P40.18 Second Line Immunotherapy After Progression on a Different First Line Immunotherapy in Advanced Non-Small Cell Lung Cancer With Focus On Elderly

Abstract

Background: Immune check point inhibitors (ICI) have become the standard of care in treatment of patients with advanced non-small cell lung cancer (NSCLC). After progression on first line ICI, 2nd line treatment with chemotherapy poses a challenge especially in elderly (age ≥70) or borderline performance status (ECOG ≥2) patients, as potential adverse effects could negatively impact quality of life. Current guidelines do not recommend switching to another immunotherapy after progression of disease (POD); however, there are some case series showing effectiveness of this strategy in select patients. We report here our experience in patients treated with a second line ICI after POD on first line ICI at Mayo Clinic, Florida, between 2016-2020, with focus on elderly and borderline performance status patients. A list of 153 NSCLC patients undergoing ICI therapy for advanced NSCLC was obtained from Mayo Clinic Florida database. A comprehensive chart review was conducted to identify patients who received a subsequent ICI therapy after progression on initial PD1-PDL1 inhibitor. Data collection included demographics, performance status, PDL1 status, overall survival (OS) ,progression free survival (PFS) and adverse events. 27 out of 153 patients were treated with a second ICI after the first ICI was stopped due to progression (25 pts) or due to adverse effects (2 pts). Among the 27 pts, 14 were elderly (≥70) and 11 had ECOG ≥2. All patients had advanced NSCLC with 22 of 27 patients having metastatic NSCLC. 15 patients were positive for PDL1 expression (>1%) while 9 patients had no PDL1 expression (<1%). Of the 27 patients, 22 were initially treated with a PD1 inhibitor (17 with pembrolizumab and 5 with nivolumab) and 5 were treated with a PDL1 inhibitor (durvalumab). After progression, therapy was switched as following: • 18 patients were switched from a PD1 inhibitor (pembrolizumab or nivolumab), to a PDL1 inhibitor (atezolizumab, durvalumab and tremelimumab, or avelumab) • 3 patients were switched from a PDL1 inhibitor (Durvalumab) to PD1 inhibitor (pembrolizumab). • 6 patients were switched to a different agent of the same class. The median overall survival in our population was 27.4 months. The median PFS on a second ICI was 4.3 months. Median PFS on a second ICI in elderly patients and those with ECOG ≥ 2 was 4.8 months and 3.6 months, respectively. Grade ≥3 adverse events were reported in 7 patients (26%) including one patient who had the drug discontinued due to grade 3 hepatitis. Specifically, in the elderly patients, grade ≥3 adverse events were reported in 21% of patients (3/14) while the same was reported in 27% of patients (3/11) with ECOG ≥2. In patients with advanced NSCLC and borderline performance status or age ≥70, treatment with 2nd line immunotherapy after progression on a different 1st line immunotherapy was well tolerated and led to a PFS that is comparable to standard 2nd line chemotherapy.