Doctors delaying immunotherapy

[Shane18]

Hi, my father has been diagnosed with Stage III (A/B) squamous NSCLC with PD-L1 expression >50%.  Surgery is apparently not an option at this point.  We just heard word from the radiologist that they are prescribing radiation and chemo first before administering any immuno drug (Pembrolizumab or Atezoliazumab) even though both drugs have been approved by Health Canada as a first line treatment and as combination therapy with chemo and/or radiation.  

Is there any reason (besides cost consideration by the government) that the initial treatment would also not include the immuno therapy right off the bat?  We were in high spirits when the biomarkers came back with PDL1 >50% but we are kind of baffled why we would not also be receiving the immuno therapy as well.  The response we are getting from the doctors was that they were "following the guidelines of Health Canada".

Is there anything more we can be doing in this situation?  

Thanks,
Shane

[Rower Michelle]

Hi Shane,

I totally understand any concern about government administered health benefit plan coupled with the reputation for cost containment.  I'm sorry your Dad has this diagnosis.  From what I can see, the doctors are actually being very aggressive with appropriate treatment.  

Stage III NSCLC is actually pretty rare as there are no symptoms most people are diagnosed at Stage IV.  In Stage III cancers, the goal of standard of care is with curative intent hitting the cancer hard with chemo/radiation first followed by any maintenance therapy such as targeted (pills) or immunotherapy.  

The PDL expression is not always a guarantee cancer will respond to immunotherapy when there is less than 90%.  There's even less evidence about the efficacy of immunotherapy in squamous cell lung cancer.  

It sounds like your Dad's team has made the best recommendation for aggressive treatment.  You can always request a second opinion.  

Michelle 

[Tom Galli]

Shane,

Agree with Michelle.  For Squamous cell NSCLC, conventional chemo (platinum doublet) and fractional radiation are still a very powerful treatment and the US standard of care (read Stage IIIA) for non surgical treatment. Radiation is the killing agent while chemo sweeps the blood and lymphatic system of cells. In 2016, I wrote this lament about the lack of new treatments for Squamous cell. The world has changed dramatically with the introduction of immunotherapy.  But if your dad's tumor is a single mass or closely spaced nodules, conventional fractional radiation (normally 30 sessions administered M-F for 6 weeks) can be curative.  However, this type of radiation can only be administered once. The problem with Squamous cell was what to do if a single cell survives this assault because it has likely mutated against the conventional chemo.  Immunotherapy and perhaps stereotactic body radiation therapy depending on the surviving nodule's location become the new second wave of treatment and this is saving lives.

Stay the course.

Tom