What are the treatment options for non–small cell lung cancer (NSCLC) in patients with PD-1 ligand (PDL-1)?

Updated: Jul 15, 2021
  • Author: Winston W Tan, MD, FACP; Chief Editor: Nagla Abdel Karim, MD, PhD  more...
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Answer

Immune checkpoint inhibitors (ICIs) should be reserved for NSCLC patients who have a PD-L1 expression ≥1% and are negative for any of the molecular variants (eg, EGFR, ALK, ROS1). Targeted therapy should take precedence over ICIs in patients with an elevated PD-L1 expression and presence of molecular variants. [91]

FDA-approved first-line therapies for metastatic NSCLC patients with PD-L1 expression and no presence of any of the molecular variants (eg, EGFR, ALK, ROS1) are pembrolizumab (Keytruda), atezolizumab (Tecentriq), and cemiplimab (Libtayo). [145]  They may be uses in combination with chemotherapy or as a single agent in first-line or subsequent therapies. Another ICI is nivolumab (Opdivo) in combination with ipilimumab approved for first-line treatment, and as monotherapy in patients with progression of metastatic NSCLC on or after platinum-based chemotherapy.

If PDL-1 expression is ≥50%, the following immunotherapy alone or with chemotherapy may be offered:

  • Atezolizumab or cemiplimab alone (preferred)
  • Pembrolizumab with or without carboplatin or cisplatin and pemetrexed (preferred)
  • Atezolizumab/carboplatin/albumin-bound paclitaxel
  • Nivolumab/ipilimumab with or without pemetrexed and carboplatin or cisplatin

If PDL-1 expression is ≥1% to 49%, immunotherapy with standard chemotherapy may be offered, as follows:

  • Pembrolizumab with or without carboplatin or cisplatin and pemetrexed (preferred)
  • Atezolizumab with carboplatin/paclitaxel/bevacizumab
  • Nivolumab/ipilimumab with or without pemetrexed and carboplatin or cisplatin

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