Lung cancer

Performance status a limiting factor for immunotherapy in NSCLC: SA study

Despite the demonstrated efficacy of immunotherapy in many patients with NSCLC, those with poor performance status (PS) do not enjoy the same survival benefit, an Australian study has shown.

Findings from a retrospective study of nivolumab therapy in 66 South Australian patients with advanced NSCLC suggest careful assessment of patients is warranted before initiating immunotherapy, according to investigators.

In the study, published in Cancer Reports, 40% of patients had a baseline ECOG PS ≥2. The median overall survival was 3.04 months for these patients compared to 10.23 months for patients with PS ≤1.

There was no significant difference in response rates or toxicity between the two patient groups however duration of response was shorter in those with poor PS (5.5 v 10.1 months).

The study said its findings were consistent with prospective studies such as last year’s CheckMate 171 which also found outcomes were worse in patients with poorer PS.

“Our series demonstrates that patients in real-world practice, outside the clinical trials, receive immune therapy despite having a poor PS,” the investigators said.

“We suggest that in the majority of the cases these decisions are driven by the enthusiastic approach of the treating physician or in some cases strong patient wishes to try the immunotherapy with anticipation that immunotherapy will be less toxic and better tolerated as compared to chemotherapy.”

They said there were no clear guidelines to help choose which patients with poor PS were suitable for immunotherapy.

Lead investigator Dr Nazim Abbas, from the Flinders Medical Centre, told the limbic there were cost implications as well.

However the study highlighted the need for careful consideration of individual patient factors.

“So a patient can have a poor PS and be bed bound because of knee pain from infection. It’s ECOG 3 at least with limited mobility but in reality once the infection settles down then the patients will have a better PS.”

“If there are some reversible conditions that are impairing patients’ ability to function at an acceptable level, that needs to be assessed on an individual basis.”

“In elderly patients particularly, geriatric assessment can be done to optimise their care. That includes for example, rationalising polypharmacy and work on optimising care for conditions such as heart failure or diabetes.”

Dr Abbas said clinicians were in a difficult situation in some cases.

“As a treating doctor, you feel you have to give something to the patient and we are quite enthusiastic about immunotherapy being new and with less side effects. And the patient always wants something.”

He said it was easier to make decisions about chemotherapy, partly due to risk stratification tools such as G8 and CARG.

“We don’t have good tools to assess fitness for immunotherapy at this stage.”

The study found 21% of patients died within 30 days of their last nivolumab dose.

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