Dr Durm on Perioperative Treatment Strategies in Early-Stage NSCLC

“Neoadjuvant immunotherapy while the tumor is in place makes a lot of sense scientifically. We often favor neoadjuvant treatment for our patients with resectable disease because when the tumor is in place, it [leads to] more neoantigen exposure when we are priming with these immune therapies.”

Greg Durm, MD, an associate professor of clinical medicine in the Department of Medicine, Division of Hematology/Oncology; an associate professor of clinical otolaryngology-head & neck surgery in the Department of Otolaryngology–Head and Neck Surgery; and a full member in the Department of Experimental and Developmental Therapeutics at Indiana University Melvin and Bren Simon Comprehensive Cancer Center, discussed clinical factors that influence his decision to utilize perioperative treatment in patients with early-stage non–small cell lung cancer (NSCLC).

Using neoadjuvant immunotherapy before disease metastasis is often favored for the treatment of patients with resectable disease, Burm began. This is partially due to the heightened neoantigen exposure when the tumor is primed with immune therapy, he added. Most patients are a good fit for neoadjuvant therapy with chemotherapy and/or immunotherapy, especially those with N2 and stage III disease, he noted.

At the time of surgery, patients should be evaluated for any signs of residual disease, Burm said. Patients who achieved a pathologic complete response at the time of surgery do not appear to benefit from additional treatment after surgery, although certain patient subgroups are being further evaluated, he added. Comparatively, patients with residual disease at the time of surgery do seem to derive a benefit from additional immune therapy, he noted.

Historically, patients with a higher PD-L1 tumor proportion score have had a greater chance of achieving benefit with perioperative immunotherapy, Burm explained. However, in some cases, PD-L1 status can be misleading and has not aided in patient selection, he said. Further studies are ongoing aimed at elucidating which PD-L1 subgroups most need additional treatment, he concluded.