First-Line Immunotherapy for Cancer: How the Treatment Order Is Changing in India

Mumbai : For much of the past two decades, immunotherapy was thought of as a treatment held in reserve — an option to try after chemotherapy and radiation had run their course. That understanding is now out of date. For a growing list of cancers, first-line immunotherapy is the standard of care from the very start of treatment, sometimes alone and increasingly in combination with chemotherapy. The shift has been quiet but substantial, and it is reshaping how oncologists in India plan care for newly diagnosed patients.

Why the Old Treatment Sequence No Longer Fits

Cancer care traditionally followed a predictable sequence: surgery where possible, then chemotherapy and radiation, with newer approaches such as immunotherapy considered only if standard treatment failed. That order made sense at the time. Chemotherapy and radiation had decades of clinical evidence behind them. Immunotherapy — including the class of drugs known as immune checkpoint inhibitors — was newer, and its role earlier in the treatment pathway had simply not been studied enough to guide practice.

What has changed is the evidence base. Years of clinical trial data across multiple cancer types have made a specific pattern clear: for certain cancers, patients who receive immunotherapy earlier — sometimes as their first treatment — have outcomes as good as, or measurably better than, those who receive it only after other options are exhausted. That evidence has moved immunotherapy from the back of the queue to the front for a defined and growing set of diagnoses.

Which Cancers Now Start Treatment With Immunotherapy?

First-line immunotherapy is now well established for several cancer types. Certain lung cancers, melanoma, some kidney cancers, some head and neck cancers, and select cases of advanced or recurrent cervical cancer are among those where immunotherapy is either the initial treatment or combined with chemotherapy from day one. The specific role differs by cancer type, stage, and the individual biological characteristics of the tumour, but the direction of travel is consistent — immunotherapy is moving earlier in the treatment plan, not later.

This shift is not universal. It applies to specific cancers, and often to patients whose tumours carry particular biological markers that predict a strong response. Which is why biomarker testing has moved from something considered nice-to-have to something oncologists routinely rely on before finalising a treatment plan.

For patients and families researching what this means at diagnosis, this detailed explainer on whether immunotherapy can be used as the first treatment for cancer walks through the specific cancers, the biomarkers involved, and how the decision is made.

Why Do Doctors Combine Immunotherapy With Chemotherapy?

For a meaningful number of cancers, the strongest evidence supports not immunotherapy alone but immunotherapy combined with chemotherapy from the outset. The reasoning is more logical than it might first appear.

Chemotherapy and immunotherapy work through completely different mechanisms. Chemotherapy attacks dividing cells directly. Immunotherapy takes a different route — helping the immune system recognise and respond to cancer cells that have been evading detection. Using them together allows oncologists to attack the cancer directly while simultaneously reactivating the immune system — two distinct lines of attack rather than one stronger version of the same approach.

There is a further biological reason the combination often outperforms either treatment alone. Chemotherapy, in addition to killing cancer cells directly, causes dying cells to release signals that make the tumour more visible to the immune system. This can amplify the effect of the immunotherapy component. Chemotherapy can also lower some of the tumour’s defences within its surrounding microenvironment, creating conditions in which the reactivated immune response has a better chance of succeeding.

This deeper look at combination therapies and why doctors sometimes use immunotherapy with chemotherapy unpacks the mechanism-level reasoning in accessible language, and is worth reading alongside any treatment discussion where combination therapy has been proposed.

How Do Oncologists Decide Who Is a Candidate?

Whether immunotherapy is appropriate as a first treatment — alone or in combination — depends on several factors that an oncology team assesses together.

Cancer type and stage sit at the top of the list. First-line immunotherapy is established for specific cancers and stages; it is not a universal first option. Biomarker testing follows closely — tumour tissue is often tested for markers such as PD-L1 expression, tumour mutational burden, and mismatch repair status, which help predict how likely a patient is to respond. Overall health matters too, because immunotherapy activates the immune system broadly, so autoimmune conditions and general health are factored into the decision. Finally, the oncologist weighs the specific strength of clinical evidence for that exact diagnosis and stage.

The side-effect profile is different from chemotherapy’s. Immunotherapy’s side effects relate to immune system activation rather than broad cell damage, and combination treatment means patients may experience side effects from both — though not simply doubled. Careful monitoring for immune-related reactions applies from the start of treatment, not only later on.

What Newly Diagnosed Patients in India Should Know

For patients and families weighing options in India, the practical implication is that the first treatment decision after diagnosis matters more than it used to. In the past, the sequence was largely predetermined by cancer type. Today, it depends increasingly on the specific biology of an individual tumour — biology that can only be identified through molecular and biomarker testing done at the point of diagnosis.

This makes the choice of treatment centre consequential in a new way. Centres equipped for detailed biomarker testing, and with multidisciplinary teams accustomed to weighing first-line immunotherapy and combination approaches against traditional sequencing, are increasingly the ones best positioned to guide these decisions well. What used to be a single-track question — which chemotherapy regimen? — has become several: is immunotherapy indicated at all? On its own, or with chemotherapy? What does the biomarker profile suggest? Is the patient’s general health suited to an immunotherapy-based approach?

Getting those answers right early has become one of the most consequential parts of modern cancer care. A second opinion at a specialist oncology centre is worth considering before finalising any first-line plan, particularly for cancers where immunotherapy has become part of the standard approach.

About SunAct

SunAct provides advanced therapies for haematological and oncological conditions, with locations in Khar and Thane, Mumbai. Its multidisciplinary team of medical oncologists, haematologists, transplant physicians and cellular therapy specialists supports patients across the full spectrum of care — from diagnosis and molecular workup through to advanced treatment options, with the same specialists involved from initial consultation to long-term follow-up.

Further reading from the SunAct Information Centre:

• Read more on immunotherapy as the first treatment for cancer.

• Read more on why doctors combine immunotherapy with chemotherapy.