Drug treatment of metastasized non-small cell lung cancer

Treatment algorithms for metastatic non-small cell lung cancer (NSCLC) have changed dramatically. Newly identified oncogenic alterations and new targeted treatment options as well as immunotherapies increase survival and quality of life for patients. Patients with treatable oncogenic alterations, i.e. oncogenic genetic alterations in the epidermal growth factor receptor (EGFR), anaplastic lymphoma kinase (ALK), ROS proto-oncogene 1 receptor tyrosine kinase (ROS-1) and B-rapidly accelerated fibrosarcoma (BRAF) genes benefit from targeted treatment. For patients with activating mutations on EGFR, first-line options include afatinib, dacomitinib, erlotinib, gefitinib and osimertinib. Possible first-line treatment of patients with ALK translocations includes alectinib, brigatinib, ceretinib, crizotinib, and lorlatinib. For patients with ROS-1 fusions crizotinib and for patients with BRAF mutations dabrafenib/trametinib are recommended. Patients without such oncogenic alterations should receive immunotherapy with checkpoint inhibitors as monotherapy or in combination with chemotherapy (after determining the programmed death ligand 1 [PD-L1] status). The PD-L1 expression is fundamental to decide the preferred first-line treatment.