Episode 9: Continuous treatment with immunotherapy does not improve OS in metastatic NSCLC patients

In this episode of WND, Prof Johan Vansteenkiste from University Hospitals Leuven and Prof Mariana Brandao, a medical oncologist at Institut Jules Bordet in Brussels, explore the optimal duration of immunotherapy for metastatic NSCLC patients.

Immunotherapy shows benefits across all stages of NSCLC. Determining the optimal treatment duration is crucial due to its potential toxicity and cost but remains challenging without clear guidelines from clinical trials. While one-year durations are common in non-metastatic stages, the majority of patients have stage four disease. Early trials in the second-line treatment phase continued until progression. The approach changes in first-line treatment, where durations in clinical trials currently are limited to a maximum of two years. However, in real-world practice, the absence of clear clinical guidance leads to treatment continuation until progression.

A retrospective cohort study involving 706 patients compared those who ceased immunotherapy after two years without progression with those who continued indefinitely. The primary endpoint, OS from day 760 (the cessation of fixed immunotherapy treatment), revealed that while a majority of patients (593 versus 113) continued immunotherapy, there was no significant difference in OS between the two groups. Four years post-treatment, 80% of patients remained alive, regardless of whether they discontinued treatment at the two-year mark.

Experts view this as a compelling rationale to cease immunotherapy after two years if the patient’s condition remains favourable. Alongside the toxicological and financial burdens on the healthcare system, prolonged immunotherapy usage may lead to late immune toxicity, impacting quality of life. Therefore, limiting treatment duration is advisable.

In clinical practice, it’s crucial to inform patients that treatment will be capped at two years. Upon reaching this milestone, patients should undergo imaging to confirm remission, including a brain scan via CT or MRI.

Both experts agree on the importance of continuous reevaluation, as there may be an opportunity to shorten treatment duration without impact on efficacy outcomes.