Frontline Immunotherapy Options in NSCLC: Are Checkpoint Inhibitors Interchangeable?

Welcome back to another Pharmacy Times Practice Pearls series. In "Frontline Immunotherapy Options in NSCLC: Are Checkpoint Inhibitors Interchangeable?," moderator Amanda Cass, PharmD, BCPS, BCOP is joined by Darren Luon, PharmD, BCOP and Alia Lynch, PharmD, BCOP to open the series on non-small cell lung cancer.

Dr. Cass introduces the program, titled Inside the Non-Small Cell Lung Cancer Immunotherapy Conversations Shaping Pharmacy Practice. She serves as a clinical pharmacy specialist in thoracic oncology at Vanderbilt University in Nashville, Tennessee. Dr. Luon introduces himself as a thoracic oncology clinical pharmacy specialist at Yale New Haven Hospital in Connecticut. Dr. Lynch describes her role as ambulatory oncology lead pharmacist at UVA Health in Charlottesville, Virginia, with a clinical practice in thoracic oncology.

The first question asks which agents make up the frontline landscape for patients without actionable genomic drivers, and whether those agents are interchangeable. Dr. Luon names pembrolizumab or cemiplimab combined with chemotherapy as the most common choices in his practice. He also lists combinations that add a CTLA-4 inhibitor, namely ipilimumab with nivolumab and durvalumab with tremelimumab, each given with chemotherapy. Focusing on the PD-1 agents, he considers them interchangeable because head-to-head data are lacking. His team mostly uses pembrolizumab by habit, since the KEYNOTE-189 data came out first.

Dr. Lynch would like to treat the agents as interchangeable, but she cites nuances that prevent it. FDA approvals differ in their thresholds, with some agents holding frontline approval for PD-L1 of 50% or higher and others not. Regimens also carry different histology-specific chemotherapy backbones, and some approvals attach a set treatment duration. In the advanced and metastatic setting, her group primarily uses pembrolizumab or cemiplimab, while nivolumab anchors their early-stage neoadjuvant chemo-immunotherapy regimen. She describes these choices as data-driven.

The next episode in this series, "What Drives First-Line Immunotherapy Selection in NSCLC? Data, Payers, and Habit," features Drs. Lynch and Luon explaining what weighs most heavily in their regimen choices.