Liza C. Villaruz, MD, associate professor of medicine, medical oncologist, Division of Hematology/Oncology, UPMC Hillman Cancer Center, discusses updated data from the phase 3 CheckMate-227 trial (NCT02477826) examining nivolumab (Opdivo) with or without ipilimumab (Yervoy) in patients with non–small cell lung cancer. 

The updated survival data demonstrated preserved survival benefits with the combination of nivolumab and ipilimumab over chemotherapy, across all levels of PD-L1 expression, according to Villaruz. The primary end point of the study was survival in patients with a PD-L1 tumor proportion score (TPS) of 1% or more, and data showed a significant benefit in favor of the combination, Villaruz says.

Data with checkpoint inhibitors in this patient population are scarce. However, findings from this trial suggest that combining checkpoint inhibitors with nivolumab could be considered for select patients depending on certain characteristics, Villaruz concludes. 

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Liza C. Villaruz, MD, discusses updated data from the phase 3 CheckMate-227 trial examining nivolumab with or without ipilimumab in patients with non–small cell lung cancer. 

Dr. Villaruz on Updates From the CheckMate-227 Trial With Nivolumab/Ipilimumab in NSCLC 

Liza C. Villaruz, MD, associate professor of medicine, medical oncologist, Division of Hematology/Oncology, UPMC Hillman Cancer Center, discusses selecting between single-agent and combination immunotherapy in non–small cell lung cancer (NSCLC).

Several single-agent and combination immunotherapy regimens, such as nivolumab (Opdivo) plus ipilimumab (Yervoy), are approved for use in patients with NSCLC based on PD-L1 status, Villaruz explains. Additionally, some chemoimmunotherapy combinations are approved irrespective of PD-L1 status.

Patients with PD-L1–high NSCLC by tumor proportion score (TPS) of 50% or higher are typically treated with single-agent immunotherapy with pembrolizumab (Keytruda) or cemiplimab-rwlc (Libtayo), Villaruz says. Although single-agent pembrolizumab is also approved for patients with PD-L1 TPS of 1% or greater, it is important to note that this group has more variable responses to single-agent immunotherapy that are not as pronounced compared with those in the PD-L1–high population. 

As such, patients with a PD-L1 status of 1% to 49% should be considered for combination chemoimmunotherapy. For symptom control, chemoimmunotherapy should also be considered for patients with PD-L1–high NSCLC who have significant tumor burden to potentially elicit an early cytoreductive effect, Villaruz concludes.

Liza C. Villaruz, MD, discusses selecting between single-agent and combination immunotherapy in non–small cell lung cancer. 



Dr. Villaruz on Selecting Between Single-Agent and Combination Immunotherapy in NSCLC 

Liza C. Villaruz, MD, assistant professor of medicine, Division of Hematology/Oncology, University of Pittsburgh, discusses EGFR-targeted therapies in non—small cell lung cancer (NSCLC).

Villaruz says that osimertinib (Tagrisso) is still the frontline tyrosine kinase inhibitor (TKI) of choice in the treatment of 

-mutant NSCLC, both with regard to systemic disease control and central nervous system (CNS) involvement control. Osimertinib is well tolerated and a has a very good therapeutic index. It will be important for researchers to follow the data with lazertinib, another third-generation TKI that could widen the options in this space, notes Villaruz. In September 2018, the FDA approved dacomitinib (Vizimpro) for the frontline treatment of patients with 

 exon 19 deletion or exon 21 L858R substitution mutations.

Ongoing research is also looking at novel combinations of TKIs with VEGF inhibitors like ramucirumab (Cyramza) and bevacizumab (Avastin). Villaruz concludes that these combinations could be particularly effective for patients with CNS metastases.

Liza C. Villaruz, MD, assistant professor of medicine, Division of Hematology/Oncology, University of Pittsburgh, discusses EGFR-targeted therapies in non–small cell lung cancer.

Dr. Villaruz on EGFR-Targeted Therapies in NSCLC

Liza C. Villaruz, MD, assistant professor of medicine, Division of Hematology/Oncology, University of Pittsburgh, discusses PD-L1 expression in lung cancer.

The level of PD-L1 expression is the most important factor in the selection of immunotherapy for patients with lung cancer, says Villacruz. For patients who have an overexpression of PD-L1 in their tumors, Villacruz says that she usually prescribes single-agent pembrolizumab (Keytruda). This is due to the significant response rates of about 45%, but that rate of response can be increased with the addition of chemotherapy.

This comparison needs to be taken with a grain of salt, Villacruz says, as the data with pembrolizumab and the data with pembrolizumab plus chemotherapy have not been studied head-to-head. With that being said, Villacruz says that in patients who express less than 50% PD-L1, her standard of care is pembrolizumab plus chemotherapy. For patients who overexpress PD-L1, pembrolizumab monotherapy is still Villacruz’s first choice.

Liza C. Villaruz, MD, assistant professor of medicine, Division of Hematology/Oncology, University of Pittsburgh, discusses PD-L1 expression in lung cancer.
 

Liza C. Villaruz, MD

Articles

Dr. Villaruz on Updates From the CheckMate-227 Trial With Nivolumab/Ipilimumab in NSCLC

Dr. Villaruz on Selecting Between Single-Agent and Combination Immunotherapy in NSCLC

Dr. Villaruz on EGFR-Targeted Therapies in NSCLC

Dr. Villaruz Discusses PD-L1 Expression in Lung Cancer