What is the preferred treatment option between nivolumab (nivolumab) and pembrolizumab (pembrolizumab) for a patient with nasopharyngeal cancer?

Nivolumab vs Pembrolizumab in Nasopharyngeal Cancer

For recurrent or metastatic nasopharyngeal carcinoma, both nivolumab and pembrolizumab are acceptable second-line options with similar efficacy profiles, though pembrolizumab demonstrates a numerically higher response rate (25% vs 20%) while nivolumab shows superior tolerability in head and neck cancers. 1, 2, 3

Treatment Selection Algorithm

Second-Line Setting (After Platinum Failure)

Both agents are appropriate choices for patients with recurrent/metastatic NPC who have progressed on platinum-based chemotherapy, with the decision based on the following factors: 1

• Nivolumab is specifically mentioned in ESMO-EURACAN guidelines for NPC with demonstrated safety and activity (ORR 20%) 1
• Pembrolizumab is also listed as an acceptable option with slightly higher response rates (ORR 25%) 1
• Camrelizumab shows the highest response rate (34%) but may not be available in all regions 1, 2

Key Efficacy Data

Response rates favor pembrolizumab numerically in the second-line setting: 2, 3

• Pembrolizumab: 26.3% ORR in second-line or later 2
• Nivolumab: 19.0-20.5% ORR in second-line or later 2, 3
• First-line nivolumab achieves 40% ORR when used earlier 2

Survival outcomes with nivolumab in NPC show promising durability: 3

• 1-year overall survival: 59% 3
• 1-year progression-free survival: 19.3% 3
• 20% of patients remained on nivolumab beyond 12 months 3

Safety Considerations

Nivolumab demonstrates superior tolerability in head and neck cancers: 2

• Grade 3-5 adverse events: 17.4% with nivolumab vs 29.6% with pembrolizumab 2
• Grade 1-5 adverse events: 54.2% with nivolumab vs 74.1% with pembrolizumab 2

PD-L1 Testing

PD-L1 testing is not required for treatment decisions in the second-line setting for NPC: 1

• Both agents show activity regardless of PD-L1 status 1
• Higher response rates are observed in PD-L1-positive tumors (28.4% vs 17.4%) but this does not reach statistical significance 2
• The ESMO-EURACAN guidelines state therapeutic positioning is still to be defined 1

Practical Recommendations

Initiate treatment without delay for PD-L1 testing as both agents work independently of PD-L1 expression: 1

• Standard nivolumab dosing: 240 mg IV every 2 weeks 4
• Standard pembrolizumab dosing: 200 mg IV every 3 weeks 1

Consider nivolumab as first choice when: 2, 3

• Minimizing toxicity is paramount
• Patient has significant comorbidities
• Prior cetuximab exposure (though both work regardless) 5

Consider pembrolizumab as first choice when: 2

• Maximizing response rate is the priority
• Patient has good performance status to tolerate potential higher toxicity rates

Important Caveats

Combination strategies require caution: 6

• Nivolumab plus gemcitabine shows promising results (ORR 36.1%, median PFS 13.8 months) but remains investigational 6
• First-line chemotherapy (cisplatin-gemcitabine) remains standard for newly diagnosed metastatic disease 1

Treatment should be discussed in a multidisciplinary team and patients should be treated at high-volume facilities: 1

• No standard second-line treatment exists beyond immunotherapy 1
• Alternative chemotherapy agents (paclitaxel, docetaxel, capecitabine) remain options if immunotherapy fails 1

Monitor for immune-related adverse events which occur less frequently than chemotherapy toxicities but require prompt recognition: 4, 3