Nivolumab as first line monotherapy for advanced non-small cell lung cancer: could we replace first line chemotherapy with immunotherapy?

While conventional chemotherapy has been the cornerstone of first line treatment of advanced non-small cell lung cancer (NSCLC) historically, there is a great appeal to the concept of bypassing this potentially toxic and only modestly effective approach with molecularly targeted therapies or immunotherapies that hold the promise of greater efficacy and improved quality of life. Over the past 5-10 years, we have seen novel agents such as epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK) inhibitors demonstrate striking activity and a generally favorable toxicity profile that have led these agents to be widely adopted as first line therapy ahead of conventional chemotherapy, albeit only in narrowly and molecularly defined subsets. One of the leading aspects of the excitement around immune checkpoint inhibitors such as nivolumab is that they appear to have impressive clinical activity that is not limited to a particular histologic subtype or comparatively small subpopulation, and with a very different and typically milder range of adverse effects than standard chemotherapeutic agents.