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Role of Immunotherapy in Cancer

Dec 14 | 1:30 PM

Immunotherapy, activating the bodys immune system to initiate or enhance its anti-tumor activity, has become a potent tool in the physicians armory against cancer. The use of immune checkpoint inhibitors and monoclonal antibodies has radically altered the landscape of cancer treatment worldwide. With the constantly evolving body of literature in oncology, the physicians role in understanding how immunotherapy fits into their cancer treatment plan has never been higher. To further understand the role of immunotherapy in the clinical setting and the conditions suitable for its use, join Dr. Meenu Walia as she explores these pressing issues live on Medflix!

[Music] good evening everyone i am doctor and on behalf of team netflix i welcome you all for today's session today we have with us uh inspiring personality dr minovalia mom is a renowned cancer specialist with almost 30 years of experience in treating cancer patients she is the first dnb medical oncologist of india mam has won several awards to name a few bharat jyothi award medical excellence awards inspiring healthcare leaders dronacharya award she is the author of a hugely popular book among cancer patients tips for happiness in the shadow of cancer she has also been aborted as the most influential woman of 2021 and is featured amongst the nine successful women by the outlook maxine a very warm welcome ma'am over to you ma'am thank you for have so without wasting much time i think we start with today's topic so what i am going to talk about is immunotherapy for cancer we know that that with various metastatic solid cancers the five survival in spite of all and everything that we have done continue to remain poor for a very very long time and there is a need for newer treatments near therapeutic modalities for these patients and here is where immuno oncology found its way so immuno oncology therapies are being investigated in an attempt to fill the unmet need for improving the clinical outcomes in various cases ah before i begin let's have a look at all the traditional cancer therapies that we had so far so uh the various cancer therapies that we had the focus on cancer on cancer treatment had been for a very very long time on the local therapies so surgery was the prototype of all the cancer therapies then came radiation and it took almost 100 years before the systemic therapies found its way into the treatment of cancer with chemotherapy being the prototype of these systemic therapies and from there we now have come a very very long way we have immunotherapy that kept in and then targeted an immuno oncology and what not a whole spectrum of systemic therapies are now available and used in the treatment of cancer now that we realize that cancer is a systemic disease is very much a systemic disease even in the early stages of the disease so amino oncology is an emerging therapeutic modality which uses body's own immune system to fight diseases and to fight in this relevance we say to fight cancer so history of immunotherapy again dates back to long time back when possibly in 1796 with the first use of immunotherapy in the form of small fox vaccine and we know the entire management of diseases have undergone a sea change after that it was in 1863 that the first connection between immunotherapy and cancer was recognized and having said that it took almost another 100 years before immunotherapy actually be used for cancer so bcg vaccine that was used for various bladder cancers was one of those prototypes the initial use of immunotherapy for cancer treatment and from that yes we know that we have come again come a very very long way we had interferons then interleukins and then various monoclonal antibodies and now the pd1 and pdl1 and ctla4 inhibitors so as early as the 18th century doctors they notice that these cancer patients patients suffering from solid cancers who had these lumps and tumors after they developed fever from various infections there was some regression in these tumor masses and this led to the idea that the immune system which protects the body from infection might also be i might also fight cancer so the first attempt at immunotherapy came in the early 1890s when the new york surgeon musculoskeletal surgeon william coley he started he came out with his concoction which he named a mixed bacterial vaccine which was basically bacterial cultures or police toxin that he named and he started using in cancer patients so william cawley got interested when he uh when he when he lost a young girl who had one of his patients who died from metastatic sarcoma and he became interested in using immunotherapy for cancer patients and thereafter he injected this mbv or the police toxin in a series of more than 100 cancer patients and he claimed that at that point of time these results were published also and it was claimed that means in some of these patients beautiful responses were also seen so from that today we have come a very very long way and before i come to immunotherapy let's have a look at how does the immune system function and what are the basic immune systems that is there in our body so we have innate humility and adaptive immunity and what is the basic function of the immune system the basic function is to identify and destroy anything which is foreign or abnormal in our body so innate immunity is something which is non-specific or the first line of defense against the foreign particles it may be the the white blood cells the natural killer cells the various neutrophils and it has got an important role in the activation of adaptive immunity or adaptive risks so the adaptive immunity is something which develops over a period of time which is much more specific and it adapts specifically to the specific stimulus and it may include the b cell antibody produces it has includes both the b and this b cell antibody production as well as the t cell the t cell stimulation and it all and memory functions also have a role to play so immune surveillance of a body in short involves both innate and adaptive immune mechanisms and tumor associated antigens can be identified with these immune systems and immune mechanisms and the goal of immunotherapy for cancer is to unleash this to these immune systems of the body to educate them to recognize the cancer cells and generate immune responses against them so adapting immune response as we understand it will take time to develop so it is a multi-step process so it will require initial antigen recognition and then uh stimulation of the t cells and then clonal expansion differentiation and once the cell activation happens for the affected t cells and then comes the role of antigen elimination and it may also involve uh stimulation of the t cells and apart from that it also involves both humeral immunity where b cells are activated to produce antibodies and as well as cell mediated dominicity from the activated t cells and also there is some role of the surviving cells they do for some role of the surviving cells to develop memory for these adaptive immune responses so it was as simple as that let's see how it happens in the cancer in the tumor micro environment the tumor cells they express antigens on the surface they release these antigens these antigens are picked up by the antigen presenting cells and once these antigen presenting cells ah present these antigens to the uh cytotoxic t cells of the body to the helper and the titan toxic sea cells of the body it activates the both cell mediated humidity as well as human immunity and these cytotoxic pieces then there is a clonal proliferation and they migrate to the tumor site and help in the tumor cell kit however if we zoom in these processes so these are different steps so first step is the antigen recognition so the antigen the tumor cells which secrete antigens or express antigens on the surface these antigens are picked up by the antigen presenting cell and these are recognized with the help of with the help of msc complex and presented to the t cells with the help of this msc complex that is major histo compatibility complex and apart from the antigen presentation to the c to the t cell there are occurs a lot of core stimulation of other signals also like b7 cd28 is an important co-stimulatory uh pathway and what are the consequences of activation of the cytotoxic t cells the consequences of activation of the t cells is proliferation of the t cells cytokine production are by the t cells and yes uh the tumor cell uh kill that may occur so induction of t cell responses to tumors the induction of all these t cell activation may release may help in release of cytokines activation of the cytotoxic t cells and finally possibly the death of the tumor cell if the processes were so simple then why is it doesn't happen in all the cases where tumors develop so we know that tumors tumors fill up in spite of uh in spite of having intact immune responses in our body why because tumors they use various complex and frequently overlapping mechanisms to escape the immune system so where all things can go wrong what are the different mechanisms that you must use so at each and every step for example there may be some inhibition of tumor antigen presentation in the form of down regulation of major histocompatibility complex or the tumor cells itself may be secreting various immunosuppressive factors or recruiting the t-rex or the immunosuppressive cell types which cause which incapacitate the activated t cells or down or checks the action of the activity thesis and last but not the least the breaks to put brakes on the activated t-cells that is the various checkpoint pathways the inhibition of attack on the tumor cells by the activated diesels so these are the various mechanisms which the tumor cells can use and do use to suppress the immune system so when we talk about immuno oncology strategies so when we talk about the way these are the lacunae these are the opportunities where immuno oncology can be used so where all we can use immuno oncology we can either prime or boost the immune system or enhance the inlet humidity or possibly try to reduce immunosuppression in the tumor micro environment or the maximum opportunity that we see today is and that is being used isn't modulating the t cell function so in other words to make it simple so immuno oncology may either involve active or savability so active it can be enhancing the immune cell function or the use of therapeutic vaccines or modulation of t cell function or anti-tumor are passive in the form of either anti-tumor monoclonal antibodies or adoptive cell transfer so going further so these approaches the one active the important role of active immunization to enhance anti-tumor reaction is cancer vaccines so cancer vaccines there are two major types of cancer vaccines it can be the preventive vaccines like human papilloma or hepatitis we welcome or treatment vaccine like civilian safety and we know that these vaccines are being used uh for cancer so apart from that the other important technique can be passively you transfer activated immune cells which will have anti-tumor activity that is the adoptive cell transfer or which has been commonly being used what is uh rather giving very encouraging results in some of the leukemias recently is the car t cell therapy where t says are engineered to express the chimeric antigen receptor that recognize the cancer cells and these modified t cells are grown and expanded in culture and then reinfused into the patient so these are the various approaches that we are using apart from yes for many many years we have been using non-specific stimulation of feminine reactions like uh interferons have been used in various cancers and earlier interleukins were being used and last but not the least what more commonly is being used recently is the anti pd1 and the pdl one and cytotop and ctla for blockers so targeting the ctla4 and pd1 pathways have been used with various monoclonal antibodies so this happens what we need to understand is when we want to target the t cells it can be done at two major levels one is at the peripheral level that is at the level of the lymph node at the level of presentation of this antigen to the t cell so here the ctla four pathway is the major pathway that is that is targeted apart from that at the level of the tumor the interaction between the t cell and the tumor cell where again the major pathway that we normally target is the pdm pd1 and pdl1 pathway so blockade of these pathways at these levels seems to be a very exciting uh focus where whether this huge opportunity and we have monoclonal antibodies at present which target these pathways and this is what since 2015 onwards we say the error of pd1 pdl1 and ctla for individuals what most of us now refer as the amino oncology so going further we know that traditionally there were various cancers where chemotherapy could do little to improve the survival and something like malignant melanoma and we have enough data now to say that in these kind of tumors immunotherapy actually did wonders and the survival rates significantly improved so the immune checkpoint any better so just looking at the curves the both the curves the overall survival for metastatic melanoma before 2011 in simpler words before the io era was used to be very dismal and today with so many immune checkpoint inhibitors with immuno-oncology we see the survival even in metastatic melanoma seems to have significantly improved compared to what it used to be historical historically seen so in various cancers amino oncology seems to be finding its way and we know that slowly and steadily it does find its way in not many cancers the number of patients who are being treated with these immune checkpoint inhibitors is also growing they are they are now approved both as monotherapy and also in combination i o i o as doublets and also in combination with chemotherapy for various cancers historically these agents were used in later line of metastatic disease but now we see that they have now creeped into the earlier lines of therapy also for example as adjuvant treatment for high risk melon malignant melanoma similarly even for maintenance treatment of stage three non-small cell lung cancer we see that these io agents have found a way so patients may receive this immunotherapy at present the most important question is for how long so we know that these generally continue for years and the optimal duration apart from the adjuvant treatment we still do not know for how long to give and generally the initial strategy so far has been to continue until progression toxicity or to up till two years for some cases so coming to the responses to io therapy we need to understand that a response to immuno oncology we know all these checkpoint inhibitors is not as simple as it used to be the responses to our earlier therapies it is actually a multi-step process because it takes days to and two weeks for the new cell activation and proliferation and for that for uh the clinically visible effect to be seen on the tumor is generally several weeks two months and maybe much more later so what are the various considerations for clinicians when they are assessing these io therapies so what are the different responses that we expect potentially there can be four different patterns of response to these i o therapies one is an immediate response which is ah very very infrequent generally not seen there may be the second is there may be lack of tumor shrinkage but definitely a slowing of tumor progression much more commonly seen third is a tumor regression can occur eventually but there is an early radio uh early radiographical progression so something what we now know as pseudo progression there may be a early progression followed by tumor regression or sometimes at least the rate of growth of the tumor slows down so these are the different responses that we normally see so the example of different evolution of responses so this was uh these are from certain cases only which have been presented in various conferences so one can see that in the initial weeks there may be some kind of probably some increase initial increase in the total tumor burden which is subsequently there occurs the decrease and then possibly you get durable responses similarly another case where we see in a non-small cell lung cancer patient on iot therapy so pretreatment and then possibly some initial increase in the size of the lesions and later on uh subsequent decrease and we at present have now started using trying to use certain biomarkers although then ideal biomarker is yet to be available this pdl one is something which is very commonly used some of us in some studies have also used msi in some of the indications and tumor mutation burden so these are the various markers but possibly we yet to find the most ideal marker for indication for these immunotherapies but we know that in these immune responses the immune response criteria is may be very different than the normal responses that we have been used to seeing with the conventional therapies because it may be the tumor may there may be some increase in the site and even there may be appearance of new lesions which may not actually be the increase in the tumor cells which may be just the increase in the immune cells being recruited at that site and that is why there may be some confusion between evaluating when assessing responses of these io therapies in the early phases so not many considerations need to be taken into cu may be considered when evaluating a tube progression versus the pseudo progression so how do we yes the definite answer will definitely be a biopsy where in a true progression there will be the tumor cells which would have increased and in a pseudo progression it will be the evidence of t cell infection but what are the indirect evidences that we rely on in our clinical practice it is basically whether the patient is improving the performance status is either stable or the patient is improving the systemic symptoms whether they are improving so these are all the signs which may indicate that it may be a pseudo progression as just a pseudo progression the patient may actually be improving and you wait for something further to assess the response to these io therapies the something which we really uh say is important in the assessing the response is that the durability of the responses which is the true combat i say of io therapy because we know the overall responses may not be that great the overall percentage of patients who respond to these io therapies is still not that good it is just 20 percent or so but patients who respond seems to have durable responses and that is the reason when we say that immunotherapy responders can experience a dramatic impact on survival compared with conventional chemotherapy because one can see there is people who respond they generally have much much more longer the responses they stay for much more longer they are much more durable then the responses we have been seeing with our conventional therapies now coming to the tolerability of these therapies so we know that chemotherapy has a different mechanism of action targeted therapies have a different mechanism of action and hence the adverse events that happen with these i o therapies are also unique as a result of immune system hyperactivity or activity so the different spectrum of adverse events can be seen with each modality although the adverse events may be the same for example diarrhea may be common to all of them but with every different modality the mechanism the etiology is different and hence the management strategy the recognition of these adverse events the real cost of these adverse events and the management strategy is also different across the spectrum so immune mediated adverse events you name a system and yes immune mutated adverse events can occur early that can be lot of signs and symptoms and early recognition is something that we need to that we that we need to do however when compared to the other therapies when compared to uh chemotherapies these uh adverse evenings are much more less and these therapies are much more tolerable compared to chemotherapies so early recognition of potential immune mediated adverse events should be done close monitoring of signs and symptoms should be done and we should know when to initiate steroids when to discontinue therapy and when to withdraw so coming to these immune mediated adverse events so there is a generally a typical pattern so the earliest in your earliest uh uh side effect that is dermatological toxicity that is the earliest to develop that develops in somewhere around two to three months and this is followed by git and followed by in the time duration if you say the sequence followed by the endocrinopyleopathies in hepatotoxicity so coming to each and every system let's talk about skin toxicity seems to be the skin side effects seem to be fairly much more common compared to others rashes inflator seems to be the commonest kind which it presents and the typically the rash appears to be a maculopapular rash that generally appears either on the trunk back or extremities the median on time of onset of these toxicities approximately one and a half months and it lasts for approximately three to four months and most of these patients they respond to systemic symptomatic treatment so for curators we normally use antihistamines and sometimes topical steroids are enough for majority of the cases for rashes some skin reactions some producers may also occur in context of the infusion related reaction endocrinopathy is something which is a very much unrecognized side effect in many cases so whenever when you're giving these i o therapies i encountering non-specific symptoms like extreme fatigue or generalized weakness we should always always think of endocrinopathies among the endocrinopathies thyroid is something something which is the most commonly affected both hypo and hyperthyroidism can occur but these are typically low grade and it is not that and multiple endocrine organs may also be involved but severe endocrine related adverse events are very very rare and an endocrinologist may be required to interpret the laboratory results and guide management treatment may be continued once appropriate hormone replacement is initiated for example if it is hypothyroidism and then appropriate hormone replacement is being done then treatment can be continued and some of the subjects with endocrinopathy may require some replacement those steroids rather than high dose steroids and again we can possibly continue treatment in majority of these patients uh coming to liver toxicity much more much more less common ah again the medium time of onset is approximately two to three months and generally resolve within one one and a half months and whenever we see the lfts getting deranged one should consider the drug related toxicity also even if they are confounding factors present and the majority of these abnormalities generally respond deadly respond to low those steroids however even if the improvement occurs rapidly long steroid paper is something which is indicative gi diary and colitis is the calmness of occurring in approximately 10 to 13 percent of the cases again approximately two months the median time to onset is approximately two months and the time to resolution is just fifteen two to three weeks only diarrhea politics may be sometimes be associated with bloody stools and abdominal cramps also so early recognition should be the key and whenever uh steroids are required stores need to be started but whenever we need storage we should generally taper it slowly uh over a period of one month or so and uh monitor these patients closely for response because they may rebound when steroids are being tapered and in these patients we should actually try to avoid the use of narcotics as much as possible because it can mask the symptoms of gi population neurological adverse events generally very very rare can present all sort of different neurological problems like encephalitis encephalopathy polyneuropathy mycelia syndromes and even cranial nerve pulses and onsen has been observed as early as after a single dose also and the principles of treatment is again remains the same either those delays or steroids and in severe cases sometimes ivig may also be required however there is no clear evidence that they that there is an increased incidence of neurological illnesses in patients who are being treated with immune checkpoint inhibitors so this is something which is generally very very rare again renal toxicity most commonly presents at in elevation in serum creatinine and then again may present with generalized symptoms like malaise anorexia fatigue median time to onset is again two months and loss for three to four months and serum creatinine if it is rising they need to be closely monitored and possibly nephrologists can also be you should also be involved as part of the management team uh final prognosis may require a kidney biopsy but it is generally a diagnosis of explosion and steroids generally lead to reversal resolution in majority of cases and there is no evidence to say that the patients who have rcco who has had prior net technique they are at higher risk of female toxicity last but not the least ah pneumonitis is one of the most dreaded uh toxicity that we all oncologists fear of but the incidence of severe pneumonitis that grade for pneumonitis is less than 0.1 percent until that no underlying risk factor has been established and no apparent relation to any tumor type whether it is lung cancer or any other cancer the symptoms can be just cough breathlessness favor or even asymptomatic x-ray changes so assessment is generally done by a pulse oximetry or radiographic assessment can be done and again the management principle remains the same delaying the dosage of these therapies or steroids or maybe immunoceptins so what are the takeaways immuno oncological drugs immune checkpoint inhibitors are effective therapies and have found the way in the treatment of many cancers they can be used either alone or we are also using io combination and in today's state we are also using them along with chemotherapy biomarker testing may help us ensure that the right patient is matched to the right therapy yes we are using pdl one tumor mutation burden and msi and possibly there is also a need for identification for newer biomarkers in most specific biomarkers although these therapies are efficacious it is important that the patients are kept safe yes the side effects are much more less compared to chemotherapies but yes few side effects can still happen and the close monitoring of these patients is also required and especially the knowledge about immune related adverse events because there is also a learning curve for that for interpretation of these events and yet an identification very very important to identify pseudo progression versus real progression early identification of adverse events and early initiation of prompt steroids and whatever thank you there are quite a few questions i'll just read out to you mouse so dr varshika is asking is there any specific stage at which only immunotherapy can be useful so uh we cannot say a specific stage although at present most of these immunotherapies are advised are approved in advanced stages stage four onwards in the metastatic setting there are very few indications as i mentioned in the early stages for example only in malignant melanoma that now we have approval for immunotherapy in the adjuvant setting that is in the early stages iris malignant melanoma similarly in lung cancer in locally advanced disease post concrete chemo rt again in the maintenance phase immunotherapy is is advised is has found recognition so majority is in the advanced stages very few indications in the early stages but slowly and slowly it is uh finding its way into early stages too what is more relevant i rather feel is apart from in the stages what is more important is to recognize that which cancels for example in malignant melanoma it definitely is much more better than compared to chemotherapy then similarly in rcc in urinary bladder cancers in lung cancers so there are various cancers where we do find much more role of immunotherapy compared to much less role in certain other cancers right now um we have one more question um dr shanti uh how is pembroke carboplatin and nab pacli is useful in uh neck cancer in neck cancer yes so this combination of napali carboplatine and pembrolizumab is being used in lung cancer so there are specific indications for it it is also being used as first line in various lung cancer patients so i think the question is specifically for neck cancers and possibly you mean to say it does head and neck cancer so hedonic cancer also immunotherapy is has found approval so pembrolizumab but it is more uh in the first line with platinum plus five fu plus immunology track so the approval at present is for a platinum combination with five fu with membrulizuma that is the first line approval in because of any reason if you cannot give five fu it is contraindicated or not rollable then second line is a nap actually and a platinum and immunotherapy right ma'am dr shanti i hope that answers your question uh we have one more question from dr karna how many type of immune therapy are available has available treatment how many types of immune therapy are available yes ma'am so all that i talked about for the different types of immunotherapy so ah for example the vaccines which we are using in cancer the preventive vaccines like human papilloma vaccine or hepatitis b vaccine or uh the therapeutic vaccine like spinal cell that we use in prostate cancer these are also a type of immunotherapy then interferons that are being used all the age all over the ages for rcc and earlier for cml is also a type of immunotherapy bcg intravesicle bcg is also a type of immunotherapy that we have been using for bladder cancer for very very long time but the present era where we talk about immunotherapy is more commonly one is the monoclonal antibodies that we are using in various cancers the other is the pd1 pdl1 and the ctl for inhibitors so these will include pembrolizumab mnemoluma etizolizumab aviluma and and eplinoma so these are the various monoclonal antibodies which are now available for various cancers right now we have one more question from dr kavisha um at what stage uh acute myeloid leukemia can be treated at its best so acute myeloid leukemia we all need to understand is a very aggressive cancer and if it needs to be treated that is as earlier in the treatment phase as earlier in the disease as possible as earlier as the recognition of these cases is done so in these cases if they go into uh they develop infections they have developed pneumonias or something else so for empty they have gone into a bleeding thyroid diastasis it becomes very very difficult to salvage these cases so as early the recognition is done these cases should be taken which type of immune therapy are available for the ca 125 for the treatment of ca of 125 uh so at present me generally there is no immunotherapy available for the treatment of cm120 right so what we have to understand ca1 25 is not a disease ca 125 is the tumor mark so ca 125 can be raised in various conditions including ovarian cancer or some other cancers too so a race ca 125 per se may not mean malignancy always because it can be raised in various benign conditions also something like something like cirrhosis endometriosis ah polycystic ovarian various other conditions also and but ca 155 is generally found increased in ovarian malignancy too so race uh just for ca 155 at present there is no immunotherapy and a raise ca125 unless it is a marker of cancer some we generally do not treat a race right now is bone marrow transplant better than immune therapy uh basically there is no comparison between the two so there are definite indications of bone marrow transplant and there are definite indications of immunotherapy so most most of these most of these cancers so they will be for example at what stage you ask for a bone marrow transplant so in multiple myeloma we generally ask for autologous bone mass bone marrow transplant much more earlier and it has proven to be much superior than other therapies in a patient who is responding to normal therapies to the conventional therapies and but yes in certain cancers we have to resort to immunotherapy also so we cannot say depending on what type of cancer it is what stage is there whether it is in the relapsing or not relaxing what is the best is advocated right now we have a question from dr manus mirati how can we manage pancreatic cancer so again coming to pancreatic cancers like for any cancer we need to know the stage of the cancer so whether it is an early pancreatic cancer or it is a advanced pancreatic cancer and within the early ah pancreatic cancer we also need to know whether it is a operable pancreatic or it is an operable pancreatic cancer for example if it is a operable pancreatic cancer a localized pancreatic cancer and i am talking about exocrine pancreatic cancer then the treatment should be a surgery however if it is a it is not an operable one it is a borderline resectable possibly operable but may not be completely restrictable what we say is modeling resectable pancreatic cancers then what we go for is we give them new adjuvant chemotherapies first we give chemotherapies first decrease the disease and then try to asses the patient whether the patient can be taken up for surgery in a disease which is still localized to the pancreas not anywhere else but possibly which appears inoperable this will be the tumor which will be a candidate for radiation plus chemotherapy in an inoperable pancreatic cancer but metastatic cancer which has gone to the liver may be to some other organ these are the patients where only in chemotherapy would be the way out we have a question from dr krishna priya is there any preventive immunotherapy for a big size uterus for big size uterus we need to know what is the reason for the big cells uterus so uh a bigger size uterus can mean if the uterus is bigger than normal size can mean that there is a it's a pregnant uterus or a big size uterus can be various other reasons also they can be multiple fibroids in the uterus but they can be whether it is an endometrial carcinoma so that is something that we need to ascertain first and then think of what is to be done and as far as immunotherapy or any preventive role of immunotherapy in a big cells uterus that is not present right now actually uh she she had asked before like um my question of forehead and cancer is a valuable regimen for 69 year old woman uh like they have prescribed pembroke carboplatin is coming from the tumor so her question was this like the pus is coming from the tumor so like how to treat it so the question cannot be answered as simply as that like if the buses i understand it is an inoperable cancer that must be the disease and uh we will need to know whether whether i mean at any time surgery considered or the patient has already been operated has radiation been given or not been given where all the diseases and what all for lines of therapy has been given so in head and neck cancers our first line of treatment is generally a cis platinum 5fu and immunotherapy and it also we need to assess the pdl when how much is the combined positive score so these are the things which are very very important before we decide that what is the line of therapy that will be recommended yes ma'am oh i might think we've almost answered most of the questions oh thank you so much ma'am for coming for today's session and we're looking forward for your next session thank you so much ma'am and have a good evening everyone thank you so much arjun thank you thank you thank you thank you you

BEING ATTENDED BY

Dr. Darius Justus & 638 others

SPEAKERS

dr. Meenu Walia

Meenu Walia

Senior Oncologist in Max Super Speciality Hospital

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dr. Roma Kumar

Dr. Roma Kumar

Senior Consultant, Max Super Specialty Hospital Gurgaon & Institute of Child Health at Sir Ganga Ram Hospital, New Delhi

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dr. Meenu Walia

Meenu Walia

Senior Oncologist in Max Super Speciality Hos...

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dr. Roma Kumar

Dr. Roma Kumar

Senior Consultant, Max Super Specialty Hospit...

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