Let's move back to the advanced-stage setting. We touched upon this a little bit: liquid biopsy, plasma genotyping, and how important it is. Reiss, you mentioned you're doing this for every patient who walks through the door. At advanced-stage adenocarcinoma, is there a patient that you don't do a liquid biopsy on?

: I don't do a liquid biopsy in some cases. One example is a squamous cell lung cancer patient who has a heavy smoking history with a big chunk of tissue in the bank, which I would probably just send off. Then we have the lung master protocol, which does foundation medicine and broad genomic profiling as part of the study, so we can prescreen for that and so forth. So that's a patient where I wouldn't necessarily do plasma NGS [next generation sequencing] because that early decision is not likely to affect my treatment plan. [With] some patients, for example, who have a big chunk of tissue just waiting in the bank and have a much lower bulk of disease, I'm not pressed for treatment and can wait. Then [there’s] M1a disease, where we know there's less shared circulating tumor DNA in these patients. The sensitivity is less for M1a disease, where it's plural or pulmonary only, and those I have less confidence in circulating tumor DNA [testing].

So those would tell you nothing, essentially, for some of these patients. Any other comments about liquid biopsies and how they're used and leveraged? I'd say the only time I don't do them; I don't do them routinely in squamous cell and I don't do them in a patient with adenocarcinoma that's an advanced stage where I already know; because this doesn't happen a lot, but second opinions where I already know the mutational status. Then, I'm not sure that I would use it. Is there a role for using liquid biopsies at the time of progression for patients that are driver mutation-positive? Is that something that you would do in your everyday practice for 

And using it in any other stages other than stage IV right now?

Yes. Or using it in—let's say—a stage 3B patient, where you're going to give chemotherapy, radiation, and, most likely, durvalumab. Is there a role—if you don't have tissue in that setting—to do a liquid biopsy?

: There are some situations where you're not sure, such as stage III and stage IV, when you're not sure if it's progression or not, or you're not sure what some new nodules may mean. In some select settings, I do get circulating tumor DNA, where, if it's positive, it may inform my clinical decision-making. So, I'll give an example. I had a patient with 

 fusion-positive lung cancer on selpercatinib. We had some issues and we made some dose adjustments. I wasn't quite sure whether what we were seeing was progression or not, and I sent off a circulating tumor DNA. It was negative. I kept him going, and he's doing really well. So that's the type of example.

I think we'll learn more and more about potential uses of CT [circulating tumor] DNA maybe outside of the stage IV setting, or maybe in real-time monitoring of patients on a targeted therapy. We'll see. We've seen some of this dance. It'll be very interesting to see how this unfolds in the clinic as the research comes out.

Videos

Expert oncologists briefly highlight the role of liquid biopsy in the setting of advanced-stage non–small cell lung cancer. 

Molecular Testing in Advanced-Stage NSCLC: Use of Liquid Biopsy

Molecular testing started in the stage IV setting because that's where all the drugs were, but as we will learn in our next segment, these drugs, fortunately, both targeted therapies and immunotherapies have moved up in the early stage, and it's really put the onus now to test in early-stage disease. Jessica, I'll come back to you. In early-stage lung cancer, the importance now of molecular testing, are you the one that's ordering this, or are you consulting with your medical oncologist? Now we do have data for adjuvant osimertinib. Maybe in a few years, we'll have data for neoadjuvant-targeted therapies. How does this fold out at the University of Chicago?

: We're lucky we have a multidisciplinary tumor board. We talk about every patient who would be possibly considered for adjuvant therapy. We have that discussion right away, and we're lucky that every patient who has some consideration for adjuvant therapy gets their molecular testing, but it is like we talked about earlier: that added step that has to happen, but we are also fortunate that anyone who gets a preoperative biopsy gets their molecular testing. I think that's the way to go. Just having that in your pocket before you go really guides your conversations with your patients. It's very helpful.

 that you're ordering, or is it just the usual next-generation sequencing panel that you're doing?

: We order a whole panel on anybody who has a preoperative diagnosis.

Any other comments from institutions on how they leverage the ADAURA data and use that in everyday practice? Jonathan?

: I would just like to amplify what Jessica said—that it's really important now with multimodality treatment, just for early-stage and for locally advanced disease [it] is more important than ever to adjudicate these patients at multidisciplinary tumor boards in terms of how to best sequence and what molecular testing to do because things have evolved much more and gotten more complicated. We have neoadjuvant chemo-IO [chemotherapy plus immunotherapy], we've got adjuvant targeted therapy, we've got adjuvant IO and chemotherapy, and how to best sequence those is really important to talk about in a multidisciplinary setting.

: I think as we talk about this, it's really the full biomarker panel, and so it's that PD-L1 testing, of course, but that's not enough. I think you’ve brought this up a few times. I'm going to keep echoing it because I think it's so critical, that just because there's a high PD-L1 does not mean immunotherapy's going to work in the metastatic or the early-stage setting. We need to make sure there's not a driver mutation, which would kind of negate that PD-L1 result before we make that decision because we can cause real harm to people if you send them down the wrong path.

Increased toxicity, less efficacy, or no efficacy. It's a really great point. I'm going to ask everyone an unfair question. One of the only slippery slopes I think for next-generation sequencing and early-stage is you sometimes get an 

 [mutation], and the question is, “Gosh, osimertinib works really well in the adjuvant setting for patients that [have] an 

-sensitizing mutation.” Are we part of the slippery slope, where you would say, apply this to 

? Is this something that you would do? We don't have any data on this yet. I want to say that.

There are open trials, and I encourage everyone who finds these to enroll in these trials. It's a hard question. Is this something that you would use? Would you use a resected ALK if it was ALK and give alectinib?

: I think if you went around the table and asked everybody, I'm going to speak out loud and say that we all probably have done it. I mean a stage 3A that ends up being 3B resected—that looks really bad, and you know [it] has a 98% recurrence rate? We’ve done crazier things in oncology over the years than give somebody an ALK inhibitor. The other option is even off study. Since we're moving to a neoadjuvant world, neoadjuvant ALK sometimes might be helpful for patients for the resection or down staging as well.

: I think what everybody's saying brings up the broader question, which is how much can we extrapolate from ADAURA [trial]? We have the trials, and there are ongoing trials in 

, and others, but with the great data in ADAURA, and extrapolating from the metastatic setting, you've got great drugs: alectinib and 

, as well as others. I think it's a reasonable extrapolation. I would say I would feel more confident giving adjuvant alectinib than, for example, adjuvant atezolizumab in a patient who is PD-L1–positive and ALK-positive.

: I think if you went around this table and asked us if it was, God forbid, any of us, and we had a reasonable stage lung cancer and it was ALK-positive, would you do this? And I would. Yes.

Yeah, on the record, I've never done it. Off the record, I've done it many times [laughter].

: Are we on the record or off the record here?

: I think we need to be careful, though, because we do have examples of giving adjuvant EGFR TKIs [tyrosine kinase inhibitors] with gefitinib and erlotnib where the trials did show DFS [disease-free survival] benefit, but no overall survival [OS] benefit. So were those patients actually helped by being on that medication early? Now, we have that osimertinib data with ADAURA of course. That disease-free survival data is absolutely compelling—no question about it—and I very much hope that we see that OS benefit when the data comes through. But we have to be careful because not every TKI story is the same as osimertinib and the setting of 

, yes: we have amazing progression-free and overall survival data in the metastatic setting, and so it's harder. But with some of the other drivers, that toxicity-to-benefit ratio, even in metastatic, it is a bit more questionable—the duration of response. So I think we do need to be careful on the slippery slope.

: I would add 2 more points: toxicity and the quality of life have to be kept in mind because we really don't know at this point what those would mean. If you start someone out, early-stage resected, what would that mean 5 years later for that patient, and then definitely the economics of it? Who is going to pay for it?

: The only thing I will say is: 100% you brought us back down to earth, Heather, because we've all been burned with, “Oh, this is going to work.” We have all seen some recent immunotherapy data where the phase 2 looked great and phase 3 was a bust. However, I think there's a clinical trial for almost any actionable mutation, and even if you don't have it, send them somewhere else. It'll take care of the patient and answer the question.

: I think the other thing I would just bring up to Heather's point is where you draw the line? We all talk about ALK and alectinib, and you could say in the metastatic setting that the medium PFS [progression-free survival] is about 36 months, and then for osimertinib, they have 19 months, and you have the ADAURA data. Those are all reasonable extrapolations, but I think that is fundamentally different than, say, 

 Exon 20 with mobocertinib and amivantamab and others, where the median PFS and the activity in the metastatic setting is much less. So where do you draw that line, again? It’s a slippery slope.

Where do you draw that line with the slippery slope? When does that slippery slope get too slippery, is the question?

: But you know what? If I were that patient, I know I'd at least like to have that discussion with my doctor, and I think all the more information helps. It's that shared decision-making we're talking about.

A focused discussion on the use of molecular profiling in early-stage non–small cell lung cancer to inform decisions on adjuvant and neoadjuvant strategies.

Use of Molecular Profiling in Early-Stage Non–Small Cell Lung Cancer 

Let's talk about that journey and the challenges of that journey. We all think we're involved in best practices and that all of our institutions get 100% results in all of our patients. We know that's not true in the real world. Alex, you were involved in some of the real-world data looking at next-generation sequencing. How it's done in the community, and what percentage of patients are actually getting this? This was presented last year at the 2021 ASCO [American Society of Clinical Oncology] Annual Meeting. It was from the US Oncology Network. You were part of this. Can you walk us through some of that?

: Essentially, what they did was they looked back. Now it is a few years old, of course, but they went back and looked at the rates of testing of multiple different biomarkers. The first 1 and the most common 1 is 

 has been around as long as I've been a medical oncologist. I know I'm dating myself. Even in this day and age, at its peak, it was still only about 70% to 75% of adenocarcinomas getting 

. Remember the story's not old. This isn’t an old story. The fact that we're still not testing—when in the breast cancer world, everyone gets tested for ER [estrogen receptor] and PR [progesterone receptor]. They would gasp at this. Then when you took another step back and you went to 

 it was down in the 40% to 50% range. Some of that, of course, is tissue quantity. Some of it's a little bit dated, but the reality is that it needs to be better. That's the challenge that we're living in right now and it's obviously affecting patient care. It was a little bit embarrassing when this data comes out because you're part of it and like here's what we're doing and we're not really doing a very good job, but thankfully we raised a lot of eyebrows and said, “We all need to be doing a better job.”

I just want to mention some of the data in line with some of your experience at US Oncology, there will be a poster presented on Monday at ASCO looking at CancerLinQ data with roughly 37,000 patients, the NGS [next-generation sequencing] completion rate was not that good. It was around 50%, so you're not the only one. There are other data sets that would suggest the same thing. We're going to have another poster on Monday by Dr [Madeline] Hooper et al about reflex testing vs not reflex testing. Do you want to walk us through that, Alex, just briefly?

: It's the AmeriPath group, Quest Diagnostics. They basically went back and looked at 2 different time periods, so you have to take that with a grain of salt. The 2 time periods were before reflex testing was instituted and after reflex testing was instituted. In essence, the turnaround time was 35 days versus 18 days.

: That's huge. That's twice as long. It's not just the time. There are patients waiting to get treatment or maybe not waiting to get treatment, and maybe getting the wrong treatment as well. There was also a huge number of patients that would've had their treatment changed and a lot more patients were even found with biomarkers when they went back and looked versus not. This raises a lot of eyebrows, should it be reflex tested or not? You probably should.

We have challenges at my institution instituting reflex testing. We've had a rule that the pathologist can no longer be the ordering physician for next-generation sequencing. That leaves it up to the medical oncologist, the surgeon, the interventional pulmonologist, or these through an epic function. It's a real challenge. I'd like to hear from everyone here. Just what are the greatest barriers? We mentioned the tissue journey and it even starts with some sort of communication about how tissue's going to be procured. Jonathan, what do you see as the biggest barrier to this? We've seen this real-world data come out over and over again that we're just not doing a great job. What do you think is the biggest challenge in biomarker testing for lung cancer?

: I think some challenges are just the logistics of that [tissue] journey: getting the tissue, the order, the pathologist cutting the slides, and then getting it sent out. Sometimes there are some insurance issues. Those things can lead to a substantial delay, which is why I find myself sending off both tissue and plasma more and more when I initially see patients. We're working with our pulmonologists and other in-services and so forth to get tissue and plasma done as early as possible, because it really can be very informative in terms of getting that early data. It's very gratifying to get an 

 or 1 of these oncogene driver positives within a few days of seeing a patient and already have that data when you see the patient. It really accelerates getting patients onto the most appropriate treatment and not missing those game-changer mutations.

:Chaitali, any other thoughts on the challenges of tissue biopsies at your institution? Is it tissue procurement? Is it not enough tissue that you're not getting? What do you see as the biggest challenge at your institution?

: I think the first challenge I see because we do get a lot of referrals from the community as well as, is who's going to request the test. Who's going to be the guardian of requesting the test. I think half the time is wasted right there because they don't necessarily get to see medical oncologists right off the bat, but everybody's nervous ordering, including pathologists. They want to know what tissue you want to be sent out. You may have mixed histology, so that makes a difference. They want the medical oncology input and it takes a while before they even get to a medical oncologist. I think insurance is also a big player in this. There are some very restrictive medical groups. They will not let you do an extended panel, or they limit you by doing just PD-1 testing and nothing else.

: I would just like to amplify that. That's becoming more and more of a challenge for the earlier stages where you have the ADAURA data. Sure, there's a single test for 

 that would be a PCR test, for example, that would be available. But as mentioned before, you really want to know those 

s—not only for studies and potential future treatment—but also now with immunotherapy coming to the fore, they may not be the right patients for adjuvant or neoadjuvant immunotherapy.

Any other comments on challenges of tissue?

: It is kind of ironic. These tests are expensive. They're not cheap, but when you think about how much we spend on lung cancer patients per month, we're talking about a couple of thousand dollars, maybe even less for some of this testing, but the cost of immunotherapy for a month is $15,000. When you talk about the marginal cost to get all the information, it makes no sense whatsoever that that should even come into play.

: I think another thing I would like to say is the adequacy of the tissue sample. That also plays a big part. Sometimes you go through this whole exercise just to wait 2 to 3 weeks only to find out that it was an inadequate sample. That's why I'll end up doing the plasma as well, because I can’t be sure that I'm going to get the results back, or they may end up doing the whole process and say, well, I can only report you one. Which one would you like to know?

: That's actually going to become even more important. We will talk more about neoadjuvant stuff and neoadjuvant protocols. You get chemo-IO [chemotherapy plus immunotherapy], but what do you do? You need all that information.

I would bookmark this because I want to ask everyone again about the data coming out with neoadjuvant—chemo-IO, getting the results, and then 

 results before you pull a lever on neoadjuvant chemotherapy. That's tough, and how that patient went on, we'll talk about. Do you have any other comments on tissue stewardship, Heather?

: I think that patients who come in and get admitted in the hospital and are diagnosed at that point, that that's even harder, because I don't really have anyone who feels like 

. “This is a patient who is mine while I'm in the hospital for today's shift.” That becomes a problem. Then there are reimbursement issues around that that are even bigger than what we've talked about before. I think these are real challenges, also.

: That's a great point. I would just highlight that. It's really important. We have patients that get admitted to the hospital that really need to be treated, and being able to get timely biomarker testing can be critical. I just got paged the other day. We sent off plasma, and it came back 

 and the patient is in the ICU [intensive care unit] getting crizotinib through a feeding tube. Testing can make a huge difference.

Not wrong to do. Absolutely. Jessica, you've been waiting patiently here.

: I was just going to say the entire inpatient reimbursement thing affects all the surgical patients because they're all inpatients and none of it is reimbursed while they're in the hospital. So they all have to go home. They all have to wait 14 days, and then someone has to remember to order it. Just adding that delay and that extra step is just asking for it to fall through the crack.

: All I will say, though, is I know this is much more expensive and much more complicated than IHC [immunohistochemistry] standing, but in the breast cancer world, a breast cancer patient might have 5 biopsies and they're all checked for ER, PR, and HER2 [human epidermal growth factor receptor 2]. It shouldn't be this complicated.

There's no excuse, really. We have too many good therapies that we can now give even to ICU [intensive care unit] patients and turn them around. It's inexcusable that we're still currently at the rate that we are. One of the other things is that we published a paper maybe 10 years ago—just best recommendations for molecular testing. I think having a physician-champion—somebody in the health system that can marshal this through, specifically in the community—makes a lot of sense. There are so many hurdles along the way, as we've mentioned with this tissue journey from procurement, as Chaitali mentioned, all the way to the result. Getting the result and then interpreting the result—there are educational needs there, too, with some of these rare mutations. I hope if we meet in another 3 or 4 years, we can talk about better percentages for our patients in the completion of NGS.

A brief review of real-world data behind molecular profiling in non–small cell lung cancer, followed by a discussion on barriers to testing and uptake.

Real-World Data and Barriers to Use of Molecular Testing in NSCLC

 titled “Advances in Testing and Targeted Therapy for Non–Small Cell Lung Cancer:

Translating Evidence to Clinical Practice.” I'm Dr Benjamin Levy, an associate professor at Johns Hopkins School of Medicine [in Washington, DC]. A panel of experts in the field of lung cancer joins me today. I would like to welcome my esteemed fellow panel to introduce themselves.

: I'm Jessica Donington, professor of surgery and chief of the section of thoracic surgery at the University of Chicago [Chicago, IL].

: I'm Jonathan Riess, medical director of thoracic oncology and associate professor of medicine, University of California, Davis Comprehensive Cancer Center [in Sacramento, CA].

: I'm Alex Spira, medical oncologist with Virginia Cancer Specialist in US Oncology Research.

: I'm Heather Wakelee, chief of the division of medical oncology at Stanford University [in Stanford, CA] and deputy director of the Stanford Cancer Institute, and president of the International Association for the Study of Lung Cancer, IASLC.

: Hi, I’m Chaitali Nangia. I am a medical director of head and neck oncology for the Verity Health Systemand also co-director of the immunotherapy program at Hoag Cancer Institute in Newport Beach [CA].

Let's dive right in. I think, appropriately, we’ll start with molecular testing and non–small cell lung cancer. I'm biased. I think we all are, but lung cancer is truly the poster child for precision medicine and lung cancer. Of course, we have 

 as chapters 1 and 2 of this precision medicine story, but the story is still being written. It's quite remarkable. I'm going to start with Dr Chaitali here. Can you give us your approach on molecular testing at your institution, what you're testing for, how you're testing, and then how you're using that information to make treatment decisions?

: I do agree that lung cancer has been the pioneer in getting precision medicine up-front, and hopefully, the tumor types will follow as well, too. I think molecular testing is a key component. It's almost like a diagnostic evaluation—like we do staging workup. I think it's a part of staging work-up because as you're looking—all the way from early stages to late stages—you want that information because it may influence your new adjuvant approach—your adjuvant approach, your systemic approaches, and your combinatorial approaches. We pretty much do it at [all] diagnoses for most patients.

What type of testing are you doing? We've witnessed an evolution in testing for lung cancer. We've had single-gene testing and we've moved on to more comprehensive testing. What type of testing are you routinely doing for your patients? Are you doing adenocarcinoma and squamous cell or just adenocarcinoma? How does this hold out in your clinic in everyday practice?

: I think, again, it’s pretty reflex testing based on histology—like adenocarcinoma get more comprehensive testing than the squamous do. They're probably not going to get tested for some mutations, but comprehensive testing—not single-gene testing—and both liquid and tissue if accessible, and not just liquid only.

I think we'll talk a lot about the role of liquid later on in this session. Jonathan, any other comments? At UC Davis, are we doing reflexive testing on all patients, or is the medical oncologist ordering this? How do you do this at your institution?

: That's a great question. We at UC Davis have been not doing reflexive testing, but our medical oncologists generally order the tests, so it's done earlier and in the earlier stages. We do both adenocarcinoma and squamous cell. Now, of course, not just the never/light smokers or when there is scant tissue, but more and more, we're able to match squamous cell lung cancer patients to clinical trials as well. We've been doing that and also with the ADAURA data and 

 and studies and other oncogene drivers moving to the earlier stages. We've been doing it more and more earlier-stage, not just to identify patients for those trials, but also to think about whether we want to give immunotherapy to some of these patients who may not benefit from those nonsmoking oncogene drivers.

Good point. Immunotherapy doesn't work for everyone. Identifying the genetic alteration up-front can save you. We'll talk a little bit about that later. Heather, at Stanford, is there in-house testing, or are you sending it out? How does this work?

: We do a mix of both. I think with a newly diagnosed patient, you balance between wanting the comprehensive [testing], but you also need the fast response, so we do a liquid biopsy, which we send out just because it comes back faster. Our tissue testing is in-house. We do a rapid 

 and then we still do FISH [fluorescence in situ hybridization] testing for ALK and ROS so we can get those quickly. Then we do a comprehensive panel that is also going to be looking for the fusions and a much larger array.

The turnaround time for your in-house testing is?

: It's still 2 to 3 weeks. I think that's the challenge. While we're doing the liquid biopsy, the challenge we all face with the tissue testing is time. Even if you have results come back as fast as possible, you still have to get the tissue and then get the tissue sent out. They still have to extract the DNA. The big challenge that we face as a community is how do we get that information so we can get the patients on the right treatment as fast as possible.

It's a long journey that tissue takes. From the patient, all the way to the lab, and then the bioinformatics and the next-generation sequencing and then the readout and then back to you. A lot of challenges along the way. We'll talk about that. Alex, is the US Oncology [Network] experience maybe a little bit different?

: It's different. We're a community-based group, so we don't have control over everything. It's multiple institutions. One group can have 3 or 4 or even 5 or 6 hospitals between where we go, and they all do something different. Sometimes they do reflexive testing. Sometimes they don't. It's hard because if you're not in direct ownership of the pathology or work with them exclusively, everybody does something different, and even a different pathologist will do something different as well, so it's a challenge. As we all know, 90% of care is outside of the academic setting, so we are in predominance in this and it's where some of the limitations are.

Jessica, just at the University of Chicago, you're not a medical oncologist. The lone surgeon, we welcome you here. What’s your perspective on the molecular testing that's done at the University of Chicago?

: Ours is all in-house. We have our own large panel. Everything is a big panel; not my choice, but that's what we do. We're pretty good about getting things as soon as possible. We have an interventional pulmonary team. It's very academic. As soon as they know it's lung cancer, everything gets sent right from there, which I think is really important. They're really focused on getting what they need and making sure if they have another biopsy that they do it. That's been super helpful because you're right: the journey is long, and while tissue's the issue, it's not easy.

Expert panelists share insight on molecular testing practices across all subtypes of non–small cell lung cancer to optimally inform treatment decisions.

Optimal Molecular Testing Practices in Non–Small Cell Lung Cancer

Jessica Donington, MD, MSCR, professor of surgery and chief of the Section of Thoracic Surgery at the University of Chicago Medicine, discusses the role of neoadjuvant immunotherapy in patients with stage II non—small cell lung cancer (NSCLC).

Trials evaluating neoadjuvant immunotherapy in NSCLC included patients with stage II and stage III disease, says Donington. However, its role in patients with stage II disease is unclear.

It is not standard of care to give patients with stage II disease neoadjuvant chemotherapy prior to surgical resection, explains Donington. Instead, these patients typically undergo resection followed by adjuvant chemotherapy.

Until the field has long-term data with neoadjuvant immunotherapy, patients with stage II disease should continue to undergo up-front surgical resection, concludes Donington.

Jessica Donington, MD, MSCR, discusses the role of neoadjuvant immunotherapy in patients with stage II non–small cell lung cancer. 

Dr. Donington on the Role of Neoadjuvant Immunotherapy in Stage II NSCLC

Jessica Donington, MD, MSCR, professor of surgery and chief of the Section of Thoracic Surgery at the University of Chicago Medicine, discusses the role of neoadjuvant immunotherapy in patients with stage II non–small cell lung cancer (NSCLC).

Trials evaluating neoadjuvant immunotherapy in NSCLC included patients with stage II and stage III disease, says Donington. However, its role in patients with stage II disease is unclear.

It is not standard of care to give patients with stage II disease neoadjuvant chemotherapy prior to surgical resection, explains Donington. Instead, these patients typically undergo resection followed by adjuvant chemotherapy.

Until the field has long-term data with neoadjuvant immunotherapy, patients with stage II disease should continue to undergo up-front surgical resection, concludes Donington.

Jessica Donington, MD, MSCR, discusses the role of neoadjuvant immunotherapy in patients with stage II non–small cell lung cancer. 

Jessica Donington, MD, MSCR, professor of surgery and chief of the Section of Thoracic Surgery at the University of Chicago Medicine, discusses the effectiveness of neoadjuvant immunotherapy and how it compares with neoadjuvant chemotherapy in patients with lung cancer.

Initial safety data pulled from trials evaluating neoadjuvant immunotherapy in lung cancer show that induction immunotherapy seems to be similar to that of induction chemotherapy, says Donington. There is some surgical attrition with induction immunotherapy, meaning some patients start their induction therapy with a plan of moving on to surgery but do not make it to surgery, explains Donington. About 10% of patients start immunotherapy and do not make it to surgery, which is similar to the number of patients who receive induction chemotherapy for locally advanced disease.

Similarly, about 10% or less of patients appear unresectable post-immunotherapy and -chemotherapy. The complications are a little higher than expected for patients with stage I disease but not dramatic, ranging from 20% to 30%. Most of these patients have adverse events (AEs) in the grade 3 range, which is ideal when evaluating surgical complications, says Donington. The need to replace potassium in a patient is not concerning, but grade 4 or 5 AEs are major issues that require immediate attention. Induction immunotherapy appears to be as safe as induction chemotherapy; the former does not appear to derail surgery any more than the latter, concludes Donington.

Jessica Donington, MD, MSCR, discusses the effectiveness of neoadjuvant immunotherapy and how it compares with neoadjuvant chemotherapy in patients with lung cancer.

Jessica Donington, MD, MSCR

Articles

Molecular Testing in Advanced-Stage NSCLC: Use of Liquid Biopsy

Use of Molecular Profiling in Early-Stage Non–Small Cell Lung Cancer

Real-World Data and Barriers to Use of Molecular Testing in NSCLC

Optimal Molecular Testing Practices in Non–Small Cell Lung Cancer

Dr. Donington on the Role of Neoadjuvant Immunotherapy in Stage II NSCLC

Dr. Donington on the Role of Neoadjuvant Immunotherapy in Stage II NSCLC

Dr. Donington on Neoadjuvant Immunotherapy in Lung Cancer