1.1 Pembrolizumab with pemetrexed and platinum chemotherapy is recommended as an option for untreated, metastatic, non-squamous non-small-cell lung cancer (NSCLC) in adults whose tumours have no epidermal growth factor receptor (EGFR)‑positive or anaplastic lymphoma kinase (ALK)‑positive mutations. This is only if:
it is stopped at 2 years of uninterrupted treatment, or earlier if the disease progresses and
the company provides pembrolizumab according to the commercial arrangement.
Why the committee made these recommendations
This appraisal reviews the additional evidence collected as part of the Cancer Drugs Fund managed access agreement for pembrolizumab with pemetrexed and platinum chemotherapy (pembrolizumab combination) for untreated, metastatic, non‑squamous NSCLC (NICE technology appraisal guidance 557).
Standard care for tumours that have no EGFR‑positive or ALK‑positive mutations depends on PD‑L1 status. If tumours are PD‑L1 negative, or PD‑L1 positive with a tumour proportion score below 50%, pemetrexed with carboplatin or cisplatin (pemetrexed platinum chemotherapy) may be offered. If tumours are PD‑L1 positive with a score of at least 50%, pembrolizumab monotherapy is offered. Pembrolizumab combination would be offered whether or not tumours are PD‑L1 positive, and regardless of tumour proportion score.
Clinical evidence collected while pembrolizumab combination was in the Cancer Drugs Fund shows that people having pembrolizumab combination for up to 2 years are likely to live longer than those who have pemetrexed platinum chemotherapy. There are no clinical trials directly comparing pembrolizumab combination with pembrolizumab monotherapy. But an indirect comparison suggests that for people with PD‑L1 positive tumours with a tumour proportion score of at least 50%, there is no difference in how long people having pembrolizumab combination live compared with pembrolizumab monotherapy.
Pembrolizumab combination meets NICE's criteria to be considered a life-extending end of life treatment compared with pemetrexed platinum chemotherapy but does not meet the criteria when compared with pembrolizumab monotherapy.
The cost-effectiveness estimates for pembrolizumab combination are within what NICE considers to be an acceptable use of NHS resources, if it is stopped at 2 years. So, it is recommended.