Pembrolizumab Monotherapy for Patients With HighPD-L1 Non-Small Cell Lung Cancer

At the 2022 Great Debates & Updates in Lung Cancer meeting in New York, Edward Garon, MD, David Geffen School of Medicine - UCLA, Los Angeles, California, debated the controversial topic of how best to treat patients with non-small cell lung cancer and a PD-L1 expression of ≥50%. The debate looked at two main treatment courses: chemotherapy plus immunotherapy, or immunotherapy alone.

Dr Garon defended pembroluzimab monotherapy as his treatment of choice for this patient population. He also mentioned cemiplimab and atezolizumab as potential options.  

Transcript

I’m Edward Garon from the David Geffen School of Medicine at UCLA, and I'm speaking here at the Great Debates and Updates in Lung Cancer Meeting. This is the first time we've been able to meet in person in a long time, so that's exciting. We're here in Brooklyn, New York. I had the pleasure of debating Leena Gandhi regarding the appropriate management of patients who have PD-L1 expression of at least 50%. This is an area of controversy. There is an ongoing cooperative group clinical trial that will eventually address this topic, but to date we just don't have any data to address whether this population of patients who have PD-L1 of at least 50% should get chemotherapy plus immunotherapy, or immunotherapy alone.

My position in the debate aligned with what I typically do in my practice, which is to treat most of these patients with single-agent therapy. I've traditionally used pembrolizumab as that has the most long-term data of these agents, but there are also approvals for cemiplimab and atezolizumab in this setting. The strength of my debate point is that in cross-trial comparison, there is not clear data to indicate that you're gaining anything by adding chemotherapy, from an efficacy perspective. However, when one adds chemotherapy, you are adding toxicity. That is why my debate position is aligned with what I typically do in practice.

There are rare indications where I do not do that. Patients who have not been smokers in the past are a group of patients that has not done that clearly well on immunotherapy alone, whereas the data for that population with chemo-immunotherapy is much stronger. Also, although we didn't talk about it much, there is a population of patients who have a very aggressive disease and need therapy quickly, where you don't have the opportunity to have immunotherapy fail in their case. That's a situation where I have used chemotherapy and immunotherapy. I think with the lack of randomized data, I would say that to date, the safety and efficacy data for the 2 approaches really disfavor using single-agent immunotherapy in that setting.

Source:

Garon E. Debate: How to Handle PD-L1 > 50% - Use Pembrolizumab alone. Presented at: Great Debates & Updates in Lung Cancer; Oct 14-15, 2022; New York, New York.