Chair, Stephen V. Liu, MD, and Ibiayi Dagogo-Jack, MD, prepared useful Practice Aids pertaining to NSCLC for this CME/MOC activity titled “Perfecting Precision in Modern NSCLC Practice: Are You Optimally Integrating Biomarker-Driven Therapy?.” For the full presentation, downloadable Practice Aids, and complete CME/MOC information, and to apply for credit, please visit us at http://bit.ly/3imkOU8. CME/MOC credit will be available until February 26, 2024.

1. NSCLC Treatment Algorithm1
Full abbreviations, accreditation, and disclosure information available at PeerView.com/RYC40
NSCLC treatment algorithm
Stage and workup based on stage
•
cT1abc, N0: PFT, bronch, mediastinal staging, PET
•
cT2a-4, N0-3, M0-1: PFT, bronch, mediastinal staging, PET, brain MRI, and biomarker/mutation testing
Stage IA
Surgical candidate?
Lobectomy (preferred)
or
Segmentectomy/wedge
resection (in select cases)
SBRT
or
conventionally fractionated
RT
Surgical resection
Consider mutation and PD-L1 testing results
EGFR ex19del/ex21 L858R present?
Surgical resection
T1
N0
M0
Operable disease
Yes
Yes
Yes
No
No
No
Multidisciplinary discussion for neoadjuvant candidacy
Stage IB-IIIA (resectable)
Mutation (minimum EGFR; broad NGS
if possible) and PD-L1 testing
T1–2, N1–2, M0
T3–4, N0–1, M0
Neoadjuvant chemoimmunotherapy
Nivolumab + platinum-based chemotherapy x 3 cycles
CheckMate -816: Nivo + chemo vs chemo
mEFS: 31.6 vs 20.8 mo (HR, 0.63)
Adjuvant chemotherapy
Platinum-based chemotherapy
LACE Meta-analysis: 5-y OS improvement of 5.4% vs no chemo
Adjuvant immunotherapy (stage II-IIIA)
Atezolizumab x 16 cycles (PD-L1 1%)
IMpower010: Atezo vs BSC
mDFS: NR vs 35.3 mo (HR, 0.66)
Adjuvant targeted therapy
Osimertinib x 3 y
ADAURA: Osimertinib vs placebo
2-y DFS (stage II-IIIA): 90% vs 44% (HR, 0.17)
Pembrolizumab x 1 y
PEARLS/KEYNOTE-091: Pembro vs placebo
mDFS: 53.6 vs 42.0 mo (HR, 0.76)

2. NSCLC Treatment Algorithm1
Full abbreviations, accreditation, and disclosure information available at PeerView.com/RYC40
Stage IIIA (unresectable) or IIIB/C
Definitive chemoradiation → durvalumab
Concurrent platinum-based chemotherapy and radiation with
consolidation durvalumab
PACIFIC: Durvalumab vs placebo
mPFS: 16.8 vs 5.6 mo (HR, 0.52)
BRAF V600E
Dabrafenib + trametiniba
BRF113928: Dabrafenib + trametinib single arm
ORR: 64% (95% CI, 46-79)
2nd line: KRAS G12C
Sotorasib
CodeBreaK100: Sotorasib single arm
ORR: 37.1% (95%CI, 29-46); mPFS: 6.8 mo
ALK
Alectiniba
ALEX: Alectinib vs crizotinib
1-y PFS: 68.4% vs 48.7% (HR, 0.47)
Brigatiniba
ALTA-1L: Brigatinib vs crizotinib
mPFS: 24 vs 11.1 mo (HR, 0.48)
Lorlatiniba
CROWN: Lorlatinib vs crizotinib
mPFS: NR vs 9.3 mo, (HR, 0.28); 1-y PFS: 78% vs 39%
Ceritinib
ASCEND-4: Ceritinib vs chemo
mPFS: 16.6 vs 8.1 mo (HR, 0.55)
Crizotinib
PROFILE 1007: Crizotinib vs chemo
mPFS: 7.7 vs 3 mo (HR, 0.49)
NTRK
Larotrecteniba
Entrectiniba
ALKA/STARTRK: Entrectinib single arm
ORR: 70% (NSCLC)
RET
Selpercatiniba
LIBRETTO-001: Selpercatinib single arm
ORR: 64%; mDOR: 17.5 mo
Pralsetiniba
ARROW: Pralsetinib single arm
ORR: 61% (95% CI, 50-71)
2nd line: EGFR (ex20)
Amivantamab
CHRYSALIS: Amivantamab single arm
CBR: 74% (95%CI, 63-83); mPFS: 8.3 mo
Mobocertinib
AP32788-15-101: Mobocertinib single arm
DCR: 78% (95% CI, 69-85); mPFS: 7.3 mos
ROS1
Crizotiniba
PROFILE 1001: Crizotinib single arm
ORR: 72% (95% CI, 58-84)
Entrectiniba
ALKA STARTRK: Entrectinib single arm
ORR: 67.1%; mPFS: 19 mo
Ceritinib
YONSEI: Ceritinib single arm
ORR: 67% (95% CI, 48-81)
EGFR (ex19 del or L858R)
Osimertiniba
FLAURA: Osimertinib vs erlotinib/gefitinib
mPFS: 18.9 vs 10.2 mo (HR, 0.46)
Erlotinib
EURTAC: Erlotinib vs chemo
mPFS: 9.7 vs 5.2 mo (HR, 0.37)
Afatinib
LUX-Lung 3: Afatinib vs cis/pemetrexed
mPFS: 13.6 vs 6.9 mo (HR, 0.47)
Gefitinib
IFUM: Gefitinib single arm
mPFS: 9.7 mo
Dacomitinib
ARCHER 1050: Dacomitinib vs geftinib
mOS: 34.1 vs 27 mo (HR, 0.75)
Erlotinib + ramucirumab
RELAY: Erlotinib + ramucirumab vs elotinib
mPFS: 19.4 vs 12.4 mo (HR, 0.59)
Erlotinib + bevacizumab
ARTEMIS-CTONG1509: Erlotinib + bevacizumab vs erlotinib
mPFS: 17.9 vs 11.2 mo (HR, 0.55)
MET (exon 14)
Capmatiniba
GEOMETRY mono-1: Capmatinib single arm
mPFS: 12.4 mo
Tepotiniba
VISION: Tepotinib single arm
mPFS: 8.5-11 mo
2nd line: HER2
Trastuzumab deruxtecan
DESTINY-Lung01
T-DXd single arm
ORR: 55% (95% CI, 44-65); mPFS: 8.2 mo
T1-2, N2–3, M0
T3, N1–3, M0
T4, N0–3, M0
Tx
Nx
M1
Actionable mutation detected
• EGFR (ex19, ex20ins)
• ALK
• ROS1
• BRAF V600E
• RET
• MET (ex14)
• HER2
• NTRK1/2/3
• KRAS G12C
Mutation (minimum EGFR; broad NGS if possible) and PD-L1 testing
NSCLC treatment algorithm
Stage and workup based on stage
•
cT1abc, N0: PFT, bronch, mediastinal staging, PET
•
cT2a-4, N0-3, M0-1: PFT, bronch, mediastinal staging, PET, brain MRI, and biomarker/mutation testing
Please see the next page for recommendations if no actionable mutation is detected
Stage IV
KRYSTAL-1: Adagrasib single arm
ORR: 43% (95% CI, 34-53); mDOR: 8.5 mo

3. NSCLC Treatment Algorithm1
Full abbreviations, accreditation, and disclosure information available at PeerView.com/RYC40
a
Denotes NCCN-preferred regimens.
1. Created by Aakash Desai, MBBS, MPH, and Matthew Ho, MD, PhD. Used with permission from the authors.
PD-L1 1%
IMMUNOTHERAPY + CHEMOTHERAPY
SQUAMOUS:
• Pembrolizumab + chemotherapya
(carboplatin + paclitaxel/nab-paclitaxel)
KEYNOTE-407: Pembro + chemo vs chemo
mPFS: 6.4 vs 4.8 mo (HR, 0.56); mOS: 15.9 vs 11.3 mo (HR, 0.64)
NONSQUAMOUS:
• Pembrolizumab + chemotherapy (carboplatin + pemetrexed)a
KEYNOTE-189: Pembro + chemo vs chemo
mPFS: 8.8 vs 4.9 mo (HR, 0.52), 12-mo; OS: 69% vs 49% (HR, 0.49)
• Atezolizumab + chemotherapy (carboplatin + paclitaxel + bevacizumab)
IMpower150: Atezo + chemo vs chemo
mPFS: 8.3 vs 6.8 mo (HR, 0.62)
DUAL IMMUNOTHERAPY + CHEMOTHERAPY
Nivolumab + ipilimumab + chemo (2 cycles)
CheckMate -9LA: Nivo/ipi + chemo vs chemo
mOS: 14.1 vs 10.7 mo
Durvalumab + tremelimumab + chemo (4 cycles)
POSEIDON: Durva/treme + chemo vs chemo
mOS: 14 vs 11.7 mo (HR, 0.77)
DUAL IMMUNOTHERAPY
Nivolumab + ipilimumab
CheckMate -227: Nivo/ipi vs chemo
mOS: 17.1 vs 14.9 mo
DUAL IMMUNOTHERAPY + CHEMOTHERAPY
Nivolumab + ipilimumab + chemo (2 cycles)
CheckMate -9LA: Nivo/ipi + chemo vs chemo
mOS: 14.1 vs 10.7 mo
Durvalumab + tremelimumab + chemo (4 cycle)
POSEIDON: Durva/treme + chemo vs chemo
mOS: 14 vs 11.7 mo (HR, 0.77)
IMMUNOTHERAPY MONOTHERAPY
Pembrolizumab
KEYNOTE-042: Pembro vs plat-based chemo
mOS: 16.7 vs 12.1 mo (HR, 0.81)
Ramucirumab + docetaxela
REVEL: Ram/docetaxel vs docetaxel; mOS: 10.5 vs 9.1 mo (HR, 0.86)
Docetaxela
TAX320: Docetaxel vs vinorelbine/ifosfamide; 1-y OS: 32% vs 19%
Gemcitabine
DUAL IMMUNOTHERAPY
Nivolumab + ipilimumab
CheckMate -227: Nivo/ipi vs chemo
mOS: 17.1 vs 14.9 mo
DUAL IMMUNOTHERAPY + CHEMOTHERAPY
Nivolumab + ipilimumab + chemo (2 cycles)
CheckMate -9LA: Nivo/ipi + chemo vs chemo
OS: 14.1 vs 10.7 mo
Durvalumab + tremelimumab + chemo (4 cycles)
POSEIDON: Durva/treme + chemo vs chemo
mOS: 14 vs 11.7 mo (HR, 0.77)
PD-L1 1%-49%
IMMUNOTHERAPY + CHEMOTHERAPY
SQUAMOUS:
• Pembrolizumab+chemotherapya
(carboplatin+paclitaxel/nab-paclitaxel)
KEYNOTE-407: Pembro + chemo vs chemo
mPFS: 6.4 vs 4.8 mo (HR, 0.56); mOS: 15.9 vs 11.3 mo (HR, 0.64)
NONSQUAMOUS:
• Pembrolizumab + chemotherapy (carboplatin + pemetrexed)a
KEYNOTE-189: Pembro + chemo vs chemo
mPFS: 8.8 vs 4.9 mo (HR, 0.52); 12-mo OS: 69% vs 49% (HR, 0.49)
• Atezolizumab + chemotherapy (carboplatin + paclitaxel + bevacizumab)
IMpower150 : Atezo + chemo vs chemo
mPFS: 8.3 vs 6.8 mo (HR, 0.62)
• Cemiplimab + chemotherapy (carboplatin + pemetrexed)
EMPOWER-Lung 3: Cemi + chemo vs chemo
mOS: 21.9 vs 13 mo (HR, 0.7)
PD-L1 50%
IMMUNOTHERAPY MONOTHERAPY
Pembrolizumaba
KEYNOTE-024: Pembro vs platinum-based chemo
mPFS: 10.3 vs 6 mo (HR, 0.50)
Atezolizumaba
IMpower110: Atezo vs platinum-based chemo
mOS: 20.1 vs 13.1 mo (HR, 0.59)
Cemiplimaba
EMPOWER-Lung1: Cemi vs platinum-based chemo
mPFS: 8.2 vs 5.7 mo; mOS: NR vs 14.2 mo (HR, 0.57)
IMMUNOTHERAPY + CHEMOTHERAPY
SQUAMOUS:
• Pembrolizumab + chemotherapya
(carboplatin + paclitaxel/nab-paclitaxel)
KEYNOTE-407: Pembro + chemo vs chemo
mPFS: 6.4 vs 4.8 mo (HR, 0.56); mOS: 15.9 vs 11.3 mo (HR, 0.64)
NONSQUAMOUS:
• Pembrolizumab + chemotherapya
(carboplatin + pemetrexed)
KEYNOTE-189: Pembro + chemo vs chemo
mPFS: 8.8 vs 4.9 mo (HR, 0.52); 12-mo OS: 69% vs 49% (HR, 0.49)
• Atezolizumab + chemotherapy (carboplatin + paclitaxel + bevacizumab)
IMpower150: Atezo + chemo vs chemo
mPFS: 8.3 vs 6.8 mo (HR, 0.62)
No actionable mutation detected (stratify based on PD-L1 staining %)
Second-line therapy