Balancing Safety, Cost, and Duration in Immunotherapy for NSCLC: Lauren Antrim, MD

At a recent Institute for Value-Based Medicine® event, Lauren Antrim, MD, a medical oncologist at City of Hope Cancer Center Duarte in California, discussed how clinicians navigate complex decisions around immunotherapy in both adjuvant and advanced non–small cell lung cancer (NSCLC) settings. Antrim highlighted the balance between safety and efficacy when managing immune-related adverse events (irAEs), the importance of individualized risk–benefit discussions, and the emerging need to weigh financial toxicity alongside clinical outcomes. Antrim also reflected on ongoing research, including adaptive trials, that may help define optimal treatment duration and inform strategies for time-limited immunotherapy.

This transcript was lightly edited; captions were auto-generated.

Transcript

How confident are you in stopping therapy in the adjuvant setting should irAEs occur, and what data support such decisions?

In the adjuvant setting, if it's grade III or IV, I'm going to want to probably stop because the package inserts suggest you indefinitely stop. I feel that you can allow for some immunotherapy side effects if a patient has something like a very high PD-L1 or a very aggressive disease. If this patient has a lot of markers that suggest that it's high risk for recurrence, you're going to try to reintroduce immunotherapy again if you can. Ultimately, it is very important to have a discussion of risk and benefits, and the patient should be off of steroids, or at least under [10 mg of prednisone] every day.

In advanced disease, how do we weigh indefinite immunotherapy against financial burden and explore time-limited strategies?

I think financial toxicity is very important, and it's not really studied as often as the other toxicities, and not reported in the adverse events usually on these big studies, and it's something that's really important. That's a consideration that we really need to start taking into account and maybe discussing with patients. Although we never want to give subpar care because of the financial toxicity, I think really investigating ways to allow patients to get the therapies that they need without breaking the bank is very important. I think that being diagnosed with cancer is an extraordinarily hard thing, and to have it and to go undergo treatment is horrible, so there's no reason that we should be causing more stress on patients with insurance hassles, etc. People didn't sign up for cancer. They deserve to be given the best care, and they shouldn't be penalized for it. They did nothing wrong. I think that's something that we need to really take into account now.

In terms of indefinite therapy vs a shorter course, historically, for metastatic setting, the 2-year marker is when we typically stopped immunotherapy. But that really does need to be investigated further. Are there people that after 1 year could potentially stop? Are there people that need more treatment afterwards? The bioimmunotherapy study that we have, or that's coming in the next couple of months, is really going to help investigate if shorter is better or longer is better in certain patients. It's very adaptive, so I think it's going to be very exciting.