Defining Surgical Candidacy in Newly Diagnosed Early-Stage NSCLC

Patients with early-stage lung cancer increasingly receive neoadjuvant systemic therapy rather than proceeding directly to surgery, reflecting the evolution toward multimodal treatment approaches. The rare patients who proceed directly to surgery typically have specific medical contraindications to immunotherapy, such as autoimmune conditions like multiple sclerosis, or have very early-stage disease with negative nodal sampling where the risk-benefit ratio of neoadjuvant therapy remains unclear. Health care providers generally prefer administering systemic therapy before surgery when patients will likely need adjuvant treatment, as this approach ensures better treatment completion rates compared to postoperative therapy administration.

Multidisciplinary team discussions become essential for patients with actionable genetic mutations, as the optimal timing of targeted therapy (neoadjuvant vs adjuvant) continues to evolve with ongoing clinical trial results. Patients with EGFR mutations or other targetable alterations require careful consideration of staging accuracy and treatment sequencing, particularly given the high rates of nodal upstaging discovered during surgery even after negative imaging and biopsy results. Health care teams must balance the known benefits of adjuvant targeted therapy with emerging data supporting neoadjuvant approaches.

Patient selection for direct surgical resection requires careful consideration of tumor characteristics, patient fitness, and the likelihood of requiring additional systemic therapy. Health care providers recognize that approximately 40% of patients do not receive planned adjuvant therapy when treatment is delayed until after surgery, emphasizing the importance of delivering systemic therapy in the neoadjuvant setting whenever appropriate. Patients with larger tumors, concerning imaging features, or high-risk histologic characteristics generally benefit from neoadjuvant treatment approaches that provide early systemic therapy and may facilitate less extensive surgical procedures through tumor response.