[sam2426679]

I’m sure there are exceptions, but ime chemoradiation is often still the most effective treatment, statistically. There’s also no such thing as “risk free” immunotherapy, e.g. it can occasionally result in colitis and other unpleasantries.

[mcbain]

There is no "most effective" treatment because cancer isn't one thing.

Chemo is effective for a few cancers but not for others. Immuno might be the most effective for those. Or chemo followed by immuno. Maybe it is CRT (chemoradio).

Or maybe there is no systemic treatment and all we can use is surgery and then maybe RT.

[pazimzadeh]

Well, chemotherapy destroys/reboots the immune system. So of course, if you always give chemotherapy before immunotherapy, it will keep being the most effective treatment. That is my point.

And to qualify for the vast majority of clinical trials you need to have failed existing treatments (chemo) before testing the new stuff.

Also, if the immunotherapy gives you colitis, then chemotherapy should shut that down too (it is already used in bad cases of colitis, e.g. methotraxate, cyclophosphamide)

[lostapathy]

> Well, chemotherapy destroys/reboots the immune system

That's a pretty gross oversimplification. Chemotherapy isn't one thing, it's a whole range of cocktails of drugs given in different combinations and doses for different specific cancers (even different sub-types of cancers).

They do generally weaken it, but most chemo doesn't "destroy" the immune system at all.

[pazimzadeh]

Antigen-specific immune responses against cancer cells usually involve clonal expansion (aka rapid division) of immune cells once co-stimulation has been achieved. This is often hindered by chemotherapy, although in the best case scenario, if the chemo is effective then it can lead to antigen uptake by local immune cells (epitope spread) which leads to a cascade of immune activity to clear the tumors.

I know that I am oversimplifying. However, generally chemotherapy works by killing rapidly dividing cells, such as cancer cells, hair cells, bone marrow progenitor cells, and immune cells at the tumor site. So yes, it does often functionally destroy/reboot the immune system. If you know of a chemo combo for solid tumors which doesn't lead to neutropenia or other functional immune depletions, please let me know.

[lostapathy]

Right, I'm not arguing the basic mechanism here. I'm just saying that every course of chemo does not completely wipe out your immune system, either. Dosage and cycling of the chemo matters, and even then your body reacts differently from cycle to cycle. Chemo is scary, but not because it completely kills your immune system every time.

My cousin and I had different cancers. Both of us had cisplatin. At the dose I had, my hair was gone. He hardly lost any hair and wasn't even that sick.

We also have drugs to offset the immune problems by sending your bone marrow into overdrive. My first cycle of cisplatin knocked my ANC to effectively zero. I was given additional meds on subsequent cycles and didn't have that problem again. (Said drugs are expensive and give you a special kind of bone pain that's hard to describe, so are apparently not given unless you have problems).

[mcbain]

No, immuno isn't always a second line treatment.

No you don't need to have failed other treatments before being added to a clinical trial. Quite the opposite in many cases - they have entry criteria so that they can be sure any effects (good or bad) can be linked to the trial and not from something else.

No if you got colitis from immuno, chemo won't "reset" it, but strong doses of steroids might. (We discontinued my immuno before I got to that point.)

[pazimzadeh]

> No, immuno isn't always a second line treatment.

"for the vast majority of clinical trials" is what I said

> No you don't need to have failed other treatments before being added to a clinical trial

That wasn't my experience when looking for trials for my mom's metastatic cancer, but I hope you're right.

> No if you got colitis from immuno, chemo won't "reset" it, but strong doses of steroids might.

Two things can be true at once. I didn't say it's curative (neither are steroids), but chemo drugs can be given for severe uncontrolled autoimmune disease, because they are immunosuppressive.

> We discontinued my immuno before I got to that point

Too bad, I studied it for several years and my mom was a specialist on the adaptive immune system.

[mcbain]

> That wasn't my experience

Then stop talking like you understand cancer treatment or clinical trials, because it is exactly how it works for thousands of people every year.

> Too bad

Pardon me? "Too bad" that I had recurrence of cancer and that immunotherapy was starting to cause colitis? Immunotherapy which turned out was never going to work because of the genetics of my cancer, the sequencing of which was completed thanks to one of the multiple clinical trials I'm on.

I'm sorry about your mother, but spreading your ignorance does not help other people.

[pazimzadeh]

Sorry, I thought you meant your immunology courses were discontinued.

What type of cancer were you diagnosed with?