Tuesday November 9, 2021; 11:41 AM EST
- "I learned as an intern that “no one dies in the ICU without steroids”. Having never seen other than a rare, truly minor toxicity from this strategy this seemed reasonable. But have we now come to a place in oncology where no one should die without receiving immunotherapy?"#
- This is from my NIH fellowship director, Tito Fojo, who is now at Columbia. His editorial (available upon request and on a website that rhymes with buy-tub) references a NYT article that fawned over oncologists giving immunotherapy to anyone and everyone with incurable cancer and no known treatments. Quoth the NYT #
- With the possibility of a dramatic and prolonged response, he (one of the oncologists) said in an interview, “how can you ethically deny this to patients?”#
- How indeed? By simple math. From Fojo's editorial:#
- ��� with “success” currently claimed for an immunotherapy that achieves response rates in the low teens, tumors for which we lack evidence of efficacy are those with single digit or even zero activity – zero or close to zero if we remove the occasional tumor harboring MSI/dMMR alterations. But a recent meta-analysis examined data in 11,328 patients from 114 arms in 73 clinical trials that reported immune-related adverse events (irAE) in cancer patients treated with immune checkpoint inhibitors (ICI).#
- …(Patients) who had one or more grade 3/4/5 irAE, again significantly higher when using an anti-CTLA-4 ICI (21.5%) compared to the rates observed] with anti-PD-1 (7.1%) and anti-PD-L1 (6.3%) ICI (P < 0.001). This is important because it means that in the overwhelming majority of patients we treat in desperation, the likelihood of harm, even important harm, is greater and often much greater than the likelihood of benefit. Do we discuss this with our patients? Do we tell them we are more likely to make the remainder of their short lives worse than of bringing them benefit?#
- We don't.#