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Navigating the Latest Guidelines for ROS1+ NSCLC
An expert discusses the 2025 NCCN guideline updates for ROS1-positive non-small cell lung cancer, highlighting the inclusion of talotrectinib and repotrectinib as preferred first-line therapies due to their high efficacy and CNS activity, the shift away from older agents like crizotinib and ceritinib, and the critical importance of early molecular testing to guide targeted treatment and avoid immunotherapy in this population.
The 2025 NCCN guidelines for ROS1-positive non-small cell lung cancer (NSCLC) reflect significant progress in the field of targeted therapy. One of the key updates is the addition of talotrectinib as a recommended first-line option, based on data showing a response rate near 88% and a median progression-free survival of over 40 months in treatment-naive patients. These results come from recent studies demonstrating its strong efficacy and CNS penetration. Similarly, another agent, repotrectinib, also showed high response rates and prolonged disease control, further expanding therapeutic options for ROS1-driven disease.
These updates highlight a broader trend in lung cancer care: the shift from first-generation inhibitors, such as crizotinib, to newer, more potent therapies with improved ability to overcome resistance and target central nervous system metastases. The evolution is similar to what has been observed in other oncogenic drivers, where newer agents offer better durability and tolerability. Drugs like talotrectinib and repotrectinib are now viewed as preferred options in the first-line setting due to their superior efficacy, making earlier-generation treatments largely obsolete. The focus has clearly shifted to using these next-generation agents upfront whenever possible.
Practically, the guidelines also underscore the importance of avoiding immune checkpoint inhibitors in ROS1-positive cases, as these tumors typically do not respond to immunotherapy, and giving targeted agents after immunotherapy may increase the risk of adverse events. Additionally, ceritinib was removed from the guidelines due to limited efficacy and poor tolerability. These changes reinforce the need for early and accurate molecular testing to identify ROS1 fusions before initiating treatment. Overall, the updates reflect a rapidly evolving landscape in lung cancer, where precision medicine continues to deliver more personalized, effective, and durable treatment strategies for patients with actionable alterations.
