|LETTER TO EDITOR
|Year : 2021 | Volume
| Issue : 3 | Page : 585-587
Authors' reply to Sahoo, Veniyoor, and Vora
George M Abraham1, Vanita Noronha1, Kumar Prabhash2
1 Tata Memorial Centre, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
2 Department of Medical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
|Date of Submission||30-Aug-2021|
|Date of Acceptance||04-Sep-2021|
|Date of Web Publication||08-Oct-2021|
Professor and Head, Department of Medical Oncology, Tata Memorial Hospital, Mumbai
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Abraham GM, Noronha V, Prabhash K. Authors' reply to Sahoo, Veniyoor, and Vora. Cancer Res Stat Treat 2021;4:585-7
We thank Sahoo, Veniyoor, and Vora for their insightful comments on our article on the use of immunotherapy in older patients with cancer, and the accompanying editorial.,,,,
We agree with Sahoo that aging and immunosenescence is a continuous process and we lack data on the efficacy and safety of immune checkpoint inhibitors (ICIs) in the older population, especially those aged 75 years or older. There were only 15 patients (10%) in our dataset who were 75 years of age or older and had received ICI. Of note, we did not exclude any patients based on advanced age, and thus, our study mirrors the real-world practice in India. Further subset analysis on progression-free survival and overall survival in these patients would be futile in view of the low numbers. Most of the national programs and governmental policies have adopted the age cutoff of 60 years and older as the definition of “elderly” in India., This could be because of the early aging patterns and shorter longevity of the Indian population when compared to Western population. In our geriatric oncology clinic at the Tata Memorial Hospital, Mumbai, India, we also follow the age cutoff of 60 years and over to define the geriatric age group.
We agree with Sahoo that the efficacy of single-agent immunotherapy in driver mutation-positive non-small cell lung cancer is doubtful. Our understanding of the limited efficacy of immunotherapy in oncogene-addicted lung cancers has evolved over time. Patients in our dataset who had driver mutation-positive lung cancer and received nivolumab therapy after progression on first-line tyrosine kinase inhibitors were those who could not tolerate chemotherapy due to poor performance status or the presence of comorbidities such as chronic kidney disease or coronary artery disease. In these patients, the therapeutic options were limited, and some series have reported the benefits of ICI therapy offered on a compassionate basis.
We also agree with Sahoo that the most important prognostic factor for progression-free survival and overall survival in our older patients who received ICI therapy was the Eastern Cooperative Oncology Group performance status at the start of therapy; the other factors such as age (as a continuous variable), male sex, and chronic kidney disease had wide confidence intervals and require further validation in prospective studies.
We concede that there was an inherent selection bias in our retrospective study with regard to the type of patients who received ICI, but this is in coherence with the real-world scenario; ICI and other expensive therapies are accessible and feasible only for a small subset of the population (financial feasibility or credit availability for expensive drugs) at all centers across India. This is the harsh reality, and so far, we have very limited data on the accessibility of ICI in low- and middle-income countries. We completely agree with Veniyoor regarding the need to obtain data from the community level as well, which may better reflect the real-world scenario – we hope that other centers will come forward to fill this gap. Polypharmacy in older patients is a complex issue, with a network of drug interactions which may potentiate or hinder the efficacy of ICI use and needs further prospective data looking at the interactions of each class of drugs or comorbidities separately.
Geriatric oncology care is an emerging specialty, and it is heartening the note that newer trials such as JAVELIN 100 and KEYNOTE 024 had greater representation of older patients. Nivolumab was the first ICI available in India, and in view of the better accessibility and patient assistance programs, the majority of the patients in our dataset received nivolumab. However, there is a changing trend toward an increased use of pembrolizumab, especially after its approval in the first-line setting in metastatic non-driver-mutated NSCLC as per the KEYNOTE 189, KEYNOTE 407, and KEYNOTE 24 trials and head-and-neck cancer as per the KEYNOTE 48 study. In our study, among the patients who attained a complete remission (n = 12), 8 patients (75%) were alive and had not progressed till the last follow-up date. We agree with Vora that pseudoprogression was possibly underreported due to the retrospective nature of the study. 
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Conflicts of interest
There are no conflicts of interest.
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