The CheckMate-227 is evaluating the possibility to compare chemotherapy or nivolumab single agent or the combination of nivolumab and ipilimumab in metastatic non-small cell lung cancer first line treatment. The results are interesting because they show that there is a benefit of the combination of immunotherapy and immunotherapy in this kind of population.

These results add a new possibility for the treatment of metastatic non-small cell lung cancer, however, we have to understand better what is the right place to put this combination because in the first line setting now we have three options. The first option is monotherapy single agent with a PD-L1 more than 50%. We have all the trials combining chemotherapy and immunotherapy that demonstrated long term overall survival as well, independently by PD-L1 expression. And now we have also the combination with anti-CTLA4. The combination with anti-CTLA4 is interesting because it’s a chemo-sparing combination. The results, in particular in PD-L1 negative, in my opinion, are really interesting and for PD-L1 more than 50% we have to understand better what is the right position to do a combination rather than a single agent for this population.

I think that we have to speak very carefully with the patient that we have multiple options and to explain very well that also the toxicity profile is very different among the three strategies. As scientists we have to go back to the basic science, to the histology of these patients, to understand if we are able to personalise this treatment. There is still a lot of work to do.