Table 1.
Summary of Commonly Used Standard Medical Therapies for Advanced Non–Small-Cell Lung Cancer in 2017
| Patient Cohort | First Line | Second Line | Third Line and Beyond |
|---|---|---|---|
| Nonsquamous, wild type for driver mutations, PDL1 < 50% | Platinum + pemetrexed, followed by maintenance pemetrexed (some add bevacizumab) | PD-1 or PDL1 inhibitor | Salvage chemotherapy |
| Nonsquamous, wild type for driver mutations, PDL1 ≥ 50% | Pembrolizumab | Platinum + pemetrexed, followed by maintenance pemetrexed (some add bevacizumab) | Salvage chemotherapy |
| Squamous cell, PDL1 < 50% | Platinum + taxane or gemcitabine (some add necitumumab to gemcitabine) | PD-1 or PDL1 inhibitor | Salvage chemotherapy |
| Squamous cell, PDL1 ≥ 50% | Pembrolizumab | Platinum + taxane or gemcitabine (some add necitumumab to gemcitabine) | Salvage chemotherapy |
| Nonsquamous, EGFR mutation positive | Erlotinib, afatinib, or gefitinib | Osimertinib if T790M positive, platinum + pemetrexed, followed by maintenance pemetrexed (some add bevacizumab) if T790M negative | Salvage chemotherapy |
| Nonsquamous, ALK rearrangement positive | Crizotinib | Alectinib or ceritinib | Platinum + pemetrexed, followed by maintenance pemetrexed (some add bevacizumab) |
| Nonsquamous, ROS1 rearrangement positive | Crizotinib | Platinum + pemetrexed, followed by maintenance pemetrexed (some add bevacizumab) | Salvage chemotherapy |
Definition of abbreviations: ALK = anaplastic lymphoma kinase; EGFR = epidermal growth factor receptor; PD-1 = programmed death 1; PDL1 = programmed death ligand-1; ROS1 = ROS proto-oncogene.
Clinical trials should also be considered if available, regardless of line of therapy. Approved PD-1 inhibitors include nivolumab and pembrolizumab. Approved PDL1 inhibitor is atezolizumab. Salvage chemotherapy options include docetaxel ± ramucirumab, paclitaxel, nanoparticle albumin-bound paclitaxel, vinorelbine, and gemcitabine, and these are often given sequentially according to patient tolerance. Other rare driver mutations often have specific targeted therapies available as well, either used off-label or via clinical trials. Only Food and Drug Administration–approved indications for targeted therapies are listed here.