Once chemo-radiotherapy is completed, if there is no progression (tumour growth), consolidation treatment with immunotherapy will be administered for one year.
 
In order to receive this treatment, the tumour must express a biomarker (test requested at biopsy). There must be PD-L1 expression of ≥ 1%, as this indicates that the tumour has some susceptibility for immunotherapy to be effective.

When is immunotherapy recommended?

• Patients with PD-L1 ≥ 50%, and ALK, ROS1 negative, these patients may receive immunotherapy treatment alone (without chemotherapy) if there is no contraindication using a drug called pembrolizumab.

 

• Patients with PD-L1 ≥ 50%, in these cases the oncologist may recommend combination chemotherapy + immunotherapy (pembrolizumab).

 

• Patients with PD-L1 ≥ 1% (even in PD-L1 negative tumours) and EGFR, ALK, ROS1 negative, these patients will receive a combination of chemotherapy + immunotherapy (pembrolizumab) if there are no contraindications.

Chemotherapy with immunotherapy is given once every 3 weeks (1 cycle) with up to a maximum of 4 cycles. If after 4 cycles of combined treatment there is no tumour growth, you will receive maintenance treatment of immunotherapy and chemotherapy for up to 2 years if you have adenocarcinoma.

 
If patients have any contraindication to receiving immunotherapy, chemotherapy treatment is given exclusively for 4 to 6 cycles. If there is no disease progression it may or may not be followed by maintenance treatment, depending on the cancer subtype.

• In patients with EGFR mutation (~12% of patients with lung adenocarcinoma) regardless of whether they have elevated PD-L1, the initial treatment of choice is never immunotherapy with or without chemotherapy, it is personalised treatment (gefitinib, afatinib, erlotinib, or osimertinib).

 

• If initial treatment fails with erlotinib, afatinib, or gefitinib, in 50% of cases this is due to the acquisition of a resistant mutation called T790M, this can be treated with osimertinib. To determine the existence of this progression mutation, a tissue biopsy is required, and failing that, a liquid biopsy (to try to determine the mutation through using a blood test).

 

• For ALK-positive patients (~5% of patients with lung adenocarcinoma), the most effective treatment is personalised treatment targeted against this abnormality (alectinib, crizotinib, brigatinib, ceritinib, lorlatinib).

 

• For patients who are ROS1 positive (~2% of patients with lung adenocarcinoma), the most effective treatment is personalised treatment targeted against the abnormality (crizotinib).

Genetic abnormalities are being increasingly identified in non-small cell lung cancer, these may be determinants for targeted treatment (RET, MET exon 14, NTRK…). A massive sequencing genomic test is now therefore recommended (Next Generation Sequencing or NGS).