What Drives First-Line Immunotherapy Selection in NSCLC? Data, Payers, and Habit

In "What Drives First-Line Immunotherapy Selection in NSCLC? Data, Payers, and Habit," the panel weighs what carries the most influence when selecting a first-line regimen.

Dr. Cass asks what carries the most weight when selecting an immune checkpoint inhibitor regimen for a newly diagnosed advanced patient. She also asks which regimens each panelist chooses first line.

Dr. Lynch says clinical data and comfort level are her main drivers, describing her team as creatures of habit. In advanced and metastatic disease, her team relies on the KEYNOTE-189 and KEYNOTE-407 regimens, meaning pembrolizumab-based therapy for most patients. She adjusts for patient-specific factors, such as PD-L1 below 1%, where ipilimumab and nivolumab may be used, and poor performance status. Payers have also begun stating preferences about which immunotherapy agent to use, so a patient's plan may force an up-front choice of one PD-1 inhibitor over another.

Dr. Luon answers almost identically. He says the one thing likely to change his practice is trial data showing that one combination is better, safer, or easier for patients. Without such data, which he calls common in this setting, he defaults to chemotherapy plus pembrolizumab or other established combinations. Like Dr. Lynch, he has recently treated many patients whom payers required to switch to cemiplimab. His team has absorbed these changes without major delays, though the issue demands constant attention.

Dr. Luon adds that non-smokers, tumors with PD-L1 of 0%, and KEAP1 or STK11 alterations are markers the field is still learning about. Patients with these features may respond less well to a PD-1 or PD-L1 inhibitor alone. That raises the question of when to add a CTLA-4 inhibitor, as in CheckMate 9LA or POSEIDON, even though data are still developing. He ranks clinical data first, payers second, and patient-specific factors third. Dr. Cass agrees and reiterates that clinical data come first.

Our next episode, "Changing NSCLC Immunotherapy Practice: Data, Formulations, Payers, and Operations,"turns to what it would take to change those practice patterns.