Abstract
Introduction: Earlier this year, nivolumab, a fully human IgG4 anti–programmed death-1 (PD-1) immune checkpoint inhibitor antibody, gained approval for advanced-stage squamous-cell lung cancer in patients whose disease progressed after treatment with platinum-based chemotherapy. Survival advantages demonstrated in clinical trials led to its early approval. Management of patients receiving immuno-oncology (I-O) agents such as PD-1 checkpoint inhibitors can be challenging. Many of these patients have COPD and other comorbid conditions, making it difficult to identify side effects specific to PD-1 pathway checkpoint inhibitors. Description: Initial and ongoing management of patients with COPD and lung cancer should include thorough evaluation and collaboration with a pulmonary team, early identification and severity staging of COPD, maximization of controller medications, up-to-date vaccinations, and prompt intervention for respiratory tract infections (eg, bronchitis, pneumonia, infectious pneumonitis). Global Initiative for Chronic Obstructive Lung Disease guidelines support pulmonary rehabilitation, smoking cessation programs, regular follow-up with a pulmonary team, and avoidance of long-term oral corticosteroids. While it is not known if steroids suppress antitumor activity, it is important to identify early and manage appropriately all immune mediated adverse events, including COPD exacerbation. Further exploratory studies are needed to assess how steroids used to treat immune-mediated adverse events or COPD exacerbations impact efficacy. Oncology and pulmonary nurse practitioners and physician assistants can provide important education to lung cancer patients with COPD regarding I-O therapies. It is essential for patients to understand the mechanism of action of I-O therapies, the differences in side effects compared with traditional chemotherapy, and the importance of managing comorbid conditions to maintain underlying health and therapy administration. These patients should undergo pulmonary evaluation before initiation of therapy. Consistent follow-up and collaboration with both oncology and pulmonary teams is the key to optimizing therapy for patients with lung cancer and underlying COPD, particularly given the importance of differentiating I-O–related pneumonitis from infectious pneumonitis in this population. Collaboration across both teams on the use of oral steroids for any reason is critical. Summary: Comprehensive management of comorbid pulmonary conditions such as COPD is necessary for patients to fully benefit from I-O therapy. While nivolumab is the first I-O therapy available to patients with advanced-stage squamous non–small cell lung cancer, other promising I-O therapies for lung cancer patients are in development, making this a hopeful time for patients with metastatic lung cancer.
