the important brakes are this one called ctla-4 and particularly this one called pd-1 linking to PDL one so most of the excitement is about drugs that inhibit this brake although there's some that hibbett disc brake that are also important cancer treatments so it's inhibiting these two breaks that it's the core of all the excitement now antibodies you know are drugs that have been around for a long time so we've known for decades how to make antibodies as drugs but you've got to know the exact target for the antibody so once you discover the target you can find an antibody that will interrupt it and as I said in this circumstance you're putting a break on a break so you're if you like releasing the accelerator so when you start treating patients with these drugs the immune system around the cancers wakes up becomes active and potentially starts searching out the cancer cells and getting rid of them that in summary is the theory of what we've known it's a major advance that happened to recognize these proteins because once you do that you can start designing drugs to inhibit them so on the next couple of slides I've listed the immune drugs that are checkpoint inhibitors inhibitors of the brakes that have been developed and that have been tested and that are becoming available so the first one inhibited the CL ctla-4 brake that was called a polymer mob or yer voi it's now approved in Australia for advanced melanoma and it's available on the PBS and many patients have received it the Pember lism AB called key Trudeau works on the other break the pd-1 break again that is approved in Australia for melanoma and is funded on the PPS and has produced quite remarkable results and again many many patients have now received it this one the volume AB or opdivo is a very similar drug working on the same break again approved in Australia for melanoma funded on the PBS and many patients have received it it has also shown benefits in lung cancer and it's currently approved here for lung cancer although it's not yet on the PBS although I hope it will be in the very near future overseas particularly in the US there are different additional indications for these drugs and some other drugs have also been approved because of positive results in trials for example the polymer map the ctla-4 break has been approved in the US for melanomas that have spread to lymph nodes and been removed although the dose used in that trial was very high and caused a lot of side effects so that's not a treatment yet that we've taken on in Australia and it's not approved for that use in Australia Pemble ISM AB the anti PD one is approved in the US for lung cancers and for some types of head neck cancers cancers of the of the throat of the tongue of the mouth again all in advanced stage the volume AB approved in the US for kidney cancers and for Hodgkin's disease a lymphoma and another one called a teaser lism AB approved in the US for cancers arising in the bladder and all of these I expect will eventually and hopefully in the fairly short term get approved and funded in Australia for these indications as well the theory that I've outlined to you is not something that should apply only to a particular type of cancer you might imagine that some cancers are better at evading the immune system than others and some have different ways of doing it but there is nothing fundamental about one cancer versus another that says why this should only apply to melanomas the results in melanomas so Pharr are probably better than in other cancers but as you'll see there's a lot more that we can potentially do and there are a number of others in clinical trials including late-stage trials that we expect will get positive results and approval in years to come and there are many many more being developed particularly for the PD 1 and PDL 1 that break that I talked about and I'll tell you some more afterwards so this is just one company's development portfolio and there are multiple multiple companies working on drugs and these and this is one of them there's nothing special about it I just happened to have a slide on it showing how many patients had been in trials and this is from last year there is an updated slide with I believe a few thousand more patients on it being tested initially in melanoma and lung cancer but then going through other cancers you know so it will all all the cancers will eventually be tested with immune treatments here's some pictures from some of our patients here's a melanoma spread under the skin you can see it sort of a hard lump that would be ant you on the top of the buttocks of this patient and after treatment it's gone away a tumor that spread to the lung that round thing they're much much smaller after treatment here's a large tumor in the pelvis of a of a female patient again after treatment much smaller so these drugs do work they shrink and control cancers and I'll show you some more results in a moment now this is the slide I showed before and I said there were these checkpoints these interactions between immune cells and between immune cells and tumor cells and that these acted as brakes but it's a lot more complex than that it's probably a lot more like this in which there are multiple ways that these cells can talk to each other and there are lots of different breaks and there are also accelerators as well so there's more than two in fact there's probably Twinkie and we can now design drugs for all of these and we can give them in combinations together to turn off several breaks or push the unaccelerated bit harder so what's going to happen what is already happening but what will happen increasingly in years to come is immune checkpoint drugs will be given new ones ones in combination and it'll become a little bit like the initial days of chemotherapy which was well before I can remember but if as you will know chemotherapy started with a one or two drugs and then there's now twenty or thirty that can be used in different combinations you know some of which are quite good and clearly we know now based on decades of experience which are the best ones for different cancers so we're rapidly discovering that we can make new drugs and we've got unlimited potential to devise combinations and different ways to give them so just you just a couple of trials that we're doing many with immune combinations looking at different types of cancer and all these trials will inform us in the future about which are the ones to use which are good ideas and which are so I'll just show you a few results particularly in melanoma and lung cancer because that's where we've been using these treatments for longest and that's so we can start seeing exactly how good they are and I'm talking now about drugs sort of by themselves we've got single drugs by themselves the future is just so impossible to predict now this is the ctla-4 brake inhibitor epilim AB and this started in clinical trials or I guess about 2002 2003 so quite some time ago and this is a summary of all the patients with melanoma that were treated with trials and I'll show you some of these graphs and just to orient you across we have time in months so 12 months 24 months so 5 years 10 years and here we have the proportion of patients treated who in this case are still alive so we can see these people with advanced melanoma most of them succumb but then there's a group that 4 3 5 even 10 years are still alive and that's about 20% of people treated with this drug with melanoma and that never happened before in melanoma treatment once it was advanced and spread patients very rarely lived more than a few years and certainly not many many years like this and if we can see this we know the drug is doing something that some of these patients are surviving so much longer than expected that they must be getting their melanomas eradicated to do this you need to have a trial that started a long time ago and a lot of the newer drugs we haven't been using for that long so we don't know what will happen to people who were treated within 10 years ago because no one was treated 10 years ago with the PD one pathway drugs they started to go into trial about 2011 so we're just getting to about the stage where there are people who've been treated some years ago that we can follow up so here's some data that was presented at the American meetings earlier this year and if we look at this one and remember this is these are still months but this is 36 months or three years and you can see it's toward us starting to do the same thing but instead of a 20% it's sort of doing it maybe 40 50 percent so again that's very encouraging because it's looking like there are more people doing better for longer with this drug than the other drug we also have trials comparing different immune treatments some of these we did some years ago so we're starting to get longer term results and here's one that compared different drugs and you can see again this one is only going up to about 24 months but again the number of surviving is leveling off at around the 40 to 50 percent mark which is pretty good better than before and very encouraging but if you think of the initial curve I showed you that went out to 10 years which would be over there we don't know what will happen to the people who are still being followed up who are relatively early but we hope that we'll continue to remain alive and in good health now the other thing we look at in evaluating these treatment is what percentage of patients do get a significant shrinkage of their cancers like the pictures of the patients that I showed you before on their scans and we can we grade this in terms of what we term a response to treatment and a response is not just anything it's defined as a certain mathematical shrinkage of cancers but what you can see is that about 35% of people with these drugs were getting a good response and the hatched bars are those who had what's called a complete response a complete response is where you can no longer see the cancer on a scan so rather like the first one I showed you where you could see it there and then it's gone okay so there are some people whose cancers go away and the question then is what happens to those people what happens to people with immune treatments whose cancers go away well that's a very interesting group indeed we've now got data on over 60 people around the world receiving this drug and the data is similar with the other the other drugs that work this way but this this just happens to have the best results currently available about 60 patients who completed treatment for a couple of years they had no evidence of cancer left and the decision was made to stop the treatment and which is not something we often do in cancer treatment we sort of tend to like to keep it going but you know when someone's doing so well you think well what will happen if I stop it and of those 61 patients 97% 59 continue to maintain the disappearance of cancer of treatment so what it's starting to look like is that if these drugs work really well for a patient then treatment can be given for a limited period of time and we don't know exactly what that time interval should be but there is certainly the potential to stop treatment and remember I said the immune system has a memory and this makes sense because if you can get your immune system to recognize the cancer and get rid of it it may retain a memory that means if the cancer does start to grow back then it will quickly become active again and so you won't see it now I just I was going to show you a trial in lung cancer some results there because there are some very encouraging results in lung cancer but there was a very very good trial that was actually disclosed yesterday afternoon so I couldn't put the results in there which I think will make the field even more exciting for lung cancer so thank you that's not the one I wanted to show this is again the same sort of curve the number of patients left alive and this of patients who were given either chemotherapy this bottom green curve or the immune drug nivolumab opdivo which again works on this pd-1 break and you can see there are many more patients alive at each time point in those who are treated with the immune drug than with the standard chemotherapy treatment so it's looking like in many patients with lung cancer there is a potential to use immune acting drugs instead of chemotherapy treatment and that's something that I think will come in more and more in the years to come so again a very encouraging result here and as I say there was another trial looking very much like this that was disclosed overnight so very important indeed now one of the exciting things about these new immune drugs is not only that they can have very good results in some patients but the side effects generally are a lot less than with chemotherapy treatments so how we measure this in oncology what we term grades of side effects and side effects can be graded in two different grades from grade one which is fairly mild up to grade three and four which are very fairly serious and this shows the percentage of patients treated with the immune drug or chemotherapy who got different types of side effects and if you look at the total you can see about half the patients with chemotherapy got fairly serious side effects the main ones of which were low blood counts and as you know that's what chemotherapy can do but with the immune treatment under 10% got serious side effects and nobody gets low blood counts so in general these drugs are easier to tolerate they do have some side effects but they are preferable at least to chemotherapy in terms of side effects so why did they work for everybody why why can't we just give them to everybody with a with different cancers why don't they just work for everybody well they clearly don't they work well in some people they're very very encouraging and I think as we continue to find out more and explore these drugs and work out ways to use them better we'll get better results but they don't work in everybody and we don't yet know exactly why we don't have yet a good way of looking at the cancer and saying well that's one that's going to do well and this is one that isn't we do know at least in melanoma that tumors that are very large or that are causing a lot of symptoms are less likely to do well there is some evidence in lung cancer that measuring these immune proteins on the cancer cells can help select patients who'll do well but that's still very imprecise there is a lot of interest in taking blood cells or biopsies of tumors and looking at the immune cells there and measuring them and seeing what they're doing seeing what genes they're expressing seeing what exactly the mutations in the cancers are and using that data to try and predict whether they'll respond to immune treatments or not but that remains very much a research tool and as I say at the bottom it's nice to know if we can discover which patients won't do well but then we've got to think about if we know this how we going to make them do well how are we going to do something different for these patients that hopefully will allow them to do well with immune treatments one of the sort of paradoxical things that we know about these immune drugs and it can cause us a little bit of angst and that is that occasionally they seem to make the tumors grow before they shrink so this is a patient treated in the US has actually got stomach cancer gastric cancer and you can see here there were one two three tumors in the lung and this is at the start and as a patient had treatment you can see here and here these tumors is clearly growing but because the patient felt well it was decided to keep going and then the cancers started to shrink so if you compare here and after four months of treatment you would say well gee this isn't working they're clearly getting bigger but after a thirty two weeks so eight months of treatment they have clearly shrunk so sometimes you know we have to be very circumspect in deciding whether a treatments working or not working and we're often guided in this by exactly how the patient is feeling if patients are feeling well and the cancers seem to have grown a little bit we might push on a little more and see that this phenomena is not occurring there are a number of issues that are already being thrown at us by the use of these drugs as I said we don't really know how long to treat patients for who were doing well most of the protocols we use have 12:24 or even longer months of treatment but we don't know what the optimal duration is if you have patients doing well coming in for regular treatment every two or three weeks that's fantastic for the patients they're feeling well their cancers are shrinking they're living a lot longer but it's creating a lot of work so we don't yet know how we're going to model this work how we're going to cover all this work you know how are we going to treat all these people if the treatments are going to become really good is a number of things that are being looked at for example the sort of chemotherapy approach where you go and see the oncologist and have blood tests and then it's decided if you have treatment may be replaced by seeing the oncologist occasionally and having repeated doses of treatment before you're actually seen again particularly if you're not having major side effects and a feeling well treatment at home is very topical now it's quite feasible to give these antibody drugs which are not chemotherapy drugs you know in an environment different to where you would give chemotherapy so there's a very much of an interest in using novel novel ways of giving treatment like this and of course we have to think in a state like Western Australia how we can treat people who live in regional and remote areas it's very important we develop not just oncologists but nurse coordinators and others who can coordinate care for patients on these treatments and we have not yet worked out how many people will actually survive for the long term and what we have to do with these our long-term survivors do we have to keep seeing them do we have to keep giving them scans will there be a time when we'll have someone with metastatic lung cancer who has treatment and we say the good you've done well you don't need to come back and see me anymore you know how are we as a medical community going to cope with that and hopefully transition people from what was an inevitably fatal illness to one where some people at least may survive and of course all these treatments are costly and expensive and there are many competing demands for the healthcare dollar there are many exciting new treatments in different areas of Medicine how we're going to pay for these and how we're going to make decisions on what should be funded through government and subsidized sources and which is not so thank you for coming and we do have some time left questions thank you for your presentation my question is you're presented to an oncologist with a cancer do you then request immunotherapy or chemotherapy or is that something that the oncologist has to decide based on evidence so that will be generally something that the oncologist will decide you know based on exactly what sort of cancer it is what stage it is but yeah certainly ask your oncologist you know is immunotherapy a possibility or does it have a role in the sort of cancer that I have some of them clearly it does others that may develop over time so yeah definitely ask your oncologist if immunotherapy has a potential role exciting stuff professor side-effects is is auto increase auto immune a common side effect and if it is which which ones that's a fantastic question and the the answer is that these drugs that take the brake off can have side effects like an autoimmune condition because it takes the brake off in the wrong area of the body so just like chemotherapy can have side effects because chemotherapy attacks dividing cells and there are normal dividing cells in the body immune acting drugs can occasionally have side effects that resemble autoimmune phenomena and the most serious ones are diarrhea and bowel inflammation and liver inflammation like hepatitis there are some minor ones that are fairly common like skin rash and each which are very common immune symptoms as we all know and things like joint pains which again a common immune system are common symptoms of an immune system being active but they're generally fairly mild and not that serious the rate of these is quite low but yes it is important to know about them my question what you were talking about the the drugs and they're all maps of what are the nibs are they attacked the the cells you're talking about from a different angle and also the hope you've been giving us for these these drugs and the immuno and you brought up the indication of value and cost the indications are now that a lot of these new drugs are not on the PBS and if you have been on the trial with them and have this response and the continuation you like to continue but the cost is prohibitive and you'll just can't afford to keep going so it's a two-edged sword there so I I think you've asked two or three questions and I'll try and answer each one the all the all the drugs that I showed you and thanks for pointing it out I was going to say it but I didn't end in the word a b c or the letters a B because there are antibodies so Pemberly zu mAb okay there's a lot of drugs that end in IB okay and or in IB and those drugs are not antibodies they are drugs that work on specific signaling pathways in cancer cells and that's a whole separate topic but there are very good drugs like that for melanoma for lung cancer and for some other cancers but there are different types of drugs the question of cost yes as as you say these drugs are currently expensive the good news is as I've said because these are looking so promising virtually every major pharmaceutical company is out there developing their own and we hope we'll be in a position where like anything there's a lot of companies trying to market something then that will put cost pressure downwards because you know for many of the sort of expensive anti-cancer drugs we've had there's only been you know one or two companies making that drug so it's a bit hard to bring the cost down spit like Coles and Woolies but if you had you know 50 different independent supermarkets all competing you know that will hopefully put the prices down in the longer term that's right it's a lady up there who's had a hand up a long time but me okay um I for everyone's interest I've had one cancer with quite a few metastases and my chemotherapy and radiotherapy has treated me very well and I'm now doing really well so professor Millwood how would would I a person like me continue on if I get any more metastasis on the chemotherapy that has been very good or could i if anything else happens use those immune drugs um so you know one of one of the I think exciting things about doing well on the treatment you're on now is that you will continually hear about potential new advances and you know my advice generally for patients who are doing well on what they're on is to stick on what you're on because these things will always you know become potential backups for you that's something again that research will inform us in the future that there is some data now and using these drugs in combination with things like chemotherapy in combination with things like radiation and some promising results but whether that's the optimal to do it we don't yet know I'm fairly new to this but I've noticed that when I spoken to doctors about my concerns with chemotherapy or radiation their response is very suddenly and almost aggressively to put me in a corner in other words go out and die you're an idiot I mentioned that if I was interest or if somebody was interested in speaking about this to their oncologist as a possible treatment that they would then suggest you whether that is a possibility and I'm wondering are they actually up with this are they is this something that they see as strong indications or are they going to poopoo it like they do anything that's not chemo or radiation well I I think if if I'm oncologist shouldn't poopoo you know anything because you know it's your right and role to ask questions and you know and get what hopefully are satisfactory answers to you in terms of knowledge yes you know oncologists are all very excited about this and you know I don't know any oncologist you would get up and say oh this is all you know a lot of hype I think most oncologists are very keen to give these sort of treatments you know and to you know help their patients you know do as well as possible I think we have had a period you know where for many patients chemotherapy and/or radiation were the only treatments that we had and we are now developing new treatments in a number of areas the sort of EBEs that I've talked about from that gentleman these antibodies and other things coming along so the spectrum of treatments that we cancer's is a much wider now than just chemotherapy treatment so we're not yet at the stage where chemotherapy will disappear as a cancer treatment I think it will still be around and used frequently in ten years time but it will be one of a number of important treatments that we use rather than the only important treatment that we use I just wanted to ask you about small cell lung cancer because you spoke about non small cell lung cancer is that because the greater proportion of lung cancer is non-small-cell and or is it because it doesn't work as well with small cell the immunotherapy and then also wants to know if the small cell lung cancer has gone up to the brain how would immunotherapy react in the brain if it is in the brain okay there are two fantastic questions as as well the trial and the data I showed you was for non small cell lung cancer and that is as you say by far the most common type of lung cancer but there is another type called small cell lung cancer we do not yet have a lot of data on the role of immunotherapy in small cell lung cancer there is some data that suggests it might be useful but we don't know yet we don't know where it's going to fit into the treatment sort of paradigm for that disease so watch this space treatment of cancer when it spreads to the brain is very difficult one of the problems with treating tumors that spread to the brain is that most drugs that we have don't get into the brain you know the brain is what's called a sanctuary site in the body you know the brain has evolved to exclude drugs from it because it's a very delicate and if we ingest things that are toxic or poisonous we want to keep them out of our brain so a lot of chemotherapy drugs a lot of antibody drugs do not enter the brain so treating tumors in the brain is still more reliant on things like surgery and radiation where you're actually aiming treatment directly at the brain rather than giving it to the body and hoping it will somehow get into the brain now the question is if you give patients a treatment that works and activates an immune response on a tumor that's not in the brain and that patient happens to have a tumor also in the brain will the body's immune response work in the brain because if it does that remember you don't have to get the drug in there you only have to mount that response there now again the brain is shielded from a lot of the body's immune responses but under some circumstances yes you know these treatments can help tumors that are in the brain particularly if they're fairly small but that's again an area where there's a lot of work being done you know we they're certainly not as good but there is some hope there there's also a great deal of interest in developing this type of approach to treat tumors that start off in the brain what we call primary brain tumors and again there's some we're starting to see some encouraging results there as well so again watch this space we are running out of time thank you very a short question what are some of the image loser efficacy after a period of 18 months or two years that's a fantastic question in many patients they don't but there are certainly some where immune treatments do stop working and we don't know why we don't know what happens to those immune systems that suddenly means that they flip on more breaks we're starting to get some answers but it's very early days so I can't give you an exact answer to that question me in thanking professor Martin you

Channel: Cancer Council Western Australia

Views: 7,825

Rating: 4.6969695 out of 5

Keywords: cancer, immunotherapy, melanoma, lung cancer, immune system

Id: 0Bl7kIdb6i8

Length: 61min 28sec (3688 seconds)

Published: Sun Oct 16 2016