skip to main content

ICI Chronic Immunosuppression — SCE Medical Oncology MCQ

Instant feedback + full explanation. One question, done properly.

HardLung CancerICI Chronic ImmunosuppressionSCE Medical Oncology

A 72-year-old man with stage IV NSCLC (adenocarcinoma, PD-L1 TPS 55%) and a history of well-controlled rheumatoid arthritis (on methotrexate) asks about pembrolizumab. What is the concern with ICI in patients on chronic immunosuppression?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: C — Chronic immunosuppression may reduce ICI efficacy by dampening anti-tumour immune responses; additionally, there is risk of autoimmune disease flare (~25-40%); the balance of ICI benefit vs autoimmune flare risk must be assessed individually

Patients on chronic immunosuppression for autoimmune conditions face dual risks with ICI: (1) reduced ICI efficacy (prednisone >10 mg/day particularly associated with worse outcomes — Scott et al JCO 2019); (2) flare of underlying autoimmune disease (~25-40% flare rate). Most ICI trials excluded patients on >10 mg prednisolone equivalent. For this patient, methotrexate may partially blunt ICI efficacy while not preventing autoimmune flare. Shared decision-making with rheumatology, considering disease trajectory and autoimmune risk, is essential.

Reference: ESMO 2024 NSCLC/irAE; Abdel-Wahab et al Ann Oncol 2018; Scott et al JCO 2019