In a patient with ILD and metastatic NSCLC with positive PD-L1, would you give chemo/pembrolizumab, chemotherapy alone, or pembrolizumab alone?

We always discuss the risks and benefits of treatment to every patient; however, patients still rely upon our best judgment to guide decisions. I would not recommend a PD-1 or PD-L1 inhibitor to a patient with known interstitial lung disease. These patients were excluded from the Keynote, Checkmate, and IMpower trials. We know the risk of IO induced pneumonitis is much higher in patients with known interstitial lung disease. We do not know if the risks of IO therapy outweigh the benefits in this patient population. This is a patient population that does not tolerate the additional toxicity of pneumonitis, which can be life threatening. My recommendation would not change even in a patient with a high PD-L1 TPS.