Reduced CT + Anti-PD-1 as First Line Tx in Vulnerable Older Adults w/Adv <50% PD-L1 Non-Small Cell Lung Cancer (NSCLC)

Inclusion Criteria:

• Histologically or cytologically confirmed diagnosis of non-small cell lung cancer (NSCLC) (either squamous or non- squamous)

• Stage IV disease OR have recurrent disease and not be candidates for curativetreatment such as combined chemo-radiation

• No previous line of treatment in the recurrent or metastatic setting. Neoadjuvant oradjuvant treatment more than 6 months before enrollment is acceptable.

• Age 70 or meeting frailty definition or above at the date of signing informedconsent

• Absence of driver mutations that have first line Food and Drug Administration (FDA)approved targeted therapy

• PD-L1 tumor proportion score (TPS) of less than 50%

• Eastern Cooperative Oncology Group (ECOG) PS of 0-3

• Have measurable disease based on RECIST 1.1 as determined by the local siteinvestigator/radiology assessment

• Absolute neutrophil count (ANC) ≥ 1,000/μL

• Platelets ≥ 75,000/μL

• Hemoglobin (Hgb) ≥ 8.0 g/dL (transfusion permitted)

• Total bilirubin ≤ 2 x institutional upper limit of normal (ULN)

• Aspartate amino transferase (AST)serum glutamic-oxaloacetic transaminase (SGOT) /alanine aminotransferase (ALT)serum glutamic-pyruvic transaminase (SGPT) ≤ 5.0 ×institutional ULN

• Ability to understand and the willingness to sign a written informed consentdocument

Exclusion Criteria:

• Participants with life expectancy of less than 3 months at the time of enrollment

• Has active autoimmune disease that has required systemic treatment in past 2 years (ie, with use of disease modifying agents, or immunosuppressive drugs)

• Diagnosis of interstitial lung disease

• Creatinine clearance of <30 mL/min

• Symptomatic, untreated central nervous system (CNS) disease or leptomeningealdisease. Patients with asymptomatic or treated CNS disease are eligible

• Required ongoing use of immunosuppressive medication, including steroids, with thefollowing allowable exceptions:

• Doses less than or equal to the equivalent of prednisone 10 mg daily

• Short courses of steroids that are discontinued prior to enrollment

• Inhaled, intranasal and/or topical steroids

• Dexamethasone taper for treating vasogenic edema associated with CNS disease