Cancer immunotherapy in special challenging populations: recommendations of the Advisory Committee of Spanish Melanoma Group (GEM)

Abstract

Cancer immunotherapy based on the use of antibodies targeting the so-called checkpoint inhibitors, such as programmed cell death-1 receptor, its ligand, or CTLA-4, has shown durable clinical benefit and survival improvement in melanoma and other tumors. However, there are some special situations that could be a challenge for clinical management. Persons with chronic infections, such as HIV-1 or viral hepatitis, latent tuberculosis, or a history of solid organ transplantation, could be candidates for cancer immunotherapy, but their management requires a multidisciplinary approach. The Spanish Melanoma Group (GEM) panel in collaboration with experts in virology and immunology from different centers in Spain reviewed the literature and developed evidence-based guidelines for cancer immunotherapy management in patients with chronic infections and immunosuppression. These are the first clinical guidelines for cancer immunotherapy treatment in special challenging populations. Cancer immunotherapy in chronically infected or immunosuppressed patients is feasible but needs a multidisciplinary approach in order to decrease the risk of complications related to the coexistent comorbidities.

Keywords: immunotherapy.

Figure 1

Diagram of management of HIV-1-infected patient candidates for immunotherapy. ART, antiretroviral therapy; cART, combination antiretroviral therapy; pVL, plasma viral load.

Figure 2

Diagram of clinical management of viral hepatitis-infected patient candidates for immunotherapy. ALT, alanine aminotransferase blood levels; DAA, direct-acting antiviral agents; HBsAg, hepatitis B surface antigen; HBV, hepatitis B virus; HCV, hepatitis C virus; NUCs, nucleoside or nucleotide analogs; PD-1, programmed cell death-1; PD-L1, programmed cell death-1 ligand.

Figure 3

Diagram of TB screening and treatment of patient candidates for immunotherapy. IGRA, interferon gamma release assay; IO, Immunotherapy; LTBI, latent tuberculosis; PD-1, programmed cell death-1; PD-L1, programmed cell death-1 ligand; PE, physical examination; TB, tuberculosis; TST, Mantoux tuberculin skin test.

Figure 4

Diagram of immunotherapy management of patients with previous solid organ transplants. *Consider immunotherapy for patients with cancer histologies with high chances of responding to immunotherapy and in patients with good PS and no other comorbidities. PS, performance status; SOTRs, solid organ transplant recipients.