Immunotherapy heralds 'new era' for cancer treatment

A "whole new era" for cancer treatment is upon us, according to experts. Two new studies published in the New England Journal of Medicine provide further evidence that immunotherapy - the use of drugs to stimulate immune response - is highly effective against the disease.

Immunotherapy involves the use of drugs to boost patients' immune system response, increasing the attack on cancer cells.

Recently presented at the 2015 American Society for Clinical Oncology annual meeting, one study revealed that a drug combination of ipilimumab and nivolumab (an immune therapy drug) reduced tumor size in almost 60% of individuals with advanced melanoma - the deadliest form of skin cancer - compared with ipilimumab alone, while another study found nivolumab reduced the risk of lung cancer death by more than 40%.

Nivolumab is a drug already approved by the Food and Drug Administration (FDA) for the treatment of metastatic melanoma in patients who have not responded to ipilimumab or other medications. It is also approved for the treatment of non-small cell lung cancer (NSCLC) that has metastasized during or after chemotherapy.

According to cancer experts, however, the results of these latest studies indicate that nivolumab and other immune therapy drugs could one day become standard treatment for cancer, replacing chemotherapy.

Prof. Roy Herbst, chief of medical oncology at Yale Cancer Center in New Haven, CT, believes this could happen in the next 5 years. "I think we are seeing a paradigm shift in the way oncology is being treated," he told The Guardian. "The potential for long-term survival, effective cure, is definitely there."

Nivolumab plus ipilimumab reduced tumor size by at least a third for almost 1 year

Nivolumab belongs to a class of drugs known as "checkpoint inhibitors." It works by blocking the activation of PD-L1 and PD-1 - proteins that help cancer cells hide from immune cells, avoiding attack.

In a phase 3 trial, Dr. Rene Gonzalez, of the University of Colorado Cancer Center, and colleagues tested the effectiveness of nivolumab combined with ipilimumab - a drug that stimulates immune cells to help fight cancer - or ipilimumab alone in 945 patients with advanced melanoma (stage III or stage IV) who had received no prior treatment.

While 19% of patients who received ipilimumab alone experienced a reduction in tumor size for a period of 2.5 months, the tumors of 58% of patients who received nivolumab plus ipilimumab reduced by at least a third for almost a year.

Commenting on these findings, study co-leader Dr. James Larkin, of the Royal Marsden Hospital in the UK, told BBC News:

"By giving these drugs together you are effectively taking two brakes off the immune system rather than one, so the immune system is able to recognize tumors it wasn't previously recognizing and react to that and destroy them.

For immunotherapies, we've never seen tumor shrinkage rates over 50% so that's very significant to see. This is a treatment modality that I think is going to have a big future for the treatment of cancer."

Dr. Gonzalez and colleagues also demonstrated the effectiveness of another immune therapy drug called pembrolizumab in patients with advanced melanoma.

While 16% of 179 patients treated with chemotherapy alone experienced no disease progression after 6 months, the team found that disease progression was halted for 36% of 361 patients treated with pembrolizumab after 6 months.

Dr. Gonzalez notes that while a combination of nivolumab and ipilimumab shows greater efficacy against advanced melanoma than pembrolizumab, it also presents greater toxicity. Around 55% of patients treated with nivolumab plus ipilimumab had severe side effects, such as fatigue and colitis, with around 36% of these patients discontinuing treatment.

Dr. Gonzalez says such treatment may be better for patients whose cancer does not involve overexpression of the PD-L1 protein.

"Maybe PDL1-negative patients will benefit most from the combination, whereas PDL1-positive patients could use a drug targeting that protein with equal efficacy and less toxicity," he adds. "In metastatic melanoma, all patients and not just those who are PD-L1-positive may benefit from pembrolizumab."

Nivolumab almost doubled patient survival from NSCLC

In another study, Dr. Julie Brahmer, director of the Thoracic Oncology Program at the Johns Hopkins Kimmel Cancer Center, and colleagues tested the effectiveness of nivolumab against standard chemotherapy with the drug docetaxel among 260 patients with NSCLC.

All patients had been treated for the disease previously, but the cancer had returned and spread.

The team found that patients who received nivolumab had longer overall survival than those treated with standard chemotherapy, at 9.2 months versus 6 months.

At 1 year after treatment, the researchers found nivolumab almost doubled patient survival. Around 42% of patients who received nivolumab were alive after 1 year, compared with only 24% of patients who received chemotherapy.

The study results also demonstrated a longer period of halted disease progression for patients who received nivolumab compared with those who had chemotherapy, at 3.5 months versus 2.8 months.

Overall, the researchers estimated that, compared with patients who received chemotherapy, those who received nivolumab were at 41% lower risk of death from NSCLC.

Commenting on these findings, Dr. Brahmer says:

"This solidifies immunotherapy as a treatment option in lung cancer. In the 20 years that I've been in practice, I consider this a major milestone."

While both studies show promise for the use of immunotherapy in cancer treatment, experts note that such treatment would be expensive. The use of nivolumab plus ipilimumab for the treatment of advanced melanoma, for example, would cost at least $200,000 per patient.

As such, researchers say it is important that future research determines which cancer patients would be most likely to benefit from immunotherapy.

Medical News Today recently reported on a study conducted by investigators from Cancer Research UK, which reveals a class of drugs called AKT inhibitors may boost the effect of radiotherapy against various cancers, including breast, kidney, melanoma and brain cancers.

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Sun safety: how to protect your child from the greatest cause of skin cancer

It is well known that exposure to UV radiation from the sun or indoor tanning devices is a primary cause of skin cancer - the most common form of cancer in the US. What appears to be less well known is the risk UV radiation can pose to children, with a recent survey revealing that 1 in 5 parents are unaware that their children's skin is sensitive to the sun.

Sun protection is a key factor for reducing skin cancer risk.

According to Dr. Lisa Chipps, assistant clinical professor of the David Geffen School of Medicine at the University of California-Los Angeles (UCLA), director of dermatologic surgery at Harbor-UCLA Medical Center, skin cancer is primarily viewed as a disease of adulthood, meaning many parents may not consider their child is at risk.

"However," Dr. Chipps told, "melanoma accounts for up to 3% of pediatric cancers and 6% of cancer cases in teens 15-19 years old."

There is currently no registry or database that tracks cases of skin cancer among children in the US, but a 2013 study published in the journal Pediatrics found the rate of melanoma - the deadliest form of skin cancer - rose 2% annually among children aged 0-19 between 1973 and 2009.

Though a diagnosis of skin cancer is rare during childhood, excessive sun exposure at a young age can increase the risk of skin cancer later in life. Last year, MNT reported on a study revealing that multiple sunburns during adolescence can raise the risk of melanoma by 80%.

"Overexposure to the sun and sunburns that happen during childhood are important and preventable risk factors for developing skin cancer as an adult," says Dawn Holman, a behavioral scientist in the Division of Cancer Prevention and Control at the Centers for Disease Control and Prevention (CDC), told MNT. "This is why it's so important for us all to use sun protection at every age."

However, as the aforementioned survey revealed, many parents seem to be unaware that the sun poses a risk to their child's skin. That same survey - conducted by Nivea Sun - also found that more than half of parents are unaware that multiple sunburns cause long-lasting damage to their child's skin, while 77% do not think pink or sore skin necessarily indicates sun damage.

In this Spotlight, we look at the best ways to protect children of all ages against the damaging effects of UV (ultraviolet) radiation and look at ways to overcome some of the major challenges that threaten children's sun safety.

Shade is the best sun protection for infants

According to the Skin Cancer Foundation, infants aged 6 months and under should be kept out of direct sunlight. This is because they have low levels of melanin in their skin - the substance that gives pigment to the skin, hair and eyes and protects against the sun - meaning they are very sensitive to UV radiation.

As such, the Skin Cancer Foundation recommend that parents take their infant for walks in a stroller with a sun-protective cover before 10 am and after 4 pm - when UV radiation is lowest.

"The best protection is to keep your baby in the shade," says Dr. Hari Cheryl Sachs.

Infants should be dressed in lightweight clothing that covers the arms and legs, and their face neck and ears should be protected with a wide-brimmed hat or bonnet.

When an infant is traveling in a vehicle, it is wise to cover the windows with removable mesh window shields or UV window film to reduce sun exposure.

While sunscreen is regarded as a key form of sun protection, it is not recommended for use on infants under the age of 6 months.

"Babies' skin is less mature compared to adults, and infants have a higher surface-area to body-weight ratio compared to older children and adults," explains Dr. Hari Cheryl Sachs, a pediatrician at the Food and Drug Administration (FDA). "Both these factors mean that an infant's exposure to the chemicals in sunscreens may be much greater, increasing the risk of side effects from the sunscreen."

"The best protection is to keep your baby in the shade, if possible," she adds. "If there's no natural shade, create your own with an umbrella or the canopy of the stroller."

If it is not possible to protect an infant from the sun with protective clothing or shade, sunscreen may be applied on the advice if a pediatrician.

It is safe to use sunscreen in babies aged 6-12 months, according to the Skin Cancer Foundation, who note that a broad-spectrum sunscreen with a minimum sun protection factor (SPF) of 15 should be applied.

Wearing protective clothing and seeking shade are still key factors for protecting a baby against the sun; sunscreen should be applied on areas that are not covered - such as the hands and face - 30 minutes before sun exposure and reapplied every 2 hours after swimming or sweating.

Children aged 6 months and older should also wear wraparound sunglasses that block 99-100% of UV radiation.

The challenges of sun protection in toddlers

As a child grows, protecting them against the sun can become more difficult. They are more likely to be exposed to sunlight by playing outdoors, and they are also more likely to disobey requests to wear a hat or sunglasses.

In 2004, Dr. Lori Steinberg Benjes, a dermatologist in Cambridge, MA, led a study published in JAMA Dermatology that looked at rates of sun protection among children aged 6 and 18 months.

The results revealed that while 22% of children experienced tanned or sunburnt skin at the age of 6 months, this figure rose to 54% at 18 months. The researchers claim one reason for this is due to the difficulties parents face in controlling their children as they reach toddler age.

"Keeping babies out of the sun is often manageable, but consistent, effective sun protection of toddlers requires more effort and is more challenging," Dr. Benjes notes.

The study also revealed that while there was a higher incidence of tanned and sunburnt skin among children aged 18 months, the use of sunscreen increased. This, the team says, indicates that parents fail to action other sun-protection methods.

"Parents need to understand that sunscreen is only one vital line of defense in sun protection," says Dr. Perry Robins, president of the Skin Cancer Foundation, adding:

"Strategies such as seeking shade and dressing children in sun-protective clothing are just as important and can't be abandoned in the second year, since sunscreen cannot keep all of the sun's rays away from the skin. Teaching these techniques early to children can leave them with sun safety habits that will help prevent skin cancer later in life."

Schools: a help or hindrance to sun safety?

For school-age children, the rules for sun protection remain the same; they should use sunscreen, wear protective clothing and seek shade when UV radiation is at its strongest, which is normally around midday.

Of course, parents have a lot to think about when they are getting their child ready for school, which means they may be less likely to focus on sun protection.

"Getting a few kids ready for school in the morning involves making breakfasts, packing lunches, choosing outfits, finding shoes/homework/backpacks, so yes, sometimes parents slack on the sunscreen," Dr. Chipps told.

The Skin Cancer Foundation say schools can be a hindrance to sun safety, but they can also play an important role in increasing sun safety.

She does, however, provide a useful tip to help combat this problem: "As a parent, I advise making sunscreen part of the childrens' daily morning routine. I keep the sunscreen on the bathroom counter so my kids can apply it when they brush their teeth and comb their hair."

But how can parents ensure their children receive adequate sun protection when they are at school and out of their sight?

According to the Skin Cancer Foundation, sometimes schools can be the "biggest block" to children's sun safety. "Many schools see sunscreen as a medicine, and require either written permission to use it, or require that the school nurse apply it," they note. "Many schools also ban the wearing of hats and sunglasses during school hours, including recess."

The Foundation recommend parents talk to their child's school to find out what their policy is on sun safety. If the school is not doing enough to protect children, they recommend alerting other parents and getting them involved in encouraging the school to take action.

Schools, however, can also play an important role in increasing children's sun safety. "Evidence suggests that sun-safety interventions in child care centers, elementary schools and middle schools are effective in increasing children's use of sun protection," says Holman.

Such interventions - detailed in The Community Guide from the Community Preventive Services Task Force - include educating children about the risks of UV radiation and what can be done to protect against them, as well as implementing activities designed to influence children's, teachers' and parents' behaviors and attitudes toward sun safety.

"In addition," added Holman, "the public health community can work with partners to ensure parents have the information they need to keep their families sun-safe and that other community sectors - such as those working at schools and outdoor recreational settings - have the tools they need to support sun-safety."

Teens and tanning

We all know what it's like to be a teenager. It is a time when you may feel pressured to look a certain way and conform to common perceptions of what is attractive. For many teens - particularly girls - attractiveness means having tanned skin.

What many people - both teenagers and adults - fail to realize is that any form of tan is a reflection of skin damage. The skin turns brown because of an increase in melanin production in an attempt to protect it from further damage.

But many individuals - particularly teens - put their desire for a tan over the associated health risks. In a Spotlight investigating the dangers of UV exposure last year, Tim Turnham, executive director of the Melanoma Research Foundation, told us:

"Despite elevated awareness of the dangers of UV radiation, people still choose to ignore the dangers in the pursuit of what they consider to be a 'healthy tan.' This is particularly an issue among young people who tend to ignore health risks in favor of enhancing their social status and popularity. We know that tanning appeals to people who are interested in being included, and this is a primary driver for teens - being part of the 'in' crowd."

Unfortunately, the desire for being part of the "in" crowd pushes many teenagers toward indoor tanning. According to the American Academy of Dermatology, around 17% of teenagers have reported using a tanning bed at some point in their lives.

Indoor tanning can dramatically raise the risk of skin cancer - with the rays that tanning devices emit being around 10-15 times stronger than those given off by the midday sun.

A 2014 study estimated that each year, around 400,000 cases of skin cancer in the US may be related to indoor tanning, while a study reported by MNT last year linked the use of tanning beds in teenagers to greater risk of basal cell carcinoma (BCC) - the most common skin cancer in the US.

The dangers of indoor tanning have hit the headlines recently after a 29-year-old woman shared a picture of wounds caused by treatment for skin cancer. Tawny Willoughby, from Kentucky, was first diagnosed with BCC aged 21 - a diagnosis she puts down to her excessive sunbed use as a teenager.

"If anyone needs a little motivation to not lay in the tanning bed and sun here ya go! This is what skin cancer treatment can look like," she wrote alongside her posted picture. "Wear sunscreen and get a spray tan. You only get one skin and you should take care of it."

A spray tan is certainly a healthier alternative to using indoor tanning devices for those who yearn for a golden glow, though it should be noted that a spray tan does not protect the skin against the sun. The use of sunscreen is still required. Another alternative is tanning lotions, some of which have an SPF of 15 and above.

As well as the use of sunscreen, it is recommended that teenagers also seek shade during midday hours and wear sun-protective clothing. If your teen complains that such clothing isn't fashionable, try to find items that are more stylish that still cover them up - like a pretty sarong for a teenage girl, for example.

But of course, one of the best ways to encourage sun safety in children - no matter what their age - is to lead by example. As the Skin Cancer Foundation say:

"The most important thing to remember when thinking about sun protection is this: you are your children's role model. Be sure to let them see you protecting yourself from the sun. If you have great skin, so will they."

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