Integrating Radiation Therapy With Neoadjuvant IO in Early-Stage NSCLC

Patients who receive neoadjuvant chemoimmunotherapy but cannot proceed to surgery due to medical complications or disease progression require careful consideration of radiation therapy integration, with treatment approaches tailored to their specific clinical circumstances. Health care providers typically recommend treating only visible disease rather than large prophylactic volumes when delivering radiation after immunotherapy, with most favoring abbreviated fractionation schedules (3 to 5 weeks) to minimize patient burden and complete treatment efficiently. The decision to add concurrent chemotherapy during radiation depends on patient fitness and prior treatment tolerance.

The question of additional immunotherapy following radiation in patients who have already received multiple cycles during neoadjuvant treatment remains complex, with limited data to guide optimal sequencing decisions. Health care providers consider patient-specific factors including prior treatment tolerance, development of immune-related toxicities, smoking history, PD-L1 expression levels, and tumor mutational burden when deciding whether to continue immunotherapy after radiation completion. The risk of local recurrence following radiation therapy, particularly in-field failures, supports consideration of additional systemic therapy in appropriate patients.

Treatment planning for patients receiving radiation after neoadjuvant immunotherapy requires attention to potential increased toxicity risks and careful patient monitoring throughout treatment delivery. Health care providers recognize that patients have already received significant systemic therapy exposure and may benefit from treatment breaks between modalities to allow recovery and minimize cumulative toxicity. The integration of radiation therapy with immunotherapy continues to evolve, with ongoing clinical trials investigating optimal sequencing, dosing, and patient selection strategies that will inform future treatment approaches for this challenging patient population.