Lung: Metastatic NSCLC - first-line immunotherapy

Why B is correct

KEYNOTE-024 showed that in previously untreated metastatic NSCLC with PD-L1 TPS of at least 50% and no EGFR or ALK alterations, single-agent pembrolizumab improved overall survival versus platinum chemotherapy (median OS 26.3 versus 13.4 months; HR 0.62). ESMO guidance strongly recommends single-agent anti-PD-1/PD-L1 therapy such as pembrolizumab for driver-negative disease with PD-L1 at least 50%.

And why the others are not

• AChemotherapy alone is inferior to pembrolizumab in this high PD-L1, driver-negative setting per KEYNOTE-024.
• COsimertinib is an EGFR tyrosine kinase inhibitor and is ineffective in EGFR wild-type disease.
• DBest supportive care alone is inappropriate for a fit patient with a highly effective licensed first-line option.
• ENivolumab plus ipilimumab is the regimen for malignant pleural mesothelioma in CheckMate 743, not the standard first-line choice here where single-agent pembrolizumab is indicated.

Source KEYNOTE-024 - First-line pembrolizumab in metastatic NSCLC with PD-L1 TPS at least 50% (5-year outcomes) — Reck M, Rodriguez-Abreu D, Robinson AG, et al. Five-Year Outcomes With Pembrolizumab Versus Chemotherapy for Metastatic Non-Small-Cell Lung Cancer With PD-L1 Tumor Proportion Score >=50%. J Clin Oncol. 2021;39(21):2339-2349.