Treatment options after first-line immunotherapy in metastatic NSCLC

Introduction: The recent approvals of checkpoint inhibitors as single agents or in combination with chemotherapy with programmed death ligand 1 expression of < or ≥1% have challenged clinicians when it is time to begin a metastatic lung cancer patient in second-line therapy. The advantages given by immunotherapy over conventional chemotherapy such as improved overall survival and a better toxicity profile make the second-line clinical scenario more difficult for a patient who faces a likely inferior regimen as well as toxicity which may significantly impact the quality of life.Areas covered: Options given today by the National Comprehensive Cancer Network are very limited, and essentially, we go back to conventional cytotoxic agents alone or in combination with biological agents if possible. In this article, we discuss the actual treatment available for this difficult scenario and some of the ongoing trials which aim to address this dilemma.Expert commentary: This is an unmet need in lung cancer management; we need a better understanding of the mechanism of resistance to immunotherapy so we can target them once the patient moves to second-line treatment.