Treatment Options in Non–Small Cell Lung Cancer

Roy S. Herbst, MD, PhD, provides insight on selecting the optimal therapy for non–small-cell lung cancer and shares considerations for the use of combination chemotherapy and immunotherapy.

Kristie Kahl: Hi, and welcome to our CancerNetwork® OncView program titled “Immunotherapy Response Monitoring in Lung Cancer.” I’m Kristie Kahl, the vice president of content with CancerNetwork®. We have with us Dr Roy Herbst, the director of the center for thoracic cancers and the chief of medical oncology at Yale Cancer Center and Smilow Cancer Hospital, an associate cancer center director of translational science. Thanks for joining us, Dr Herbst.

Roy S. Herbst, MD, PhD: It’s a pleasure to be here.

Kristie Kahl: Let’s get started. What are the approved therapies in non–small cell lung cancer?

Roy S. Herbst, MD, PhD: There are many. It’s incredible how many new drugs have been approved this year alone. But for immunotherapies right now, we have at least 5 drugs. We have nivolumab, which came first, and then pembrolizumab, durvalumab, atezolizumab, and recently cemiplimab. There are a whole host of others that are in clinical trials—some developed in the United States and some in other countries—but there are many options right now. Each drug has its own indication. Pembrolizumab, of course, and atezolizumab and cemiplimab are drugs used in the front line, and durvalumab is used in stage III disease. All the drugs are moving through earlier stages in this setting.

Kristie Kahl: How do you select the best therapy for a given patient? For example, are there factors that weigh efficacy vs safety or vice versa?

Roy S. Herbst, MD, PhD: It’s nice to have choices. Certainly, you’d want to use an indication, so let’s take the front line. There are 3 agents for PD-L1 greater than 50%: pembrolizumab, atezolizumab, and recently cemiplimab. All 3 are reasonable to use. Most use pembrolizumab just because it was used first and that’s what we’re most accustomed to. In the setting where someone is PD-L1 less than 50%, most are using chemotherapy plus immunotherapy in that setting. Pembrolizumab is the most commonly used immunotherapy there, but some want to avoid immunotherapy and chemotherapy combinations and use immunotherapy alone. They might use nivolumab-ipilimumab, for example. There are a lot of options, but the 1 thing that’s constant is almost every patient who can will get immunotherapy because, in metastatic lung cancer, it really is the only way to see a long-term outcome.

Kristie Kahl: Absolutely. You mentioned chemotherapy and immunotherapy. What are some of the considerations when it comes to immunotherapy? How would you decide if and when to use the combination of chemotherapy and immunotherapy?

Roy S. Herbst, MD, PhD: In patients who don’t have PD-L1 greater than 50% tumor portion score, most would use chemotherapy plus immunotherapy. Pembrolizumab, for example, is approved in patients with greater than 1% PD-L1. But data suggest that the result is probably as good as chemotherapy but not better. For patients, less than 50%, most physicians, myself included, would use chemotherapy plus immunotherapy. There are 2 major regimens. There’s the KEYNOTE-189 regimen, pembrolizumab plus chemotherapy, and then of course there’s the IMpower150, which is bevacizumab, atezolizumab, carboplatin-paclitaxel. You would use histologically specific chemotherapy, depending on whether it’s squamous or nonsquamous tumors. I’d typically use chemoimmunotherapy in that setting. Some might use ipilimumab-nivolumab, but I think quite few.

Transcript Edited for Clarity

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