4
Treatment
No Contraindications to Bevacizumab
➤ For patients receiving carboplatin plus paclitaxel, the guideline update
panel recommends the addition of bevacizumab 15 mg/kg once
every 3 weeks, except for patients with SCC histologic type, clinically
significant hemoptysis, inadequate organ function, Eastern Cooperative
Oncology Group PS >1, clinically significant cardiovascular disease, or
medically uncontrolled hypertension.
Note: Bevacizumab may be continued, as tolerated, until disease progression.
➤ There is insufficient evidence to recommend bevacizumab in
combination with pemetrexed plus carboplatin for patients who do not
have contraindications to bevacizumab.
Non-SCC, and Negative or Unknown PD-L1 status
(TPS 0–49%), and PS 0–1
➤ For patients with negative (<1% or unknown) and low positive (TPS
1%–49%) PD-L1 expression, non-SCC, PS 0–1, AND are eligible for
chemotherapy and pembrolizumab:
• 2.1. Clinicians should offer pembrolizumab/carboplatin/pemetrexed (Strong
Recommendation; H).
• 2.2. Clinicians may offer atezolizumab/carboplatin/paclitaxel/bevacizumab in
the absence of contraindications to bevacizumab (Moderate Recommendation; I).
• 2.3. Clinicians may offer atezolizumab/carboplatin/nab-paclitaxel (Moderate
Recommendation; I).
• 2.4. Patients who have the above characteristics AND have contraindications to/
declines immunotherapy, clinicians should offer standard chemotherapy with
platinum-based two drug combinations as outlined in the 2015 update (Strong
Recommendation; H).
• 2.5. Patients with above characteristics AND have contraindications to/declines
immunotherapy AND not deemed candidates for platinum-based therapy,
clinicians should offer nonplatinum based two-drug therapy as outlined in the
2015 update (Weak Recommendation; L).
• 2.6. For patients with low positive PD-L1 expression (TPS 1%–49%), non-SCC,
PS 0–1, AND who are ineligible for or decline combination of doublet platinum
± pembrolizumab, clinicians may offer single-agent pembrolizumab (Weak
Recommendation; L).
• 2.7. In addition to 2020 options, for patients with negative (0%) and low
positive PD-L1 expression (TPS 1%–49%), non-SCC, and PS 0–1, clinicians
may offer nivolumab and ipilumumab alone or nivolumab and ipilumumab plus
two cycles of platinum-based chemotherapy (Weak Recommendation; M).
