Immunotherapy for non–small cell lung cancer

Some people with lung cancer have immunotherapy. Immunotherapy helps to strengthen or restore the immune system's ability to fight cancer. Immunotherapy is sometimes called biological therapy.

You may have immunotherapy to:

• stop lung cancer cells from growing and spreading

• kill cancer cells

• control symptoms of advanced or metastatic lung cancer

Your healthcare team will consider your personal needs to plan the drugs, doses and schedules of immunotherapy. You may also receive other treatments.

The immune system normally stops itself from attacking normal cells in the body by using specific proteins called checkpoints, which are made by some immune system cells. PD-1 is an immune checkpoint protein that stops T cells from attacking other cells in the body. It does this by attaching to PD-L1, a protein found on some normal cells and some cancer cells.

Checkpoint inhibitor drugs may target either PD-1 or PD-L1 proteins.

These PD-1 and PD-L1 checkpoint immunotherapy drugs may be used to treat non–small cell lung cancer:

• pembrolizumab (Keytruda)

• nivolumab (Opdivo)

• durvalumab (Imfinzi)

• atezolizumab (Tecentriq, Tecentriq SQ)

• ipilimumab (Yervoy)

• cemiplimab (Libtayo)

Pembrolizumab is used in different ways to treat different types of lung cancer:

• To treat metastatic non–small cell lung cancer that has not had been treated with chemotherapy, pembrolizumab may be combined with carboplatin and paclitaxel or nab-paclitaxel (chemotherapy drugs).

• To treat non-squamous cell non–small cell lung cancer that has not been treated with chemotherapy and does not have mutations in the EGFR gene or ALK gene, pembrolizumab is combined with pemetrexed and cisplatin.

• To treat non–small cell lung cancer that has mutations in the EGFR gene (EGFR+) or ALK gene (ALK+) and that has stopped responding to a targeted therapy drug used to treat these genetic changes, pembrolizumab is used on its own.

Nivolumab may be used to treat locally advanced or metastatic non–small cell lung cancer that has stopped responding to chemotherapy or has come back after chemotherapy.

It may also be used to treat non–small cell lung cancer that is EGFR+ or ALK+ that has stopped responding to a targeted therapy drug used to treat these genetic changes.

Nivolumab combined with ipilimumab may be used as the first treatment for metastatic non–small cell lung cancer that does not have EGFR or ALK gene mutations and has very little PD-L1 in the cancer cells. Nivolumab and ipilimumab may also be used in combination with cisplatin or carboplatin plus another chemotherapy drug.

Atezolizumab (Tecentriq, Tecentriq SQ) may be offered for stage 2 to 3A non–small cell lung cancer tumours that express PD-L1. If the cancer hasn't grown or spread after chemotherapy has finished, then surgery is done to completely remove the tumour. Atezolizumab may be given after surgery.

Atezolizumab may be used as the first treatment for metastatic non–small cell lung cancer that doesn't have EGFR or ALK gene mutations. It can be given alone or in combination with bevacizumab (Avastin) or biosimilar drugs, paclitaxel and carboplatin.

It may also be used to treat locally advanced or metastatic non−small cell lung cancer that has stopped responding to chemotherapy or has come back after chemotherapy.

Atezolizumab may also be used to treat locally advanced or metastatic non–small cell lung cancer that has the EGFR or ALK gene mutation. It is offered if the cancer stops responding to a targeted therapy drug used to treat cancer with these genetic changes.

This drug may be given through a vein (intravenously) or under the skin (subcutaneously).

Durvalumab may be used to treat stage 3 non–small cell lung cancer that has responded to and is no longer growing after chemoradiation, in people who can't have surgery because of poor health or because of where the tumour is.

Cemiplimab (Libtayo) is used to treat non–small cell lung cancer that expresses a lot of PD-L1, but doesn't have mutations in the EGFR, ALK or ROS-1 genes.

It may be offered to people with locally advanced non–small cell lung cancer who can't have surgery or chemoradiation. It may also be used to treat metastatic non–small cell lung cancer.

Necitumumab (Portrazza) is a type of monoclonal antibody used to treat locally advanced or metastatic squamous non–small lung cancer in people who have not yet had any treatment. It is combined with the chemotherapy drugs gemcitabine (Gemzar) and cisplatin.

Immunotherapy is not used for small cell lung cancer very often. The immunotherapy drugs that target molecules in non–small cell lung cancer do not work on the molecules in small cell lung cancer. We need more research to find more drugs that are effective against small cell lung cancer.

Atezolizumab may be used in combination with the chemotherapy drugs carboplatin and etoposide (Vepesid) as the first treatment of extensive stage small cell lung cancer.

Side effects can happen with any type of treatment for non–small cell lung cancer, but everyone’s experience is different. Some people have many side effects. Other people have few or none at all.

Side effects of immunotherapy will depend mainly on the type of drug or drug combination, the dose, how it's given and your overall health. Some common side effects of immunotherapy for non–small cell lung cancer are:

• flu-like symptoms, such as fever and chills
• fatigue
• skin problems, including redness, itching and dryness
• inflammation of the lungs, thyroid, kidney, heart, liver or intestines
• changes to the endocrine system
• cytokine release syndrome
• low levels of magnesium, calcium, phosphorous or potassium in the blood (with necitumumab)

Tell your healthcare team if you have these side effects or others you think might be from immunotherapy. The sooner you tell them of any problems, the sooner they can suggest ways to help you deal with them.

Details on specific drugs change regularly. Find out more about sources of drug information and where to get details on specific drugs.

Find out more about immunotherapy. To make the decisions that are right for you, ask your healthcare team questions about immunotherapy.