REVOLUTION CHANGING HOW DOCTORS THINK
WHAT SORT OF DRUG IS IT?
IT IS a form of immunotherapy that can considerably extend the life of patients. Rather than kill healthy cells along with cancer cells, as chemotherapy does, immunotherapy harnesses the immune system to attack the cancer.
‘Nivolumab works by targeting and blocking a protein called PD-L1 found on the surface of T-cells, a form of immune cell which fight infections,’ says Professor Christian Ottensmeier, a Consultant Medical Oncologist and Professor of Experimental Cancer Medicine at Southampton University.
‘This activates T-cells, which are put to sleep by cancer, so they start fighting it.’ T-cells perforate cancer cells and ‘blow them up,’ shrinking the tumour.
WHO IS IT AVAILABLE FOR?
NOT many. Nivolumab has been given to only 10,000 people worldwide. For while it can work well for some — it was licensed for use in the UK for lung cancer after trials that found that the survival rate after a year was nearly double that compared with chemotherapy in some patients — the cost means it has yet to be approved by NICE, the NHS body who approves drugs on the basis of value for money as well as efficacy.
So although it is licensed, i.e. passed as safe and effective for patients with skin cancer, advanced kidney cancer and lung cancer, it has only been approved by NICE for patients with advanced melanoma (a type of skin cancer). For other cancers, such as lung cancer, patients could apply for NHS funding or pay for it privately.
WHO DOES IT WORK FOR?
THE drug currently works for between 20 and 30 per cent of people with nonsmall-cell lung cancer, and for a similar proportion of melanoma and kidney cancer patients — although the evidence seems stronger for skin cancer.
‘Each person will have a different response but, in trials, lung cancer patients taking nivolumab who had more PD-L1 on their cancer cells lived up to seven months longer than those
with less. Very importantly, more patients were alive several years after treatment ended,’ says Prof Ottensmeier. Other forms of immunotherapy can be even more effective. Pembrolizumab was approved by NICE after doctors described its shrinking of skin cancers as ‘jaw-dropping’. In trials, it was found to be twice as effective as chemo in patients with malignant melanoma. This month it was also approved by NICE for lung cancer.
HOW DO SIDE-EFFECTS DIFFER?
UNLIKE chemotherapy, nivolumab does not make your hair fall out or make you sick and it doesn’t affect your blood count or make you vulnerable to infections. However, it can cause tiredness, a rash and diarrhoea and it can cause inflammation of internal organs. In 10 per cent of patients, the side-effects of nivolumab can be life-threatening.
WHY ISN’T IT AVAILABLE FOR ALL?
NICE has ruled that while it is cost-effective for melanoma and kidney cancer patients (this is still a draft recommendation), it is not cost-effective for lung cancer patients.
However, NICE is currently reviewing the drug for lung cancer, head and neck cancer, brain cancer and Hodgkin’s Lymphoma. It costs around £60,000 to £100,000 a year — around four times the cost of chemotherapy.
HOW CAN I GET IT?
IF IT is not available for your condition on the NHS, you can pay for it privately at a cost of between £60,000 and £100,000 a year, or you may be able to get it through your private health insurance.
WHY IS IT SO EXPENSIVE?
WHILE the cost of developing a new cancer drug is huge — to take a drug to trial can cost £50 million to £100 million — as it is one of the only treatments that is useful for skin cancer and showing promising results for other types of cancers too, there is little competition.
IN WHAT FORM IS IT GIVEN?
IT IS given intravenously every two weeks. In trials the drug has been stopped if the cancer disappeared, the patient suffered side-effects, or the cancer got worse after two years.
IS IT BEING TESTED FOR ANYTHING ELSE?
IT IS being tested for a range of cancers.
IS IMMUNOTHERAPY THE FUTURE FOR CANCER TREATMENT?
YES. ‘These are revolutionary drugs that are changing the way we think about and treat cancer,’ says Professor Ottensmeier. However, it doesn’t work for all patients.
WHY CAN IT WORK WHEN OTHER DRUGS DON’T?
IT USES a completely different approach to chemotherapy and radiotherapy. As it uses the body’s own immune system cancer cells will not become resistant to it as is often the case with chemotherapy.
WHY DOES IT WORK FOR SOME CANCERS AND NOT OTHERS?
AT THE moment, scientists don’t really know why it works better for some cancers than others, and some patients than others.
Everybody responds differently because we are all unique but hopefully over time this will be understood better.
CAN IT MAKE OTHER DRUGS MORE EFFECTIVE?
YES, scientists believe it makes chemotherapy, cancer vaccines and radiotherapy more effective because it makes the immune system alert and ready to fight disease.
WHAT IS THE NEXT GREAT HOPE FOR IMMUNOTHERAPY?
AT THE moment only around a third of patients respond to immunotherapy. The hope is to increase that to 50 per cent and then higher in the future with more research.