NEW YORK — A combination of immunotherapy and chemotherapy should be used as first line treatment for many patients with non-small cell lung cancer and some patients with small cell lung cancer, according to a presenter at HemOnc Today New York.
Patients with NSCLC who have PD-L1 tumor proportion score (TPS) less than 50%, those with NSCLC who have PD-L1 TPS of at least 50% and high tumor burden or evidence of rapid tumor growth rate, and those with extensive small cell lung cancer are prime candidates for this regimen, Philip D. Bonomi, MD, professor of medical oncology in the department of internal medicine at Rush University Medical College, said during his presentation.
Bonomi also left open the possibility that all patients with NSCLC could be treated with this regimen.
“With immunotherapy, [some] have asked if chemotherapy is going away,” Bonomi said. “I actually think chemotherapy is quite a good partner to immunotherapy in lung cancer. I think we are going to see immunotherapy and chemotherapy used together more and more.”
An update on the randomized phase 3 KEYNOTE-024 trial demonstrated that monotherapy with the anti-PD-1 agent pembrolizumab (Keytruda, Merck) continued to show a survival advantage over chemotherapy among patients with advanced, previously untreated NSCLC who had a PD-L1 TPS of 50% or greater but do not have EGFR/ALK aberrations.
An independent data and safety committee recommended the trial be discontinued after an interim analysis — performed at median follow-up of 11.2 months — showed significant improvement in PFS (HR = 0.5; 95% CI, 0.37-0.68) and OS (HR = 0.6; 95% CI, 0.41-0.89) with pembrolizumab. The study was stopped so patients who were receiving chemotherapy could switch to pembrolizumab.
“These results [for PFS] are amazing. We never thought we would see an HR like this,” Bonomi said. “I do believe some of these [patients with stage IV disease] will be cured with immunotherapy alone.”
However, several other studies published in The New England Journal of Medicine have shown the immunotherapy-chemotherapy combination to be safe and effective for patients with metastatic NSCLC, squamous NSCLC and extensive-stage SCLC.
Chemotherapy also has the potential to enhance checkpoint inhibitors by causing the release of tumor antigens, deplete myeloid suppressor cells, deplete T regulatory cells and potentially deplete neutrophils, Bonomi said.
“It’s amazing to me how many options we have now,” Bonomi said. “It’s a luxury I thought we would never have.” – by John DeRosier
Bonomi, P. Immunotherapy: The Beginning of the End of 1st Line Chemotherapy in Stage IV NSCLC? Presented at: HemOnc Today New York; March 21-23, 2019; New York.
Reck M, et al. J Clin Oncol. 2019;doi:10.1200/JCO.18.00149.
Bonomi reports advisory roles with AstraZeneca, Biodesix, and Merck.