Immuno-Oncology Alone for Patients With Lung Cancer and High PD-L1 Expression

Eddie Garon, MD, University of California, Los Angeles, makes the case for immuno-oncology alone as the optimal course of treatment for patients with lung cancer and PD-L1 expression of 50% or greater, a position he took in a debate session at the Great Debates and Updates in Lung Cancer conference in Chicago, Illinois.

Transcript

I’m Eddie Garon from the David Geffen School of Medicine at UCLA. We are at the 2023 Great Debates in Lung Cancer meeting in Chicago, Illinois.

The first debate that I did, I was taking on Patrick Forde, [MD, Johns Hopkins Medical Institute]. In fact, I was debating with him on both of my 2 debates today. In the first debate, I was debating whether patients who have PD-L1 expression of 50% or greater should receive monotherapy with a PD-1 inhibitor or the combination of PD-1 inhibition along with chemotherapy. My position, which is in general what I believe, is that patients should receive monotherapy with PD-1 inhibition. Certainly, I would say that the data is emerging that the long-term benefit in general in these patients are from the PD-1 inhibitor. In most of the studies that we have had to date, there does not appear to be a group of patients who does particularly poorly at the beginning when the study population is restricted to the 50% or greater population.

The KEYNOTE-024 study, for instance, that study really did show that that there was not a drop-off at the beginning in terms of survival in patients who received monotherapy and that the benefits of monotherapy continued over time as opposed to chemotherapy. The data with chemoimmunotherapy is certainly respectable and it is possible that it is a slightly different patient population. There certainly are situations in which I do use chemoimmunotherapy in that situation. Patients, for instance, who have been lifetime non-smokers, I have generally preferred chemotherapy and immunotherapy. Certainly, patients who have aggressive disease where there are symptoms that I think need to be imminently treated. In those cases, I also have looked to chemoimmunotherapy, even among patients who have this high level of expression of PD-L1.

However, in these cross-trial comparisons – and of course, these are what we are always advised not to do, but often there's not much else we can do – it does appear that the outcomes are very similar between the 2 approaches. Obviously, the toxicity is going to be better if one does not include chemotherapy in their regimen. Also, there is now some real-world data, as well as data from the FDA, indicating similar outcomes in patients with 50% or greater PD-L1 expression when they receive monotherapy with a PD-1 inhibitor as opposed to chemotherapy and a PD-1 inhibitor. In conclusion, my position, which is in this case the position with which I agree, is that in a general case of someone without tremendous symptoms with a smoking history who has PD-L1 of 50% or greater to use PD-1 inhibition or PD-L1 inhibition as monotherapy.

Source:

Garon, E. “Debate: How to Handle PD-L1 >50% - IO Only.” Presented at Great Debates & Updates in Lung Cancers. May 4-6, 2023; Chicago, IL