Highlights

So, if they don’t have actionable mutations, of course we do PD-L1 testing for all patients. If they do have PD-L1+ tumors, greater than 50% PD-L1, they get treated with pembro monotherapy. But if they have less than 50% PD-L1 they get chemo-immunotherapy. But in some rare exceptions, even if they have a high PDL1, sometimes I use chemo-immunotherapy for those patients as well.

You know, patients who progress on PD-1 could potentially go onto a combination of IO, and some of the trials, which are ongoing. Of course, there are some subsets like KRAS, if they have a KRAS-G12C mutation, then sotorasib could be an option for them. In terms of the things that are still in the pipeline, there are cytokine-based approaches looking at other immuno-regulated pathways like TIM-3 in the second line setting. So, we are waiting for some of those data readouts to see if that will change practice.

So, all patients with any PD-L1 expression in the adjuvant setting they get immunotherapy in my practice, and I think with some of these imminent readouts, with peri-operative sandwich treatment approaches like neoadjuvant followed by surgery, followed by adjuvant immunotherapy, we will have to see what the data readouts look like… But the problem we have when you give three cycles of nivo with chemo, and you have somebody with ongoing response at the time of surgery, I just begin to wonder if that’s a short duration of response, and they may be inadequately treated because post-operatively, once you give immunotherapy in the neoadjuvant setting, you may not be able to get adjuvant immunotherapy approval because the trial
did not have any adjuvant component.