What are the single-agent therapy recommendations for non-small cell lung cancer (NSCLC) stage IV or recurrent disease?

Updated: Mar 08, 2021
  • Author: Marvaretta M Stevenson, MD; Chief Editor: Nagla Abdel Karim, MD, PhD  more...
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Single-agent therapy is a reasonable first-line option in patients with good performance status (ECOG score ≤2) disease or in the elderly; the goal is to complete four to six cycles. Systemic chemotherapy is not indicated for patients with poor performance status (ECOG 3-4), except for erlotinib in patients who are EGFR-mutation positive. [7]

Single-agent regimens include the following:

  • Paclitaxel 200 mg/m2 IV every 21 d [75, 76]  or

  • Docetaxel 35 mg/m2 IV weekly for 3 wk every 4wk [54, 60, 63, 77] or

  • Docetaxel 75 mg/m2 IV every 21 d [60, 61, 62, 63]  or

  • Gemcitabine 1000 mg/m2 IV on days 1, 8, and 15 every 4 wk [78, 79]  or

  • Gemcitabine 1250 mg/m2 IV on days 1 and 8 every 21 d [35, 55]  or

  • Vinorelbine 25 mg/m2 IV weekly [80, 81]  or

  • Vinorelbine 30 mg/m2 IV on days 1 and 8 every 21d [55, 82, 83]  or

  • Pemetrexed 500 mg/m2 IV every 21d [64] (non-squamous histology)

PD-L1 Inhibitors

Pembrolizumab is indicated as first-line monotherapy for patients with stage III NSCLC, who are not candidates for surgical resection or definitive chemoradiation, or metastatic NSCLC, and express PD-L1 (TPS ≥1%) with no EGFR or ALK genomic tumor aberrations. Also indicated after platinum-containing chemotherapy for tumors that express PD-L1 (TPS ≥1%). Patients with EGFR or ALK aberrations should have disease progression on US Food and Drug Administration (FDA)–approved therapy for these aberrations before receiving pembrolizumab; dose as follows: [51, 59, 52]

  • Pembrolizumab 200 mg IV q3wk or 400 mg IV q6wk; continue until disease progression or unacceptable toxicity (for up to 24 mo)

Atezolizumab is indicated as first-line treatment of adult patients with metastatic NSCLC whose tumors have high PD-L1 expression (PD-L1 stained ≥50% of tumor cells [TC ≥50%] or PD-L1 stained tumor-infiltrating immune cells [IC] covering ≥10% of the tumor area [IC ≥ 10%]), as determined by an FDA approved test, with no EGFR or ALK genomic tumor aberrations:

  • Atezolizumab 840 mg IV q2wk, 1200 mg IV q3wk, or 1680 mg IV q4wk until disease progression or unacceptable toxicity [84]

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