guide to scoring pd-l1 expression using ...6 7 identify patients with pd-l1 expression using cps...

GUIDE TO SCORING PD-L1 EXPRESSION USING COMBINED POSITIVE SCORE (CPS)

FOR PATHOLOGISTS

PD-L1 = programmed death ligand 1.

2 3

YOUR REPORT MAY INDICATE POTENTIAL ELIGIBILITY FOR TREATMENT WITH KEYTRUDA

SELECTED SAFETY INFORMATION

Severe and Fatal Immune-Mediated Adverse Reactions

• KEYTRUDA is a monoclonal antibody that belongs to a class of drugs that bind to either the programmed death receptor-1(PD-1) or the programmed death ligand 1 (PD-L1), blocking the PD-1/PD-L1 pathway, thereby removing inhibition of the immuneresponse, potentially breaking peripheral tolerance and inducing immune-mediated adverse reactions. Immune-mediatedadverse reactions, which may be severe or fatal, can occur in any organ system or tissue, can affect more than one body systemsimultaneously, and can occur at any time after starting treatment or after discontinuation of treatment. Important immune-mediated adverse reactions listed here may not include all possible severe and fatal immune-mediated adverse reactions.

• Monitor patients closely for symptoms and signs that may be clinical manifestations of underlying immune-mediated adversereactions. Early identification and management are essential to ensure safe use of anti–PD-1/PD-L1 treatments. Evaluateliver enzymes, creatinine, and thyroid function at baseline and periodically during treatment. In cases of suspected immune-mediated adverse reactions, initiate appropriate workup to exclude alternative etiologies, including infection. Institute medicalmanagement promptly, including specialty consultation as appropriate.

Cancer Indication PD-L1 Expression

KEYTRUDA, as a single agent, is indicated for the first-line treatment of patients with metastatic or with unresectable, recurrent head and neck squamous cell carcinoma (HNSCC) whose tumors express PD-L1 (CPS ≥1) as determined by an FDA-approved test.

CPS ≥1

KEYTRUDA, in combination with platinum and fluorouracil (FU), is indicated for the first-line treatment of patients with metastatic or with unresectable, recurrent HNSCC.

No testing required

KEYTRUDA, as a single agent, is indicated for the treatment of patients with recurrent or metastatic HNSCC with disease progression on or after platinum-containing chemotherapy.

No testing required

KEYTRUDA is indicated for the treatment of patients with locally advanced or metastatic urothelial carcinoma (mUC) who are not eligible for cisplatin-containing chemotherapy and whose tumors express PD-L1 (CPS ≥10), as determined by an FDA-approved test. This indication is approved under accelerated approval based on tumor response rate and duration of response. Continued approval for this indication may be contingent upon verification and description of clinical benefit in confirmatory trials.

CPS ≥10

KEYTRUDA is indicated for the treatment of patients with locally advanced or mUC who are not eligible for any platinum-containing chemotherapy regardless of PD-L1 status. This indication is approved under accelerated approval based on tumor response rate and duration of response. Continued approval for this indication may be contingent upon verification and description of clinical benefit in confirmatory trials.

No testing required

KEYTRUDA is indicated for the treatment of patients with locally advanced or mUC who have disease progression during or following platinum-containing chemotherapy or within 12 months of neoadjuvant or adjuvant treatment with platinum-containing chemotherapy.

No testing required

YOUR REPORT MAY INDICATE POTENTIAL ELIGIBILITY FOR TREATMENT WITH KEYTRUDA

Cancer Indication PD-L1 Expression

KEYTRUDA is indicated for the treatment of patients with recurrent locally advanced or metastatic gastric or gastroesophageal junction (GEJ) adenocarcinoma whose tumors express PD-L1 (CPS ≥1) as determined by an FDA-approved test, with disease progression on or after two or more prior lines of therapy including fluoropyrimidine- and platinum-containing chemotherapy and if appropriate, HER2/neu-targeted therapy. This indication is approved under accelerated approval based on tumor response rate and durability of response. Continued approval for this indication may be contingent upon verification and description of clinical benefit in the confirmatory trials.

CPS ≥1

KEYTRUDA is indicated for the treatment of patients with recurrent locally advanced or metastatic squamous cell carcinoma of the esophagus whose tumors express PD-L1 (CPS ≥10) as determined by an FDA-approved test, with disease progression after one or more prior lines of systemic therapy.

CPS ≥10

KEYTRUDA is indicated for the treatment of patients with recurrent or metastatic cervical cancer with disease progression on or after chemotherapy whose tumors express PD-L1 (CPS ≥1) as determined by an FDA-approved test. This indication is approved under accelerated approval based on tumor response rate and durability of response. Continued approval for this indication may be contingent upon verification and description of clinical benefit in the confirmatory trials.

CPS ≥1

HER2/neu = human epidermal growth factor receptor 2; ESCC = esophageal squamous cell carcinoma.

• Withhold or permanently discontinue KEYTRUDA depending on severity of the immune-mediated adverse reaction. Ingeneral, if KEYTRUDA requires interruption or discontinuation, administer systemic corticosteroid therapy (1 to 2 mg/kg/dayprednisone or equivalent) until improvement to Grade 1 or less. Upon improvement to Grade 1 or less, initiate corticosteroidtaper and continue to taper over at least 1 month. Consider administration of other systemic immunosuppressants in patientswhose adverse reactions are not controlled with corticosteroid therapy.

Immune-Mediated Pneumonitis

• KEYTRUDA can cause immune-mediated pneumonitis. The incidence is higher in patients who have received priorthoracic radiation. Immune-mediated pneumonitis occurred in 3.4% (94/2799) of patients receiving KEYTRUDA,including fatal (0.1%), Grade 4 (0.3%), Grade 3 (0.9%), and Grade 2 (1.3%) reactions. Systemic corticosteroids wererequired in 67% (63/94) of patients. Pneumonitis led to permanent discontinuation of KEYTRUDA in 1.3% (36)and withholding in 0.9% (26) of patients. All patients who were withheld reinitiated KEYTRUDA after symptomimprovement; of these, 23% had recurrence. Pneumonitis resolved in 59% of the 94 patients.

Immune-Mediated Colitis

• KEYTRUDA can cause immune-mediated colitis, which may present with diarrhea. Cytomegalovirus infection/reactivationhas been reported in patients with corticosteroid-refractory immune-mediated colitis.

HNSCC

Advanced urothelial carcinoma

Advanced gastric or GEJ

cancer

Advanced cervical cancer

Advanced ESCC

Before prescribing KEYTRUDA, please read the accompanying Prescribing Information. The Medication Guide also is available.

SELECTED SAFETY INFORMATION (continued)Severe and Fatal Immune-Mediated Adverse Reactions (continued)

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Examples of HNSCC tumor specimens using PD-L1 IHC 22C3 pharmDx2

© Agilent Technologies, Inc.Reproduced with Permission, Courtesy of Agilent Technologies, Inc.

IDENTIFY PATIENTS WITH PD-L1 EXPRESSION USING CPS

PD-L1 expression status helps inform treatment decisions with KEYTRUDA

Hepatotoxicity and Immune-Mediated Hepatitis

KEYTRUDA as a Single Agent

• KEYTRUDA can cause immune-mediated hepatitis. Immune-mediated hepatitis occurred in 0.7% (19/2799) of patients receivingKEYTRUDA, including Grade 4 (

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SELECTED SAFETY INFORMATION (continued)Severe and Fatal Immune-Mediated Adverse Reactions (continued)Immune-Mediated Endocrinopathies

Adrenal Insufficiency

• KEYTRUDA can cause primary or secondary adrenal insufficiency. For Grade 2 or higher, initiate symptomatictreatment, including hormone replacement as clinically indicated. Withhold KEYTRUDA depending on severity.

Examples of gastric tumor specimens using PD-L1 IHC 22C3 pharmDx4

© Agilent Technologies, Inc. 2018Reproduced with Permission, Courtesy of Agilent Technologies, Inc.



Examples of cervical tumor specimens using PD-L1 IHC 22C3 pharmDx6

© Agilent Technologies, Inc. 2018 Reproduced with Permission, Courtesy of Agilent Technologies, Inc.

Adrenal insufficiency occurred in 0.8% (22/2799) of patients receiving KEYTRUDA, including Grade 4 (

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CPS =

PD-L1 staining on both tumor cells and certain tumor-associated immune cells are evaluated when determining the CPS numerator1

PD-L1–staining cells are1,3,4:• Tumor cells with convincing partial or complete linear membrane staining (at any intensity) that is perceived as

distinct from cytoplasmic staining.

• Lymphocytes and macrophages (MICs) within the tumor nests and/or adjacent supporting stroma with convincingmembrane and/or cytoplasmic staining (at any intensity). MICs must be directly associated with the responseagainst the tumor.

Tumor cells and immune cells demonstrating convincing partial, , and/or complete, , linear membrane staining at any intensity (including weak [1+], ) should be included in the CPS numerator (gastric specimen). Note that MICs can have membrane and/or cytoplasmic staining.


When positioning the tumor cells in the approximate center of a 20× field, PD-L1–staining MICs that are present within the same field should be included in the numerator (20x magnification, urothelial specimen).3


Hypophysitis

• KEYTRUDA can cause immune-mediated hypophysitis. Hypophysitis can present with acute symptoms associatedwith mass effect such as headache, photophobia, or visual field defects. Hypophysitis can cause hypopituitarism.Initiate hormone replacement as indicated. Withhold or permanently discontinue KEYTRUDA depending on severity.Hypophysitis occurred in 0.6% (17/2799) of patients receiving KEYTRUDA, including Grade 4 (

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• KEYTRUDA can cause immune-mediated thyroid disorders. Thyroiditis can present with or without endocrinopathy.Hypothyroidism can follow hyperthyroidism. Initiate hormone replacement for hypothyroidism or institute medicalmanagement of hyperthyroidism as clinically indicated. Withhold or permanently discontinue KEYTRUDA dependingon severity. Thyroiditis occurred in 0.6% (16/2799) of patients receiving KEYTRUDA, including Grade 2 (0.3%). Nonediscontinued, but KEYTRUDA was withheld in

12 13Before prescribing KEYTRUDA, please read the accompanying Prescribing Information. The Medication Guide also is available.

Other Immune-Mediated Adverse Reactions (continued)

Some cases can be associated with retinal detachment. Various grades of visual impairment, including blindness, can occur. If uveitis occurs in combination with other immune-mediated adverse reactions, consider a Vogt-Koyanagi-Harada-like syndrome, as this may require treatment with systemic steroids to reduce the risk of permanent vision loss; Gastrointestinal: Pancreatitis, to include increases in serum amylase and lipase levels, gastritis, duodenitis; Musculoskeletal and Connective Tissue: Myositis/polymyositis, rhabdomyolysis (and associated sequelae, including renal failure), arthritis (1.5%), polymyalgia rheumatica; Endocrine: Hypoparathyroidism; Hematologic/Immune: Hemolytic anemia, aplastic anemia, hemophagocytic lymphohistiocytosis, systemic inflammatory response syndrome, histiocytic necrotizing lymphadenitis (Kikuchi lymphadenitis), sarcoidosis, immune thrombocytopenic purpura, solid organ transplant rejection.

Infusion-Related Reactions

• KEYTRUDA can cause severe or life-threatening infusion-related reactions, including hypersensitivity andanaphylaxis, which have been reported in 0.2% of 2799 patients receiving KEYTRUDA. Monitor for signs andsymptoms of infusion-related reactions. Interrupt or slow the rate of infusion for Grade 1 or Grade 2 reactions. ForGrade 3 or Grade 4 reactions, stop infusion and permanently discontinue KEYTRUDA.

Complications of Allogeneic Hematopoietic Stem Cell Transplantation (HSCT)

• Fatal and other serious complications can occur in patients who receive allogeneic HSCT before or afteranti–PD-1/PD-L1 treatments. Transplant-related complications include hyperacute graft-versus-host disease(GVHD), acute and chronic GVHD, hepatic veno-occlusive disease after reduced intensity conditioning, andsteroid-requiring febrile syndrome (without an identified infectious cause). These complications may occurdespite intervening therapy between anti–PD-1/PD-L1 treatments and allogeneic HSCT. Follow patients closely forevidence of these complications and intervene promptly. Consider the benefit vs risks of using anti–PD-1/PD-L1treatments prior to or after an allogeneic HSCT.

Increased Mortality in Patients With Multiple Myeloma

• In trials in patients with multiple myeloma, the addition of KEYTRUDA to a thalidomide analogue plusdexamethasone resulted in increased mortality. Treatment of these patients with an anti–PD-1/PD-L1 treatment inthis combination is not recommended outside of controlled trials.

Embryofetal Toxicity

• Based on its mechanism of action, KEYTRUDA can cause fetal harm when administered to a pregnant woman.Advise women of this potential risk. In females of reproductive potential, verify pregnancy status prior to initiatingKEYTRUDA and advise them to use effective contraception during treatment and for 4 months after the last dose.

Adverse Reactions

• In KEYNOTE-048, KEYTRUDA monotherapy was discontinued due to adverse events in 12% of 300 patients withHNSCC; the most common adverse reactions leading to permanent discontinuation were sepsis (1.7%) and pneumonia(1.3%). The most common adverse reactions (≥20%) were fatigue (33%), constipation (20%), and rash (20%).

• In KEYNOTE-048, when KEYTRUDA was administered in combination with platinum (cisplatin or carboplatin) andFU chemotherapy, KEYTRUDA was discontinued due to adverse reactions in 16% of 276 patients with HNSCC. Themost common adverse reactions resulting in permanent discontinuation of KEYTRUDA were pneumonia (2.5%),pneumonitis (1.8%), and septic shock (1.4%). The most common adverse reactions (≥20%) were nausea (51%),fatigue (49%), constipation (37%), vomiting (32%), mucosal inflammation (31%), diarrhea (29%), decreased appetite(29%), stomatitis (26%), and cough (22%).

• In KEYNOTE-012, KEYTRUDA was discontinued due to adverse reactions in 17% of 192 patients with HNSCC.Serious adverse reactions occurred in 45% of patients. The most frequent serious adverse reactions reported inat least 2% of patients were pneumonia, dyspnea, confusional state, vomiting, pleural effusion, and respiratoryfailure. The most common adverse reactions (≥20%) were fatigue, decreased appetite, and dyspnea. Adversereactions occurring in patients with HNSCC were generally similar to those occurring in patients with melanomaor NSCLC who received KEYTRUDA as a monotherapy, with the exception of increased incidences of facial edemaand new or worsening hypothyroidism.

• In KEYNOTE-052, KEYTRUDA was discontinued due to adverse reactions in 11% of 370 patients with locallyadvanced or metastatic urothelial carcinoma. Serious adverse reactions occurred in 42% of patients; those ≥2%were urinary tract infection, hematuria, acute kidney injury, pneumonia, and urosepsis. The most common adversereactions (≥20%) were fatigue (38%), musculoskeletal pain (24%), decreased appetite (22%), constipation (21%),rash (21%), and diarrhea (20%).

• In KEYNOTE-045, KEYTRUDA was discontinued due to adverse reactions in 8% of 266 patients with locally advancedor metastatic urothelial carcinoma. The most common adverse reaction resulting in permanent discontinuation ofKEYTRUDA was pneumonitis (1.9%). Serious adverse reactions occurred in 39% of KEYTRUDA-treated patients; those≥2% were urinary tract infection, pneumonia, anemia, and pneumonitis. The most common adverse reactions(≥20%) in patients who received KEYTRUDA were fatigue (38%), musculoskeletal pain (32%), pruritus (23%), decreasedappetite (21%), nausea (21%), and rash (20%).

• Adverse reactions occurring in patients with gastric cancer were similar to those occurring in patients with melanomaor NSCLC who received KEYTRUDA as a monotherapy.

• Adverse reactions occurring in patients with esophageal cancer were similar to those occurring in patients withmelanoma or NSCLC who received KEYTRUDA as a monotherapy.

• In KEYNOTE-158, KEYTRUDA was discontinued due to adverse reactions in 8% of 98 patients with recurrent ormetastatic cervical cancer. Serious adverse reactions occurred in 39% of patients receiving KEYTRUDA; the mostfrequent included anemia (7%), fistula, hemorrhage, and infections [except urinary tract infections] (4.1% each). Themost common adverse reactions (≥20%) were fatigue (43%), musculoskeletal pain (27%), diarrhea (23%), pain andabdominal pain (22% each), and decreased appetite (21%).

Lactation

• Because of the potential for serious adverse reactions in breastfed children, advise women not to breastfeed duringtreatment and for 4 months after the final dose.

SELECTED SAFETY INFORMATION (CONTINUED)

Adverse Reactions (continued)Severe and Fatal Immune-Mediated Adverse Reactions (continued)

NSCLC = non–small cell lung cancer.

References: 1. Agilent Technologies, Inc. Instructions for Use: PD-L1 IHC 22C3 pharmDx. 2. Agilent Technologies, Inc. PD-L1 IHC 22C3 pharmDx:

Quick Scoring Guide – Head and Neck Squamous Cell Carcinoma (HNSCC). 3. Agilent Technologies, Inc. PD-L1 IHC 22C3 pharmDx: Quick Scoring

Guide – Urothelial Carcinoma. 4. Agilent Technologies, Inc. PD-L1 IHC 22C3 pharmDx: Quick Scoring Guide – Gastric or Gastroesophageal Junction

(GEJ) Adenocarcinoma. 5. Agilent Technologies, Inc. PD-L1 IHC 22C3 pharmDx Interpretation Manual – Esophageal Squamous Cell Carcinoma

(ESCC). 6. Agilent Technologies, Inc. PD-L1 IHC 22C3 pharmDx Interpretation Manual – Cervical Cancer.

Before prescribing KEYTRUDA, please read the accompanying Prescribing Information. The Medication Guide also is available.

Prepare a report that includes CPS as a number between 0 and 100 to help inform treatment decisions with KEYTRUDA.1

Copyright © 2021 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc. All rights reserved. US-KEY-02974 02/21 keytrudahcp.com

BIOMARKER STATUS CAN BE A ROAD MAP FOR PERSONALIZING TREATMENT

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