KRAS G12C-mutant non-small cell lung cancer: A practical guide for clinicians

KRAS G12C-mutant non-small cell lung cancer (NSCLC) occurs in approximately 15% of NSCLC with historically limited targeted treatment options. Both KRAS "OFF"" G12C inhibitors, sotorasib and adagrasib, are considered standard second-line therapy, albeit with a modest progression-free survival benefit over standard chemotherapy. Emerging next-generation KRAS "OFF" G12C inhibitors, as well as KRAS "ON", dual "ON/OFF", and pan-(K)RAS "ON" inhibitors, show promising early efficacy and safety profiles in second-line, though confirmatory phase III trials are pending. In the first-line setting, KRAS inhibitor-immunotherapy combinations appear particularly promising in tumors with high programmed death-ligand 1 (PD-L1) expression. However, incorporating KRAS inhibitors into chemoimmunotherapy regimens may yield more consistent and clinically meaningful benefit across patient populations, irrespective of PD-L1 expression. Critical clinical questions remain open regarding the optimal patient population for combinations, the influence of co-occurring genomic alterations, intracranial activity of KRAS inhibitors and dose optimization. This review synthesizes current evidence on the biology, clinical efficacy, safety, and practical considerations for treating KRAS G12C-mutant NSCLC, providing clinicians with an up-to-date, evidence-based framework for therapeutic decision-making and highlighting areas requiring further investigation.