Lung cancer is the malignant disease with highest incidence and also the leading cause of cancer

mortality. Immunotherapy with antibodies to prevent the interaction of the programmed death
ligand-1 (PD-1) with the programmed death ligand (PD-L1) receptor, also known as CD274
(cluster of differentiation 274), has dramatically improved the survival of some patients with
lung cancer. Binding of PD-1 ligand to its receptors, PD-L1 or PD-L2, can prevent an innate
cytotoxic T-cell response against tumor by inhibiting kinases that are involved in T-cell
activation. Immunotherapy with anti-PD-L1 or anti-PD-1 antibodies unleashes the innate
immune system to react to the tumor growth (Yu, H. 2016).

Now, the Food and Drug Administration (FDA) approval of immune checkpoint inhibitors has
dramatically changed treatment paradigms for patients with advanced-stage or metastatic non-
small cell lung cancer (NSCLC). Despite significant improvements in survival, the majority of
NSCLC patients fail to respond to checkpoint inhibitors, notably antibodies targeting
programmed death-1 (PD-1) and programmed death ligand-1 (PD-L1), and uncertainties remain
regarding how best to use these therapies in clinical practice.

Checkpoint inhibitors block inhibitory T-cell signaling, thereby leading to an endogenous

antitumor immune response. PD-1 is a transmembrane immunoregulatory molecule responsible
for the negative regulation of T cell activation and peripheral tolerance. It is expressed on T cells,
B cells, and natural killer (NK) cells and binds to its ligands PD-L1 and PD-L2. Expression of
PD-L1 rarely occurs on normal tissues but is prevalent on antigen presenting cells (APCs) and
tumor cells in numerous solid malignancies including NSCLC. There is constitutive expression
of PD-L1 on tumor cells, which occurs during oncogenic processes in a state of chronic antigen
presentation, and inducible expression of PD-L1 at the tumor site in the presence of pro-
inflammatory cytokines such as interferon-gamma. (Mathew, 2017)

Working:
The phase III CheckMate (CM) 017 and 057 studies evaluated the role of nivolumab 3 mg/kg
every 2 weeks in previously treated squamous and non-squamous advanced NSCLC,
respectively. PD-L1 expression was assessed using the Dako 28-8 assay, and there was no
minimum PD-L1 expression level required for study entry or primary endpoint analysis. More
recently, the FDA granted accelerated approval to pembrolizumab in combination with platinum-
based chemotherapy in first-line NSCLC (non-squamous histology), irrespective of PD-L1
expression, based on results from the KN-021 trial.

This phase II study, which capitalizes on the immunological effects of chemotherapy to improve
the efficacy of immunotherapy, demonstrated significant improvements in ORR 55% and PFS
(HR 0.53, P=0.01) for patients treated with combination therapy (pembrolizumab with
carboplatin and pemetrexed) compared to chemotherapy alone. There was a suggestion of higher
proportion of responses in patients with a TPS of ≥50%, but sample sizes were too small for
significance. In comparison to the KN-024 trial, the phase III CM 026 trial evaluating the
efficacy of first-line nivolumab in stage IV/recurrent NSCLC with PD-L1 positive tumors
demonstrated no PFS or OS 95% benefit in patients with a PD-L1 expression level of ≥5%.
Similarly IDO, a enzyme producing the immunosuppressive environment as reported in
preclinical studies. In early stage studies, it shows promising result in responding to the
checkpoint blockade. But unfortunately in advanced stages IDO combined with anti PD-L1 drug
embrolizumab didn’t show promising results in Lung cancer (Mancuso,2015).

Why did KN-024 meet its primary endpoint when CM 026 did not? The difference is unlikely
due to biological differences between nivolumab and pembrolizumab, especially given the
similarities seen in large trials of previously treated patients (e.g., CM 017, 057, and KN-010).
The most obvious reason is the difference in PD-L1 cutoff, although this cannot explain the
entire story, as a subgroup analysis from CM 026 suggested that even patients whose tumors
harbored PD-L1 levels of at least 50% did not demonstrate a significantly improved PFS or OS
benefit with nivolumab compared to chemotherapy. Other factors may include imprecise
relationship between PD-L1 expression and therapeutic benefit to anti-PD-1/PD-L1 therapy, as
well as fundamental differences in the PD-L1 assays, differences in trial design (prior radiation,
glucocorticoid use during trial) and baseline patient characteristics (smoking history, sex).

Challenges:

Challenges with PD-L1 as a biomarker in NSCLC are assay-specific, biopsy-specific and

patient-specific. Inter-assay variability for PD-L1 immunostaining between Dako 28-8, Dako 22C3,
Ventana SP142, Ventana SP263 is assay-specific challenge and its solution is Ongoing cross-industry
collaboration, the Blueprint Project, aimed at inter-assay harmonization. Impact of
concurrent EGFR mutations and ALK rearrangements in PD-L1 positive tumors is patient
specific challenges and the proposed solution is Prospective studies looking anti-PD-1/PD-L1
agents in EGFR and ALK mutated patients.

Results:

With KN-024, patients with PD-L1 levels ≥50%, representing approximately 25% of NSCLC
patients, should receive pembrolizumab up-front. It is in this context that PD-L1 testing, using
the Dako 22C3 assay, is most useful. For treatment-naïve, non-squamous patients with lower
PD-L1 levels, the results of KN-021 provide an alternative approach to first-line chemotherapy
alone. Negative PD-L1 score may help decision-making with other immunotherapy
combinations, such as combined anti-CTLA-4/anti-PD-1/PD-L1 blockade or enrollment in a
clinical trial with novel checkpoint inhibitors targeting LAG, OX40, IDO, CD137, etc.
Furthermore, phase III ANVIL and PEARLS trials seek to evaluate nivolumab and
pembrolizumab, respectively, as adjuvant therapy for patients with resected stage IB to IIIA
NSCLC.

Future Outlook:
Efforts are ongoing to clarify the role of anti-PD-1/PD-L1 therapy outside of metastatic NSCLC.
The small-cell lung cancer (SCLC) cohort of CM-032, evaluating combination nivolumab and
ipilimumab, saw objective responses in one-third of patients treated with combination therapy.
There are certainly frustrations with PD-L1, but its dynamic nature also speaks to the dynamic
interaction between the immune system and tumor. As we continue to learn more about
immunotherapy, we will continue to strive for that elusive cure. Already, we have made
incredible progress from the days of conventional chemotherapy.
Refrences

Yu, H., Boyle, T. A., Zhou, C., Rimm, D. L., & Hirsch, F. R. (2016). PD-L1 expression in lung cancer. Journal of
Thoracic Oncology, 11(7), 964-975.

Mathew, M., Safyan, R. A., & Shu, C. A. (2017). PD-L1 as a biomarker in NSCLC: challenges and future
directions. Annals of translational medicine, 5(18).

Mancuso, R., Hernis, A., Agostini, S., Rovaris, M., Caputo, D., Fuchs, D., & Clerici, M. (2015). Indoleamine
2, 3 dioxygenase (IDO) expression and activity in relapsing-remitting multiple sclerosis. PLoS One, 10(6),
e0130715.