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Abstract
Most cancers arise in individuals over the age of 60. As the world population is living longer and reaching older ages, cancer is becoming a substantial public health problem. It is estimated that, by 2050, more than 20% of the world's population will be over the age of 60 - the economic, healthcare and financial burdens this may place on society are far from trivial. In this Review, we address the role of the ageing microenvironment in the promotion of tumour progression. Specifically, we discuss the cellular and molecular changes in non-cancerous cells during ageing, and how these may contribute towards a tumour permissive microenvironment; these changes encompass biophysical alterations in the extracellular matrix, changes in secreted factors and changes in the immune system. We also discuss the contribution of these changes to responses to cancer therapy as ageing predicts outcomes of therapy, including survival. Yet, in preclinical studies, the contribution of the aged microenvironment to therapy response is largely ignored, with most studies designed in 8-week-old mice rather than older mice that reflect an age appropriate to the disease being modelled. This may explain, in part, the failure of many successful preclinical therapies upon their translation to the clinic. Overall, the intention of this Review is to provide an overview of the interplay that occurs between ageing cell types in the microenvironment and cancer cells and how this is likely to impact tumour metastasis and therapy response.
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Affiliation(s)
- Mitchell Fane
- The Wistar Institute, Immunology, Microenvironment and Metastasis Program, Philadelphia, PA, USA.
- Department of Biochemistry and Molecular Biology, Johns Hopkins School of Public Health, Baltimore, MD, USA.
| | - Ashani T Weeraratna
- The Wistar Institute, Immunology, Microenvironment and Metastasis Program, Philadelphia, PA, USA.
- Department of Biochemistry and Molecular Biology, Johns Hopkins School of Public Health, Baltimore, MD, USA.
- Department of Oncology, Johns Hopkins School of Medicine, Baltimore, MD, USA.
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Elias R, Odejide O. Immunotherapy in Older Adults: A Checkpoint to Palliation? Am Soc Clin Oncol Educ Book 2019; 39:e110-e120. [PMID: 31099630 DOI: 10.1200/edbk_238795] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
The excitement about immunotherapy is justified. Patients with advanced disease and limited life expectancy before immune checkpoint inhibitors are now having prolonged and sometimes complete responses to treatment; however, most patients do not respond to checkpoint inhibitors. The hope for a meaningful response with only a limited risk of high-grade toxicity generated a prognostic dilemma for patients with advanced cancers and their treating oncologists. Older adults with advanced cancers are at the intersection of multiple biologic and clinical factors that can influence the efficacy of immunotherapy. Treating physicians should take all of these elements into account when considering treatment options for an older adult with advanced disease. Oncologists should have an honest conversation with their patients regarding the uncertainty around the clinical profile of checkpoint inhibitors. Early high-quality goals of care discussions can help manage expectations of older adults with advanced cancer treated with immunotherapy. We review in this paper select clinical characteristics that are important to consider when evaluating an older adult for checkpoint inhibitor therapy. In addition, we discuss strategies to optimize goals of care discussion given the increasing complexity of prognostication in the immunotherapy era.
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Affiliation(s)
- Rawad Elias
- 1 Hartford HealthCare Cancer Institute, Hartford Hospital, Hartford, CT
| | - Oreofe Odejide
- 2 Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
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Elias R, Hartshorn K, Rahma O, Lin N, Snyder-Cappione JE. Aging, immune senescence, and immunotherapy: A comprehensive review. Semin Oncol 2018; 45:187-200. [PMID: 30539714 DOI: 10.1053/j.seminoncol.2018.08.006] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 07/07/2018] [Accepted: 08/01/2018] [Indexed: 12/22/2022]
Abstract
The advent of immune checkpoint inhibitors (ICIs) has changed the landscape of cancer treatment. Older adults represent the majority of cancer patients; however, direct data evaluating ICIs in this patient population is lacking. Aging is associated with changes in the immune system known as "immunosenescence" that could impact the efficacy and safety profile of ICIs. In this paper, we review aging-associated changes in the immune system as they may relate to cancer and immunotherapy, with mention of the effect of chronic viral infections and frailty. Furthermore, we summarize the current clinical evidence of ICI effectiveness and toxicity among older adults with cancer.
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Affiliation(s)
- Rawad Elias
- Hartford HealthCare Cancer Institute, Hartford Hospital, Hartford, CT, USA.
| | - Kevan Hartshorn
- Section of Hematology Oncology, Boston University School of Medicine, Boston, MA, USA
| | - Osama Rahma
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Nina Lin
- Department of Medicine, Boston Medical Center, Boston University School of Medicine, MA, USA
| | - Jennifer E Snyder-Cappione
- Department of Microbiology, Boston University School of Medicine, Boston, MA, USA; Flow Cytometry Core Facility, Boston University School of Medicine, Boston, MA, USA
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Sacco PC, Maione P, Palazzolo G, Gridelli C. Treatment of advanced non-small cell lung cancer in the elderly. Expert Rev Respir Med 2018; 12:783-792. [PMID: 30092728 DOI: 10.1080/17476348.2018.1510322] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Lung cancer is predominantly a disease that affects the elderly; about 30-40% of lung cancers are diagnosed in patients aged 70 or more. The increasing number of elderly patients over the next decades is generating a new social and health problem; despite that, these patients are underrepresented in clinical trials and undertreated in clinical practice. Areas covered: The main difficulty in treating elderly patients is to maximize the therapy benefits while minimizing the treatment risk. Elderly patients show a vulnerable clinical profile due to the higher prevalence of comorbid disease, higher polypharmacy interactions and aged organ dysfunction that increase the risk of mortality and toxicity with cancer treatments compared to younger patients. Expert commentary: The choice to treat or not to treat elderly patients cannot be taken only on the basis of the chronological age. Thus, the clinical approach should be to select patients who are effectively suitable for treatment having a better individual functional reserve and a better life expectancy. Elderly patients are a heterogeneous population and those who are fit to receive cancer treatment can be treated similarly to younger patients.
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Affiliation(s)
- Paola C Sacco
- a Division of Medical Oncology , "S.G.Moscati" Hospital , Avellino , Italy
| | - Paolo Maione
- a Division of Medical Oncology , "S.G.Moscati" Hospital , Avellino , Italy
| | | | - Cesare Gridelli
- a Division of Medical Oncology , "S.G.Moscati" Hospital , Avellino , Italy
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Ferrara R, Mezquita L, Auclin E, Chaput N, Besse B. Immunosenescence and immunecheckpoint inhibitors in non-small cell lung cancer patients: Does age really matter? Cancer Treat Rev 2017; 60:60-68. [DOI: 10.1016/j.ctrv.2017.08.003] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 08/05/2017] [Accepted: 08/09/2017] [Indexed: 01/04/2023]
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Abstract
Cancer is primarily a disease of older adults. The treatment of advanced stage tumors usually involves the use of systemic agents that may be associated with significant risk of toxicity, especially in older patients. Immune checkpoint inhibitors are newcomers to the oncology world with improved efficacy and better safety profiles when compared to traditional cytotoxic drugs. This makes them an attractive treatment option. While there are no elderly specific trials, this review attempts to look at the current available data from a geriatric oncology perspective. We reviewed data from phase III studies that led to newly approved indications of checkpoint inhibitors in non-small cell lung cancer, melanoma, and renal cell cancer. Data were reviewed with respect to response, survival, and toxicity according to three groups: <65 years, 65-75 years, and >75 years. Current literature does not allow one to draw definitive conclusions regarding the role of immune checkpoint inhibitors in older adults. However, they may offer a potentially less toxic but equally efficacious treatment option for the senior adult oncology patient.
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Pluchart H, Pinsolle J, Cohen J, Ferretti GR, Bedouch P, Giaj Levra M, Toffart AC, Moro-Sibilot D. Partial response of pulmonary adenocarcinoma with symptomatic brain metastasis to nivolumab plus high-dose oral corticosteroid: a case report. J Med Case Rep 2017; 11:183. [PMID: 28679408 PMCID: PMC5499003 DOI: 10.1186/s13256-017-1334-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Accepted: 05/26/2017] [Indexed: 11/21/2022] Open
Abstract
Background Nivolumab, a monoclonal antibody targeting the programmed death-1 receptor, is indicated in locally advanced or metastatic non-small cell lung cancer, with progression after platinum-based chemotherapy. Up-to-now, few data are available concerning brain activity of this treatment and concomitant use of corticosteroids. Case presentation A 64-year-old caucasian man with a pulmonary adenocarcinoma associated with brain metastases received four courses of nivolumab in concomitance with a high dose of corticosteroids for his neurologic symptoms. He experienced a partial response in his brain and chest with an improvement in his general condition. Nivolumab was effective in shrinking symptomatic brain metastases, and metastases at other sites, in a patient with non-small cell lung cancer and first-line chemotherapy failure. The effect of nivolumab was obtained despite concomitant high-dose corticosteroid therapy. Combined nivolumab and high-dose corticosteroid therapy did not induce unexpected adverse events. Conclusion Nivolumab and concomitant high-dose corticosteroid therapy was found to be efficient and well tolerated.
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Affiliation(s)
- Hélène Pluchart
- Pôle pharmacie, CHU Grenoble Alpes, CS 10217, 38043, Grenoble, France.
| | - Julian Pinsolle
- Clinique Universitaire de Pneumologie, Pôle Thorax et Vaisseaux, CHU Grenoble Alpes, CS 10217, 38043, Grenoble, France
| | - Julien Cohen
- Pôle radiologie et imagerie médicale, CHU Grenoble Alpes, CS 10217, 38043, Grenoble, France
| | - Gilbert R Ferretti
- Pôle radiologie et imagerie médicale, CHU Grenoble Alpes, CS 10217, 38043, Grenoble, France
| | - Pierrick Bedouch
- Pôle pharmacie, CHU Grenoble Alpes, CS 10217, 38043, Grenoble, France.,Université Grenoble Alpes/CNRS, ThEMAS TIMC UMR 5525, Grenoble, F-38041, France
| | - Matteo Giaj Levra
- Clinique Universitaire de Pneumologie, Pôle Thorax et Vaisseaux, CHU Grenoble Alpes, CS 10217, 38043, Grenoble, France
| | - Anne-Claire Toffart
- Clinique Universitaire de Pneumologie, Pôle Thorax et Vaisseaux, CHU Grenoble Alpes, CS 10217, 38043, Grenoble, France.,Institut pour l'Avancée des Biosciences, CRI UGA/Inserm U 1209/CNRS UMR 5309, Grenoble, France
| | - Denis Moro-Sibilot
- Clinique Universitaire de Pneumologie, Pôle Thorax et Vaisseaux, CHU Grenoble Alpes, CS 10217, 38043, Grenoble, France.,Institut pour l'Avancée des Biosciences, CRI UGA/Inserm U 1209/CNRS UMR 5309, Grenoble, France
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Sgambato A, Casaluce F, Gridelli C. The role of checkpoint inhibitors immunotherapy in advanced non-small cell lung cancer in the elderly. Expert Opin Biol Ther 2017; 17:565-571. [PMID: 28276698 DOI: 10.1080/14712598.2017.1294157] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Immune checkpoint inhibition is a novel treatment modality that has brought a new hope to patients with advanced NSCLC. Several molecules targeting cytotoxic T-lymphocyte antigen 4 (CTLA4) or programmed cell death 1 receptor/programmed death ligand-1 (PD1/PD-L1) pathways are under evaluation in NSCLC and three of them are currently approved: nivolumab and atezolizumab for advanced NSCLC after prior chemotherapy and pembrolizumab for advanced NSCLC expressing PD-L1 ≥ 1% after at least one prior chemotherapy regimen and > 50% as a first-line response. Areas covered: To date, the efficacy and toxicity of immune checkpoint inhibitors in the elderly is unclear because available studies involved mainly a low number of elderly patients. In this paper, the authors discuss the frailty of the elderly patient and the challenges of choosing the best therapeutic strategy, focusing on the role of immune checkpoint inhibitors. Expert opinion: There are several outstanding goals that need to be met for the proper and safe use of immunotherapeutic drugs. In terms of the elderly, it is true that age-tailored clinical trials are needed to confirm the real impact of immunotherapy and harmonize the standard of care in this specific demographic.
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Affiliation(s)
- Assunta Sgambato
- a Division of Medical Oncology , 'S. G. Moscati' Hospital , Avellino , Italy
| | - Francesca Casaluce
- a Division of Medical Oncology , 'S. G. Moscati' Hospital , Avellino , Italy
| | - Cesare Gridelli
- a Division of Medical Oncology , 'S. G. Moscati' Hospital , Avellino , Italy
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Pericardial effusion with tamponade physiology induced by nivolumab. Int J Cardiol 2016; 222:613-614. [PMID: 27517649 DOI: 10.1016/j.ijcard.2016.08.023] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Accepted: 08/02/2016] [Indexed: 01/16/2023]
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