1 Recommendations

1 Recommendations

1.1 Atezolizumab plus bevacizumab, carboplatin and paclitaxel is recommended as an option for metastatic non-squamous non-small-cell lung cancer (NSCLC) in adults:

  • who have not had treatment for their metastatic NSCLC before and whose PD-L1 tumour proportion score is between 0% and 49% or

  • when targeted therapy for epidermal growth factor receptor (EGFR)‑positive or anaplastic lymphoma kinase (ALK)‑positive NSCLC has failed.

    It is recommended only if:

  • atezolizumab and bevacizumab are stopped at 2 years of uninterrupted treatment, or earlier if there is loss of clinical benefit (for atezolizumab) or if the disease progresses (for bevacizumab) and

  • the company provides atezolizumab and bevacizumab according to the commercial arrangements.

1.2 This recommendation is not intended to affect treatment with atezolizumab plus bevacizumab, carboplatin and paclitaxel that was started in the NHS before this guidance was published. People having treatment outside this recommendation may continue without change to the funding arrangements in place for them before this guidance was published, until they and their NHS clinician consider it appropriate to stop.

Why the committee made these recommendations

Pemetrexed plus carboplatin or cisplatin, with or without pemetrexed maintenance, is the current treatment for:

  • untreated metastatic non-squamous NSCLC (with no EGFR- or ALK‑positive mutations) with a PD‑L1 tumour proportion score between 0% and 49% and

  • metastatic non-squamous EGFR- or ALK-positive NSCLC when targeted therapy is either not an option or has failed.

Pembrolizumab monotherapy is the current treatment for untreated metastatic non-squamous NSCLC with a PD‑L1 tumour proportion score of at least 50%.

An indirect comparison of studies suggests that people having atezolizumab plus bevacizumab, carboplatin and paclitaxel live longer than those having pemetrexed plus carboplatin or cisplatin, with or without pemetrexed maintenance. This comparison also suggests that they live for longer before their condition worsens.

Atezolizumab plus bevacizumab, carboplatin and paclitaxel meets NICE's criteria to be considered a life-extending treatment at the end of life. There is uncertainty about the company's long-term survival estimates, especially for people with EGFR- or ALK‑positive NSCLC. But including the most plausible assumptions and the commercial arrangements, the cost-effectiveness estimates are within what NICE normally considers acceptable for an end-of-life treatment. Therefore, atezolizumab plus bevacizumab, carboplatin and paclitaxel is recommended for metastatic non-squamous NSCLC that is untreated (with no EGFR- or ALK‑positive mutations) and when the PD‑L1 tumour proportion score is between 0% and 49%, or that is EGFR- or ALK‑positive and for which targeted therapy has failed.

Atezolizumab and bevacizumab are stopped at 2 years of uninterrupted treatment, or earlier if there is loss of clinical benefit (for atezolizumab) or if the disease progresses (for bevacizumab). This is because the cost-effectiveness evidence was primarily based on 2 years of treatment and the best duration of treatment is unknown.

No recommendation can be made for atezolizumab plus bevacizumab, carboplatin and paclitaxel for treating untreated PD‑L1‑positive metastatic NSCLC in people whose PD‑L1 tumour proportion score is at least 50% because no cost-effectiveness analyses comparing atezolizumab plus bevacizumab, carboplatin and paclitaxel with pembrolizumab monotherapy were provided.

  • National Institute for Health and Care Excellence (NICE)