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Atezolizumab Therapy - Tecentriq
Medical Oncology

Atezolizumab Therapy - Tecentriq

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Medical Oncology

Atezolizumab lifts a brake that cancer puts on the immune system. The patient's own T cells do the rest.

Atezolizumab, sold as Tecentriq, is an immunotherapy antibody given by drip every three or four weeks that blocks PD-L1, a protein tumors use to switch off the immune cells attacking them. Regulators have approved it for lung cancer at several stages, for small cell lung cancer, and for liver cancer together with bevacizumab. In the IMbrave150 trial of advanced liver cancer, 67.2 percent of patients on atezolizumab with bevacizumab were alive at one year against 54.6 percent on sorafenib tablets. In previously treated lung cancer it lengthened median survival from 9.6 to 13.8 months against chemotherapy while causing severe side effects in 15 percent of patients against 43 percent.

67.2% vs 54.6%
Alive at 1 year in liver cancer, NEJM 2020
20.2 vs 13.1 mo
Median survival, lung cancer with high PD-L1, NEJM 2020
15% vs 43%
Severe side effects against docetaxel, Lancet 2017
Free
Oncologist review of your pathology and scans
Free consultation
Send the pathology report with the PD-L1 result and any gene tests such as EGFR or ALK, the latest CT or PET-CT, a list of previous treatments with dates, recent blood tests and a note of any autoimmune disease. A medical oncologist tells you whether atezolizumab is an approved option for your cancer, what it would be combined with, and how the course could fit around travel. The review is free and places no obligation on you.

Oncologists say atezolizumab. Patients read Tecentriq on the prescription. This page carries both names in its title, Atezolizumab Therapy - Tecentriq. It explains what the drug does, the cancers it is approved for, what the trials showed, the side effects that set it apart from chemotherapy, and how a patient from abroad can start treatment in Istanbul and continue it safely at home.

How atezolizumab works

T cells, the immune system's killers, can recognize cancer cells as foreign. Many tumors defend themselves by covering their surface with PD-L1, a protein that binds to a receptor on the T cell called PD-1 and tells it to stand down. Atezolizumab, a laboratory-made antibody, sticks to PD-L1 and blocks that signal, so the T cells stay switched on and resume their attack. Because the drug acts through the immune system, it can work for a long time in the patients who respond, and it can also let the immune system attack healthy organs.

That double edge explains everything else on this page.

Blocks PD-L1 on the tumor, where its cousins block PD-1 on the T cell
Atezolizumab and durvalumab block PD-L1. Pembrolizumab and nivolumab block PD-1. The drugs are close relatives, and each was approved for the cancers in which its own trials succeeded.
Why the family members are not interchangeable
An oncologist chooses among checkpoint inhibitors by cancer type, stage, the PD-L1 result, the partner drugs and what the regulator in the patient's country has approved. A trial result for one drug does not transfer to another, so a patient offered atezolizumab for a cancer in which only a PD-1 drug was tested should ask why.

Which cancers it treats

Approvals come from specific trials. They differ between countries, and the table lists the uses that randomized trials established.

This table scrolls sideways on a narrow screen. Swipe or drag to see every column.

Established uses of atezolizumab
Cancer How it is used Key trial
Non-small cell lung cancer after surgery, stage II to IIIA One year after chemotherapy, when at least 1 percent of tumor cells show PD-L1 IMpower010
Advanced non-small cell lung cancer, high PD-L1 Alone, as first treatment, when no EGFR or ALK change is present IMpower110
Advanced non-small cell lung cancer, previously treated Alone, after chemotherapy OAK
Extensive-stage small cell lung cancer With carboplatin and etoposide, then alone as maintenance IMpower133
Advanced liver cancer, hepatocellular carcinoma With bevacizumab, as first treatment IMbrave150
Approvals that were withdrawn
Atezolizumab was once approved in the United States for bladder cancer and for triple-negative breast cancer. Both approvals were withdrawn after confirmatory trials failed to show the expected benefit, and the rules in other countries differ. A clinic offering it for those cancers should explain why, and on what evidence.

How a course runs

Tests before the first dose
Blood counts, liver and kidney tests, thyroid tests, cortisol and blood sugar give a baseline against which later changes are judged. A CT or PET-CT maps the disease. Hepatitis B and C are checked. For liver cancer, an endoscopy looks for swollen veins in the gullet, because bevacizumab raises the risk that they bleed, and any found are treated first.
The first infusion
A fixed dose of 1,200 milligrams, whatever the patient weighs, goes into a vein over 60 minutes, followed by an hour of observation. With liver cancer, bevacizumab follows in the same session. With small cell lung cancer, carboplatin and etoposide are added.
Later cycles
Every three weeks, or 840 milligrams every two weeks, or 1,680 every four weeks. Later infusions take 30 minutes. Blood tests come before each one. A form injected under the skin of the thigh in minutes has since been approved in Europe and the United States.
Scans
A CT every nine to twelve weeks. Occasionally a tumor looks larger before it shrinks while immune cells move in, so a single worse scan in a patient who feels well is sometimes repeated before treatment is stopped.
How long it lasts
One year, 16 cycles, after lung cancer surgery. In advanced disease, as long as it helps and side effects stay manageable, which for responding patients can mean years.
30 minutes in the chair
From the second cycle on, most patients spend under two hours at the hospital for each dose, blood test included.

What the trials found

Five randomized trials define the drug's place, and all five are open below.

Liver cancer, IMbrave150
The trial randomized 501 patients with unresectable hepatocellular carcinoma to atezolizumab with bevacizumab or to sorafenib. The hazard ratio for death was 0.58. Survival at one year was 67.2 against 54.6 percent, and median progression-free survival was 6.8 against 4.3 months. Severe side effects occurred in 56.5 and 55.1 percent, with high blood pressure of grade 3 or 4 in 15.2 percent of the combination group. Finn and colleagues, New England Journal of Medicine, 2020.
First-line lung cancer with high PD-L1, IMpower110
Among 205 patients whose tumors showed the highest PD-L1 and had no EGFR or ALK change, atezolizumab alone gave a median survival of 20.2 months against 13.1 with platinum chemotherapy, a hazard ratio of 0.59. Severe side effects occurred in 30.1 against 52.5 percent. Herbst and colleagues, New England Journal of Medicine, 2020.
Previously treated lung cancer, OAK
In 850 patients whose lung cancer had progressed after chemotherapy, atezolizumab gave a median survival of 13.8 months against 9.6 with docetaxel, a hazard ratio of 0.73. The benefit held whatever the PD-L1 level or tumor type. Severe treatment-related side effects occurred in 15 against 43 percent. Rittmeyer and colleagues, Lancet, 2017.
Small cell lung cancer, IMpower133
In 403 patients with extensive-stage small cell lung cancer, adding atezolizumab to carboplatin and etoposide raised median survival from 10.3 to 12.3 months, a hazard ratio of 0.70. The average gain is two months. A minority of patients gained far more, and the median hides them. Horn and colleagues, New England Journal of Medicine, 2018.
After lung cancer surgery, IMpower010
In 1,005 patients who had surgery and chemotherapy for stage IB to IIIA non-small cell lung cancer, one year of atezolizumab lowered the risk of the cancer returning in the stage II to IIIA group whose tumors showed PD-L1 on at least 1 percent of cells, with a hazard ratio of 0.66. Severe related side effects occurred in 11 percent. Four patients died of them, about 1 percent. Felip and colleagues, Lancet, 2021.
Longer life than chemotherapy, with fewer severe side effects, in lung cancer
In OAK, median survival rose from 9.6 to 13.8 months while severe treatment-related side effects fell from 43 to 15 percent. That combination, longer and easier at once, is what changed practice.

Who is a candidate

Tests that decide
The pathology report must show the cancer type. For lung cancer three tests matter most. PD-L1 staining shows how much of the tumor carries the target, and a high level predicts more benefit when atezolizumab is given alone. EGFR and ALK testing comes first, because tumors driven by those changes respond poorly to immunotherapy and have tablet treatments that work better. In liver cancer the Child-Pugh score must show that the liver still works reasonably well.
When it needs care or is unsuitable
Active autoimmune disease such as lupus, rheumatoid arthritis or inflammatory bowel disease can flare, and so can past inflammation of the lungs. A transplanted organ can be rejected. High-dose steroids taken for another reason blunt the effect, and a patient who spends most of the day in bed, too weak for ordinary activity, has a lower chance of benefit. None of these is always a bar, and the oncologist weighs each with the patient.
What to expect
Immunotherapy works very well for some patients and not at all for others. A minority respond for years. Many gain months, and some see no effect, and no test yet sorts them in advance with certainty. The first scan at nine to twelve weeks gives the first answer.

Side effects, and why they differ from chemotherapy

Common and mild
Tiredness, reduced appetite, nausea, itching, rash and joint aches head the list. Hair loss and the low blood counts typical of chemotherapy do not follow atezolizumab alone. When chemotherapy or bevacizumab is added, their own side effects come with them, including high blood pressure and protein in the urine with bevacizumab.
Immune-related side effects
Released from its brake, the immune system can attack healthy organs at any time during treatment and even after it stops. The lungs, bowel, liver, thyroid, adrenal and pituitary glands, pancreas, skin, kidneys, nerves and, rarely, the heart can be affected. Most cases are mild and settle with a pause in treatment or steroids, while severe ones need hospital care. An underactive thyroid is common and needs a daily tablet for life. Type 1 diabetes and adrenal failure are rare and permanent.
Call the treating team the same day
For a new cough or breathlessness, diarrhea of more than a few loose stools a day or blood in the stool, yellow skin or eyes, severe tiredness with dizziness, a severe headache or change in vision, chest pain or palpitations, extreme thirst with large amounts of urine, or muscle weakness. Say that you are on immunotherapy. The treatment of these problems differs from ordinary care, and early steroids prevent lasting damage.

Length of stay, flying, cost and the trip

Atezolizumab needs no hospital bed.

A first visit of five to seven days covers the length of stay for most patients, with the consultation, baseline tests and scans, the endoscopy if bevacizumab is planned, and the first infusion with observation afterward. You can fly the day after an infusion if you feel well. The next doses fall every two, three or four weeks, and patients choose among three patterns. Some fly back for each cycle. Some stay for the first two or three cycles, when side effects are likeliest to begin, and then continue with an oncologist at home using the written plan. Some take the four-weekly schedule to halve the number of trips.

The drug makes up the largest part of the cost. Because the dose is fixed, each cycle costs the same whatever the patient weighs, and bevacizumab or chemotherapy adds its own cost on top, as do scans every nine to twelve weeks, blood tests before each cycle and the treatment of any side effect. The total stays open. It depends on how many cycles the response justifies. Published packages in Istanbul cover the consultation, tests, the infusion and observation, an interpreter and transfers, and leave out the hotel, flights and the treatment of complications. A plan with a per-cycle figure follows the oncologist's review of the reports, which costs nothing.

One coordinator, every visit
The coordinator handles the case in English, Arabic, French, Russian, Serbian, Romanian or Spanish, or through an interpreter, sends the appointment confirmation and an invitation letter naming the hospital and the treating doctor ten days before each visit, and books the hotel and transfers. Two family members may attend consultations, halal, vegetarian and diabetic meals are available, a prayer room is on site, and a female doctor can be requested when you first write.

Continuing at home

Once you are back home, keep a doctor within reach who can see you the same day, for the whole course, because immune side effects can begin at any time. The file from Istanbul gives that doctor what is needed.

  • A written plan in English with the drug, dose, schedule and partner drugs
  • The blood tests required before each cycle, and the thresholds for pausing
  • The dates of the next scans
  • An immunotherapy alert card for emergency departments, where colitis or pneumonitis can be mistaken for infection
  • Thyroid and hormone checks for months after the last dose, since some effects appear late
  • The coordinator's WhatsApp number, with clinical questions passed to the treating oncologist

Atezolizumab Therapy - Tecentriq FAQ

What is atezolizumab used for?
It is approved for non-small cell lung cancer after surgery and in advanced disease, for extensive-stage small cell lung cancer with chemotherapy, and for advanced liver cancer with bevacizumab. Approvals differ between countries, and uses in bladder and triple-negative breast cancer were withdrawn in the United States.
How is Tecentriq given and how often?
By drip into a vein, 1,200 milligrams every three weeks, 840 every two weeks, or 1,680 every four weeks. The first infusion takes an hour and later ones 30 minutes. A form injected under the skin has since been approved in Europe and the United States.
How well does atezolizumab work?
In advanced liver cancer with bevacizumab, one-year survival was 67.2 percent against 54.6 with sorafenib, and in lung cancer with high PD-L1, median survival was 20.2 months against 13.1 with chemotherapy. A minority of patients respond for years. Some do not respond at all.
What are the side effects of atezolizumab?
Tiredness, rash, itching and loss of appetite are common. Immune-related side effects can affect the lungs, bowel, liver, thyroid and other glands during or after treatment. In a trial against docetaxel, severe side effects occurred in 15 percent against 43 percent with chemotherapy.
Can I start treatment in Istanbul and continue at home?
Yes. A first visit of five to seven days covers tests and the first dose, and you can fly the next day. Later cycles can be given in Istanbul or by an oncologist at home following the written plan, provided a doctor at home can see you quickly if a side effect develops.
How long does treatment with atezolizumab last?
One year after lung cancer surgery. In advanced disease it continues as long as it helps and side effects stay manageable, which for responding patients can be years.

References

  1. Finn RS, Qin S, Ikeda M, et al. Atezolizumab plus Bevacizumab in Unresectable Hepatocellular Carcinoma. N Engl J Med. 2020;382(20):1894-1905.
  2. Herbst RS, Giaccone G, de Marinis F, et al. Atezolizumab for First-Line Treatment of PD-L1-Selected Patients with NSCLC. N Engl J Med. 2020;383(14):1328-1339.
  3. Rittmeyer A, Barlesi F, Waterkamp D, et al. Atezolizumab versus docetaxel in patients with previously treated non-small-cell lung cancer (OAK): a phase 3, open-label, multicentre randomised controlled trial. Lancet. 2017;389(10066):255-265.
  4. Horn L, Mansfield AS, Szczesna A, et al. First-Line Atezolizumab plus Chemotherapy in Extensive-Stage Small-Cell Lung Cancer. N Engl J Med. 2018;379(23):2220-2229.
  5. Felip E, Altorki N, Zhou C, et al. Adjuvant atezolizumab after adjuvant chemotherapy in resected stage IB-IIIA non-small-cell lung cancer (IMpower010): a randomised, multicentre, open-label, phase 3 trial. Lancet. 2021;398(10308):1344-1357.

Editor's note

Written by the Biruni Hospital medical editorial team. Reviewed by Prof. Dr. Özcan YILDIZ, Medical Oncology.

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