Gadgeel SM, Garassino MC, Esteban E, et al. KEYNOTE-189: updated OS and progression after the next line of therapy (PFS2) with pembrolizumab (pembro) plus chemo with pemetrexed and platinum vs placebo plus chemo for metastatic nonsquamous NSCLC. J Clin Oncol. 2019;37(suppl 15; abstr 9013). doi: 10.1200/JCO.2019.37.15_suppl.9013. Socinski MA, Jotte RM, Cappuzzo F, et al. Atezolizumab for first-line treatment of metastatic nonsquamous NSCLC. N Engl J Med. 2018;378(24):2288-2301. doi: 10.1056/NEJMoa1716948. Mok TSK, Wu YL, Kudaba I, et al. Pembrolizumab versus chemotherapy for previously untreated, PD-L1-expressing, locally advanced or metastatic non-small cell lung cancer (KEYNOTE-042): a randomized, open-label, controlled, phase 3 trial. Lancet. 2019;393(10183):1819-1830. doi: 10.1016/S0140-6736(18)32409-7.

Frontline immunotherapy has shown tremendous benefit in patients with advanced nonsquamous non–small cell lung cancer (NSCLC), but it should only be given in the absence of a driver mutation, according to Jyoti D. Patel, MD, FASCO.“We need to determine upfront whether there is a genotypic driver present, so we know whether to proceed with targeted therapy versus immunotherapy,” said Patel, a professor of medicine and director of Thoracic Oncology at the University of Chicago Medicine.Both pembrolizumab (Keytruda) and atezolizumab (Tecentriq) are approved for use in combination with platinum-based chemotherapy in this setting and have demonstrated encouraging data in phase III trials. In updated data from the phase III KEYNOTE-189 study, which was the confirmatory trial for the pembrolizumab/chemotherapy approval, the addition of pembrolizumab to carboplatin and pemetrexed resulted in a 44% reduction in the risk of death versus chemotherapy alone (HR, 0.56; 95% CI, 0.45-0.70; P 50% by immunohistochemistry should receive pembrolizumab alone. For the majority of patients who have PD-L1 TPS <50%, we generally recommend a combination of chemotherapy and immunotherapy. We have established pembrolizumab in combination with carboplatin and pemetrexed from KEYNOTE-189 as a gold standard. In the trial, we saw improved response rates, progression-free survival, and OS with the addition of pembrolizumab. Moreover, updated OS analyses have been presented and the data are quite favorable.IMpower150 and IMpower130 were done in the same setting. In IMpower150, patients received carboplatin, paclitaxel, bevacizumab, and atezolizumab. There is a scientific rationale for the combination of chemotherapy and immunotherapy. We believe that the combination increases neoantigen presentation and results in a more favorable immune environment. The addition of bevacizumab inhibits the VEGF pathway, which we believe improves dendritic cell function and leads to a synergistic benefit with the quadruplet therapy.We believe that synergy exists between VEGF and PD-1 antibodies; however, the toxicities are significant. Patients with renal insufficiency who may not be eligible for pemetrexed, or those who may have had adjuvant pemetrexed [may be better suited to receive the quadruplet therapy with atezolizumab]. Additionally, [we could consider this regimen] in patients with EGFR or ALK mutations [who progressed on prior TKI therapy].Several important questions need to be answered. Duration of therapy is still open-ended. For someone who had a terrific response and still has evaluable disease, is there a time that you should stop treatment? Studies have looked at a 2-year [duration], but it’s unclear what the optimal duration is. Also, is de-escalated treatment appropriate for patients who have deep responses?The big question is, “How do we refine patient selection?” With genotyping, we can say with certitude that the patient is or isn’t going to respond to certain oral drugs. With immunotherapy, even if a patient has high PD-L1 expression, there’s a 50/50 chance of response. We need to improve our personalized treatments.Several changes have been adopted into clinical practice in recent years at a dizzying pace. One is that all newly diagnosed patients with nonsquamous NSCLC need genotyping. Getting the right answer upfront gives us many opportunities for treatment. For example, with RET translocations, we’re seeing deep responses [with RET-targeted therapy]. Although we don't currently have an FDA-approved drug [for RET], we may soon.With immunotherapy, we’ve seen dramatic and durable responses. Better prediction and assessment of which patients will respond to single-agent immunotherapy [will be important].Lung cancer has become a chronic disease in many individuals. [Treatment is] more of a marathon than a sprint, so we have to be judicious with therapy and hold onto single-agent therapies, potentially re-challenge patients, and enroll patients on clinical trials to expose them to other innovative approaches down the road.A version of this article originally appeared on OncLiveas, “ Immunotherapy Takes Hold in Frontline Advanced Nonsquamous NSCLC ”.