Abstract
Immune checkpoint inhibitors (ICPIs) have revolutionized the management and prognosis of fit patients with advanced non-small cell lung cancer (NSCLC). Recently, the publication of 5-year survival rates has cemented the role of ICPIs in NSCLC. An ongoing challenge is to determine the optimal treatment duration to find the balance between efficacy, toxicity and cost. From the onset of ICPI trials, different durations were used, ranging from treatment until progression or toxicity, to fixed durations of 2 years. Subsequently, exploratory analyses from a 1-year fixed duration trial failed to change practice. There are, to date, no adequately powered prospective trials addressing this important question. With today's severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) pandemic, more than ever, the question resurfaces with added factors tilting the already shaky therapeutic balance. Here, we will discuss current data regarding ICPI treatment duration and incorporate this into the context of the ongoing pandemic. We conclude with a discussion of pragmatic approaches, should physicians be unable to continue standard therapy.
Highlights
In March 2020, the World Health Organization declared a pandemic due to spread, number of cases and death caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) the case fatality rate seems to be about 3–4% but increases to 60.5% for critical cases [1]
The phase I Keynote 001 trial evaluated the efficacy of the anti-PD-1 inhibitor pembrolizumab in patients with advanced disease, both in treatment-naive and in subsequent lines, including a non-small cell lung cancer (NSCLC) cohort [6]
Landmark practice changing phase III randomized clinical trials were designed with variable treatment durations, ranging from a predetermined maximum of 2 years of administration, to continuation of treatment until progression or unacceptable toxicity
Summary
The publication of 5-year survival rates has cemented the role of ICPIs in NSCLC. An ongoing challenge is to determine the optimal treatment duration to find the balance between efficacy, toxicity and cost. From the onset of ICPI trials, different durations were used, ranging from treatment until progression or toxicity, to fixed durations of 2 years. Exploratory analyses from a 1-year fixed duration trial failed to change practice. There are, to date, no adequately powered prospective trials addressing this important question. With today’s severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) pandemic, more than ever, the question resurfaces with added factors tilting the already shaky therapeutic balance. We will discuss current data regarding ICPI treatment duration and incorporate this into the context of the ongoing pandemic.
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