ASCO GUIDELINES Bundle

NSCLC Stage IV without Driver Alterations

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7 B1. Second-line Therapy for Patients and PS 0–1 Squamous and Non-squamous and Negative/Unknown EGFR mutation, ALK or ROS-1 Gene Rearrangement ➤ For patients who received first-line chemotherapy and have not received prior immune checkpoint inhibitor therapy, clinicians should use single-agent nivolumab, pembrolizumab, or atezolizumab in patients with positive tumor PDL-1 expression (TPS ≥1%, 22C3 assay), in the absence of contraindications to immune checkpoint therapy (Strong Recommendation; EB-B-H). ➤ For patients with negative or unknown tumor PDL-1 expression (TPS <1%) who received first-line therapy chemotherapy, clinicians should use single-agent nivolumab or atezolizumab in the absence of contraindications to immune checkpoint therapy (Strong Recommendation; EB-B-H). ➤ There are insufficient data to recommend combination checkpoint inhibitors or immune checkpoint inhibitors with chemotherapy in the second-line setting. ➤ For patients who received an immune checkpoint inhibitor as first-line therapy, clinicians should offer standard platinum- based chemotherapy as outlined in the 2015 update (Strong Recommendation; EB-B-H), or nonplatinum based two-drug therapy if platinum contraindicated as outlined in the 2015 update (Strong Recommendation; IC-B-L). ➤ For patients with contraindications to immune checkpoint inhibitor therapy after first-line chemotherapy, docetaxel is recommended as second-line therapy (Moderate Recommendation; EB-B-I). Non-squamous Only ➤ Patients with non-SCC who have not previously received pemetrexed- based first-line or maintenance therapy should be offered pemetrexed second-line (Strong Recommendation; EB-B-H). • 5.1. (New) In addition to previously recommended regimens, for patients with non-SCC who received an immune checkpoint inhibitor and chemotherapy as first-line therapy, clinicians may offer paclitaxel plus bevacizumab in the second- line setting (Weak Recommendation; L).

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