Adjuvant Immunotherapy for Upper GI Tract Cancers

Anup Kasi, MD, University of Kansas Cancer Center, Kansas City, KS, discusses the debate on neoadjuvant vs adjuvant immunotherapy for patients with locally advanced HER2-positive upper gastrointestinal tract cancers, held at the 2023 Great Debates and Updates in GI Malignancies in Chicago.

Transcript:

Hi, I'm Anup. Anup Kasi. I'm a GI medical oncologist. I'm an associate professor at the University of Kansas Cancer Center. I'm here at the Great Debates in GI malignancies in Chicago.

The debate I was assigned to participate in was looking at locally advanced upper GI cancers that are HER2-positive. The battle was between neoadjuvant immunotherapy versus adjuvant immunotherapy. I had to defend using adjuvant immunotherapy for this population. I feel that's where we have the strongest data.

We have a randomized phase 3 trial, CheckMate 577 trial, that did show patients who underwent chemoradiation in the neoadjuvant period followed by surgery, resection of the tumor, and then received adjuvant nivolumab... The disease-free survival was significantly better for those patients. It's a positive study, NCCN recommendation, FDA approval, all of that we have to use in the adjuvant space.

We don't have any randomized data in the neoadjuvant space. There are still some studies that are ongoing. A lot of them are looking at combination of immunotherapy with targeted therapies or chemotherapies in the neoadjuvant space. We still really have to wait for that data to read out. As of now, with the level of evidence that we have with the data that's already been published, that's where we stand. We have evidence to support adjuvant immunotherapy for this patient population with HER2-positive cancers rather than neoadjuvant immunotherapy.

I also looked at some recent studies that were presented at the 2023 ASCO Gastrointestinal Cancers Symposium, which basically characterized the tumor immune microenvironment between HER2 low and HER2 high group. What we found actually was in the HER2 high group, patients had lower immunogenicity profiles, especially when the primary tissue was used to analyze this.

What works in the stage 4 setting, combination of chemotherapy plus HER2-directed treatment plus a checkpoint inhibitor, That may not necessarily work in the neoadjuvant space. Certainly, I mean, it's an evolving field. Who knows? Six months down the road, my position may change. But right now, we have evidence for adjuvant immunotherapy and not neoadjuvant immunotherapy.

Source:

Kasi A. “Debate: Neoadjuvant vs Adjuvant Immunotherapy for Locally Advanced HER-2 Positive Upper Gastrointestinal Tract (UGI) Cancers – Neoadjuvant Immunotherapy.” Presented at: Great Debates and Updates in Gastrointestinal Malignancies; March 30-April 1, 2023; Chicago, IL