Distant recurrence

For patients with distant disease, several single-agent immunotherapies have elicited durable responses and are the recommended first-line systemic therapy option for most patients. Among these agents, avelumab and pembrolizumab have longer-term follow-up data published. These agents are approved by the U.S. Food and Drug Administration (FDA).[5-7][Level of evidence C3] Retifanlimab has also received accelerated approval from the FDA, pending further follow-up.[8][Level of evidence C3]

Chemotherapy is an option for patients who are either ineligible for or have disease progression while receiving immunotherapy, or in select patients who may benefit from a more rapid response.[1-4,9,10][Level of evidence C2] Although responses with chemotherapy have been reported in selected patients with locally advanced and metastatic disease, toxicity has been significant and durability is limited. When appropriate, radiation therapy and/or surgery may be offered as palliation to sites of recurrence, particularly if chemotherapy is not considered an option.