ICI for NSCLC with comorbid IP; a prudent stance required

What is it about?

Letters sent in response to the manuscript entitled “Immune checkpoint blockade for patients with lung cancer and idiopathic pulmonary fibrosis” by Duchemann B, et al in the March issue of the European Journal of Cancer (Eur J Cancer. 2021 Jan 21;145:179-182. doi: 10.1016/j.ejca.2020.12.016.).

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Photo by Sara Bakhshi on Unsplash

Photo by Sara Bakhshi on Unsplash

Why is it important?

In the article entitled “Immune checkpoint blockade for patients with lung cancer and idiopathic pulmonary fibrosis” by Duchemann B, et al in the March issue of the EJC, the authors reported their experience using immune checkpoint inhibitor (ICI) in six non-small cell lung cancer (NSCLC) patients with comorbid idiopathic pulmonary fibrosis (IPF), and concluded that the option of ICIs in NSCLC patients with comorbid IPF should be investigated. However, we believe that the discussion in the article is inadequate, and that this conclusion risks misleading the reader, especially for the following two reasons. Firstly, the results of several studies have shown that the presence of comorbid interstitial pneumonia (IP), even if it’s mild or subtle, increases the frequency of ICI-induced pneumonitis. These data should be presented properly so that oncologists do not neglect the evaluation of comorbid IP. Secondly, it has been suggested that, among the various types of IP, IPF with honeycomb lungs on CT has a particularly high risk of fatal pneumonitis induced by ICI. We are concerned that this article by Duchemann B, et al. did not consider that there may be differences in the risk of developing pneumonitis depending on the severities, subtypes, and specific radiological findings of pre-existing IP. Most of the previous reports on NSCLC with comorbid IP have been in the Japanese population. As mentioned by Duchemann B, et al, there are racial differences in the incidence of EGFR-TKI-induced interstitial lung disease and acute exacerbation of IPF. However, there is no data that the incidence of ICI-induced pneumonitis differs by race. Therefore, the prospective clinical trial of ICI for NSCLC with comorbid IP should be recognized as high risk, even if the target patients are mainly Caucasian.

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