Immunotherapy for Skin Cancer: A New Hope

It came out of left field, so to speak. Had our visit with the new dermatologist at Bear. They were able to obtain our old records from our previous one and, together with the pathologies recently taken, decided I should see a recommended local oncologist to try a relatively new treatment. The new treatment involves kicking my immune system into high gear regarding cancer cells through a system of injecting specific drugs and letting my own body do its thing. Below is what Perplexity has to say about this treatment:

Immunotherapy injections for skin cancer work by stimulating the body’s natural defenses to seek out and destroy cancer cells. Unlike chemotherapy, which directly attacks cancer cells, immunotherapy activates or enhances components of the immune system to recognize cancer as a threat and target it.cancerresearch+1

Immune Checkpoint Inhibitors

A major class of injectable immunotherapies is called immune checkpoint inhibitors. Cancer cells often use “checkpoints” to evade immune attack—proteins like PD-1 and PD-L1 act as brakes on immune responses. Drugs such as pembrolizumab and nivolumab block these checkpoints, releasing the brakes and allowing T cells to recognize and kill cancer cells.jsstd+1

Oncolytic Virus and Immune Activation

Other immunotherapy injections, such as talimogene laherparepvec (T-VEC), involve injecting a modified virus directly into skin tumors. This virus infects and bursts the cancer cells, releasing tumor antigens (identifying proteins) that alert the immune system. T-VEC also attracts and matures dendritic cells, which help teach the immune system to recognize and attack melanoma not just in the injected tumor, but throughout the body.oncodaily+2

Cytokine and Receptor Agonists

Certain drugs or creams, like imiquimod, stimulate immune pathways by activating toll-like receptors on immune cells. This leads to the production of cytokines such as interferon-alpha and TNF-alpha, which further activate T cells and other immune cells to attack the tumor.oncodaily+1

Impact and Expansion

These immunotherapy strategies have proven especially effective for advanced or metastatic forms of melanoma and other skin cancers by directing the patient’s own immune system to seek and destroy cancer across the body, sometimes with durable, long-term responses.cancer+1

In summary, immunotherapy injections activate a cascade of immune events—lifting restrictions on immune cells, signaling distress to the immune system, or directly presenting tumor antigens—to unleash the body’s own ability to fight and clear skin cancer.jsstd+2

Of interest to me is whether patients on peritoneal dialysis can receive this immune-based treatment? Perplexity suggests:

Yes—patients on dialysis, including peritoneal dialysis (PD), can receive pembrolizumab or nivolumab in many cases, because these large monoclonal antibody drugs are not cleared by dialysis and generally do not require dose adjustment in patients with renal failure. That said, careful monitoring for immune-related side effects is essential, and solid-organ transplant recipients face a significant risk of graft rejection with PD-1 inhibitors.pmc.ncbi.nlm.nih+2

Why dialysis usually isn’t a barrier

Pembrolizumab and nivolumab are IgG monoclonal antibodies with high molecular weight, so they are not removed by hemodialysis; timing relative to dialysis is typically not critical.pmc.ncbi.nlm.nih+1
Pharmacokinetics of PD-1 inhibitors show no clinically meaningful effect of renal dysfunction on clearance, so standard dosing is generally used in end-stage kidney disease (ESKD).academic.oup+1
Case reports and series document the safe use of pembrolizumab at standard doses in dialysis patients, with responses and manageable toxicities reported. pmc.ncbi.nlm.nih+2

Peritoneal vs hemodialysis

Most published experience is in hemodialysis, but the same principles apply to PD: peritoneal dialysis does not clear monoclonal antibodies, so dose adjustment is not expected.academic.oup+1
Given limited PD-specific data, oncologists typically extrapolate from hemodialysis evidence and pharmacology, using standard dosing and close monitoring.pmc.ncbi.nlm.nih+1

Important cautions

Solid-organ transplant: PD-1 inhibitors can precipitate acute allograft rejection; documented cases include renal transplant rejection soon after nivolumab, and risk is considered high for any anti-PD-1 therapy.jitc.bmj
Immune-related adverse events (irAEs): Kidney inflammation (e.g., acute interstitial nephritis), thyroid dysfunction, colitis, pneumonitis, and others can occur and require prompt diagnosis and immunosuppression when moderate to severe.pmc.ncbi.nlm.nih
Coordination of care: Close collaboration between oncology and nephrology is recommended to track labs, manage fluid status, and distinguish irAEs from dialysis-related symptoms.academic.oup+1

Practical approach discussed in reports

Use standard dosing regimens (e.g., pembrolizumab 200 mg q3w or 400 mg q6w; nivolumab per label) without routine dose reduction for dialysis.sciencedirect+2
Dialysis timing: Not usually necessary to coordinate dosing with dialysis sessions, though some clinicians administer after dialysis for convenience and consistency.revistanefrologia+1
Monitor closely: Baseline and periodic labs (CBC, CMP, thyroid panel), urinalysis if residual kidney function, and early evaluation of new symptoms to detect irAEs.academic.oup+1

Bottom line: For PD patients without a functioning transplant, pembrolizumab and nivolumab are often feasible at standard doses, with vigilance for immune toxicities and multidisciplinary oversight; transplant recipients require individualized risk–benefit discussions due to rejection risk.jitc.bmj+2

https://onlinelibrary.wiley.com/doi/10.1155/2018/1623957

https://pmc.ncbi.nlm.nih.gov/articles/PMC5051445/

https://academic.oup.com/ckj/article/14/9/2012/6272220

https://pmc.ncbi.nlm.nih.gov/articles/PMC7467783/

https://pmc.ncbi.nlm.nih.gov/articles/PMC8958579/

https://karger.com/cro/article/15/1/187/823179/Use-of-Pembrolizumab-in-End-Stage-Renal-Disease-A

https://ascopubs.org/doi/10.1200/JCO.2017.35.15_suppl.e14553

https://jitc.bmj.com/content/4/1/64

https://www.sciencedirect.com/science/article/pii/S2666621925000304

https://www.keytrudahcp.com/dosing/options/

https://www.revistanefrologia.com/en-pembrolizumab-in-hemodialysis-patients-is-articulo-S2013251420301486

https://clinicaltrials.gov/study/NCT07117409