Navigating Treatment Selection and Access in NSCLC: Insights From a Clinical Forum

Non–small cell lung cancer (NSCLC) remains one of the leading causes of cancer-related mortality worldwide and continues to present complex treatment challenges in the era of precision oncology. For pharmacists, advances in biomarker-driven therapy and immuno-oncology have expanded therapeutic options while also increasing the need for careful navigation of treatment selection, access, and toxicity management. Among these options, cemiplimab-rwlc (Libtayo; Regeneron), along with other PD-1 and PD-L1 inhibitors, emerges as an important component of first-line treatment for selected patients.

During a Pharmacy Times Clinical Forum, a group of oncology pharmacists discussed how they are applying clinical trial data in real-world practice, integrating molecular testing, and addressing barriers to care in the management of NSCLC.

The discussion was moderated by Stefanie Houseknecht, PharmD, BCOP, a clinical pharmacy specialist in thoracic oncology at Johns Hopkins Bayview Medical Center. In her opening remarks, Houseknecht emphasized the collaborative nature of the forum. “We have a wealth of experience as well as different practice sites and different patient populations,” she said. “I think it would be great to discuss how we might treat patients differently at different practice sites.”

Early Pharmacist Involvement in Treatment Planning

A central theme throughout the forum was the importance of early pharmacist involvement in NSCLC care. Panelists described varied institutional models but shared a common goal: ensuring pharmacists are positioned to influence treatment decisions before therapy is initiated.

Simona Armanca, PharmD, BCOP, of Inova Health System, described a hybrid role for ambulatory pharmacists at her institution.“They are kind of sandwiched in between making decisions in the clinic, advising the physicians if this would be a good choice or not,” she said.

Houseknecht highlighted the value of this positioning. “That’s critical for pharmacists to be able to make an intervention if they see something that’s missing…or missing information that might be leading the provider to make a decision that’s not the best fit for the patient.”

Participants agreed that early pharmacist engagement helps prevent premature treatment initiation, particularly before molecular and biomarker results are available.

Navigating the Immunotherapy Landscape

Much of the discussion centered on selecting among approved PD-1 and PD-L1 inhibitors, including pembrolizumab (Keytruda; Merck), atezolizumab (Tecentriq; Genentech), and cemiplimab-rwlc, which demonstrated efficacy as monotherapy and in combination regimens in trials such as EMPOWER-Lung 1 (NCT03088540) and EMPOWER-Lung 3 (NCT03409614).¹

Houseknecht reminded attendees that treatment selection requires careful evaluation of multiple factors. “You have to know those 3 things in order to make a complete care plan for a patient with metastatic lung cancer…[histology, PD-L1, and molecular results].”

Participants emphasized that institutional preference often reflects provider familiarity, formulary status, and patient-specific considerations. Justin Lawson, PharmD, BCOP, of the University of Maryland Medical Center, said, “Providers are comfortable with [pembrolizumab]…because it was first. They’re aware of it.”

However, access to multiple agents allows clinicians to individualize therapy based on comorbidities, disease burden, and patient preferences.

Molecular Testing as a Foundation of Care

Panelists consistently emphasized the importance of comprehensive molecular profiling before initiating immunotherapy. Testing for actionable mutations such as EGFR, ALK, ROS1, and RET remains essential, particularly in nonsquamous disease.²

Laura Yarbro, PharmD, BCOP, of Maryland Oncology Hematology, described common challenges. “There are times when we have to be like, ‘Well, we don't see any results yet, so why don't you select this [pembrolizumab]?’ And they're like, ‘Well, I'm pretty sure it's at the hospital,’” she said.

Delays in biomarker reporting can complicate both clinical and administrative processes. Several participants described strategies to mitigate this issue, including concurrent liquid and tissue testing. According to Jianyu Dai, PharmD, from MedStar Georgetown University Hospital, “[We do liquid and solid] at the same time…they wait until most of the genetic testing [comes] back before formulating the treatment plan.”

This approach reduces the risk of inappropriate immunotherapy exposure in patients with driver mutations and facilitates faster treatment initiation.

Managing Patient Access and Financial Barriers

Beyond clinical decision-making, panelists highlighted pharmacists’ critical role in navigating insurance and reimbursement challenges. Increasingly complex payer requirements, site-of-care restrictions, and prior authorization processes make access management a major component of oncology pharmacy practice.

Bryna Delman Ewachiw, PharmD, BCOP, of Johns Hopkins Bayview, described pharmacists as central coordinators. “Pharmacists are really like the drill instructor or the captain of the ship, because they are poised to direct what the next step [is and] what the options are…. And our pharmacists, we have a whole team of [them who] just work in managed care. So we reach out to them, or sometimes they'll reach out to us, and we figure out what the patient's options are.”

Participants recounted cases in which treatment delays extended for weeks due to site-of-care mandates or benefit limitations. In response, pharmacy teams often initiate multiple pathways simultaneously, including appeals, patient assistance program enrollment, and alternative infusion arrangements. Houseknecht observed, “It surprises me still that I have providers that don't understand that authorization is not a guarantee of payment. [It] still, to this day, blows my mind that they were like, “$100,000 tonight was authorized.” It doesn't mean that you're going to get paid.”

The discussion underscored how pharmacists increasingly function as advocates, ensuring continuity of care amid administrative barriers.

Interpreting Clinical Trial Data in Practice

Houseknecht reviewed major immunotherapy trials, including KEYNOTE-407 (NCT02775435), KEYNOTE-189 (NCT02578680), IMpower150 (NCT02366143), and EMPOWER-Lung 3, highlighting improvements in overall survival and response rates with chemoimmunotherapy combinations and monotherapy in selected patients.^1,3

She cautioned against overreliance on cross-trial comparisons. “One thing here is we hesitate. We don't want to do cross-trial comparisons. It's a little bit misleading to put these trials up here that had very different patient populations done in different regions of the world,” she said.

Panelists agreed that trial data must be interpreted in the context of real-world patient populations, which often include older adults, patients with comorbidities, and individuals with limited social support. Discussion of cemiplimab focused on its role as both monotherapy in PD-L1–high disease and in combination regimens, with emerging long-term survival data supporting its use.² Participants noted that expanding therapeutic options allows pharmacists to better tailor regimens to patient needs.

Patient Counseling and Shared Decision-Making

The forum also explored the evolving role of pharmacists in patient education and shared decision-making. Many participants described routine involvement in counseling patients starting immunotherapy. “We do the patient education…for all new starts who are switching treatment,” Armanca said.

Panelists discussed how patients differ in their desire for prognostic information. Some prefer detailed discussions of outcomes, whereas others request minimal information. Lawson emphasized adaptability: “If they don’t want specifics…[that’s understandable]. But [adverse] effects are very relevant in patients’ lives.”

Ewachiw highlighted the growing influence of online information. “Patients today are different than patients even 10 or 20 years ago. The drugs are on television every 5 seconds. But they do come with good questions. Of course, there are always patients who really don’t understand what’s going on. So, as a pharmacist or as part of a clinical team, you have a responsibility to help those patients navigate their care.

“There are also a lot of patients who think they know. You don’t want to challenge them. You want to frame it in a way that validates what they came across while also cleaning up some of the mess or chatter they’ve encountered,” she said.

Pharmacists described their role in addressing misinformation while validating patient concerns, particularly as patients increasingly turn to online forums, social media, and direct-to-consumer advertising for health information. Participants emphasized the need to respectfully correct misconceptions, contextualize clinical data, and avoid overwhelming patients with excessive details, instead focusing on clear, individualized education that supports informed and confident decision-making.

Collaborative Practice and Toxicity Management

Participants also addressed collaborative practice agreements (CPAs) and their role in managing immune-related adverse events. Although regulatory requirements vary by state, CPAs increasingly allow pharmacists to initiate supportive care measures, adjust steroid regimens, and monitor toxicities. However, panelists noted barriers related to credentialing and regulatory oversight. Despite these challenges, most agreed that pharmacist-led toxicity management improves patient safety and reduces treatment interruptions.

“The more experience we get with managing immune-mediated toxicities, the better the outcomes for patients,” Houseknecht said.

Looking Ahead

As the forum concluded, participants reflected on the expanding scope of oncology pharmacy practice. From interpreting complex trial data and optimizing regimens involving agents such as cemiplimab to navigating reimbursement systems and educating patients, pharmacists continue to play a pivotal role in NSCLC care.

The discussion highlighted how multidisciplinary collaboration, supported by strong pharmacy leadership, remains essential as immunotherapy options continue to evolve.

By integrating clinical expertise with patient advocacy and operational problem-solving, oncology pharmacists are helping ensure that advances in NSCLC treatment translate into meaningful improvements in real-world outcomes.

REFERENCES

1. Sezer A, Kilickap S, Gümüş M, et al. Cemiplimab monotherapy for first-line treatment of advanced non-small-cell lung cancer with PD-L1 of at least 50%: a multicentre, open-label, global, phase 3, randomised, controlled trial. Lancet. 2021;397(10274):592-604. doi:10.1016/S0140-6736(21)00228-2

2. Ettinger DS, Wood DE, Aisner DL, et al. Non-small cell lung cancer, version 3.2022, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. 2022;20(5):497-530. doi:10.6004/jnccn.2022.0025

3. Paz-Ares L, Luft A, Vicente D, et al. Pembrolizumab plus chemotherapy for squamous non-small-cell lung cancer. N Engl J Med. 2018;379(21):2040-2051. doi:10.1056/NEJMoa1810865