Immuno-oncology has really exploded over the last six or seven years and there is a tremendous amount of data that is coming in regarding how immune therapy should be used in different settings. I'm a lung cancer expert and in lung cancer immune therapy has become certainly perhaps the dominant treatment in lung cancer nowadays. How to use it, whether to give it as first treatment, to give it with chemotherapy as part of first treatment, to give it as second line treatment and how to evaluate the patients who are most appropriate to be treated with immune therapy and how to treat their side effects for immune therapy are all major issues that oncologists are facing now.

So when they asked about the big question that was mostly referring to should it be used as initial treatment, should it be used with chemotherapy, when should it be used second line? These are all problems that we are all wrestling with right now and there's a tremendous amount of data that is coming in from many large randomised trials with immune therapy drugs that have been developed by numerous pharmaceutical companies. So it's a great challenge to have because we're getting better and better treatments, better options for patients with cancer but it is a lot for oncologists to be able to digest and understand how to interpret and act on.

That becomes combined with looking at the molecular characteristics of the lung cancer to determine what patients should get molecular therapy, which patients should get chemotherapy, which patients should get immune therapy. Ten or fifteen years ago this was much simpler but the fact that we now have effective therapies that can be personalised to a patient is an important and good problem to have now.

Are you aware of any ongoing trials that are of particular interest?

There was a very important trial, KEYNOTE-024, that compared immune therapy to standard chemotherapy in advanced lung cancer. This was in patients whose tumours had a high biomarker called PD-L1. For those patients that had tumours with this high biomarker level it was very clear that immune therapy was superior to chemotherapy - more patients had responses, they lived longer, they had less toxicity. So this was a clear breakthrough. There's now data emerging for several different agents looking at standard chemotherapy with or without immune therapy and while those trials are looking positive, which is very encouraging, because that's a lot of treatment and a lot of expense with some increased toxicity as a field we're trying to grapple with is this a new standard of care that we should move to and what is the level of evidence that we need to make that move?

How does this translate to breast?

Every cancer is going to be different in regards to immune therapy. What we're beginning to understand is that there are some cancers that do elicit an immune response and some that don't. This is due to multiple factors, one of the main ones is does the cancer have numerous mutations that generate new proteins that are not normally present in the human body so that the immune system then reacts against those proteins and attacks the cancer? So there are certain cancers like malignant melanoma, lung cancer, head and neck cancer, bladder cancer and others where that is common and then there are some other cancers like many of the breast cancers, like breast cancers that are sensitive to hormonal therapy, that are positive for oestrogen and progesterone receptor or that are driven through HER2 where those tumours aren't typically highly mutated. The immune system often does not react against those cancers so that so far immune therapy has not been efficacious in those cancers. Whereas certain types of aggressive and inflammatory breast cancer like what we call triple negative breast cancer does have a high mutational load frequently and sometimes does elicit an immune response. So that in the triple negative breast cancer we do think that immune therapy is promising.

The message from the immune therapy field is that this is only just the beginning, that the results are exciting and are really transforming the care of immune sensitive cancers like lung cancer and melanoma, head and neck cancers, bladder cancer and that's only going to accelerate. We think that the science is advancing enough that we hope to be able to take some of these what so far have been immunologically cold cancers, like many of the breast cancers, and understand the science well enough and the basic principles enough to be able to convert those cancers into immunologic hot cancers so that those cancers can also benefit from immune therapy approaches.