Optimizing Early-Stage NSCLC Management Through Multidisciplinary Strategies: ASCO 2025 - Episode 4
Surgical Perspectives: Who Are the Best Candidates for Neoadjuvant Chemoimmunotherapy?
Panelists discuss how surgeons evaluate candidates for neoadjuvant chemoimmunotherapy by emphasizing that all patients with stage II and III disease should be considered regardless of PD-L1 or mutation status, while highlighting the importance of multidisciplinary collaboration in treatment decisions.
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From the surgical perspective, the compelling long-term survival data from CheckMate 816 has fundamentally shifted the paradigm toward embracing neoadjuvant chemoimmunotherapy for virtually all appropriate candidates with stage II to III non–small cell lung cancer. Thoracic surgeons now advocate for 3 cycles of neoadjuvant treatment over 4 cycles, citing concerns about cumulative toxicity potentially compromising surgical outcomes while maintaining equivalent efficacy. This preference aligns with the strategy of maximizing pathologic complete response rates through neoadjuvant intensification rather than relying solely on adjuvant approaches.
The multidisciplinary tumor board has emerged as the cornerstone of optimal patient selection, with successful programs characterized by seamless communication between medical oncologists, thoracic surgeons, radiation oncologists, and support teams. The collaborative approach ensures that treatment decisions consider not only oncologic factors but also patient social circumstances, travel distances, work schedules, and family responsibilities. This comprehensive evaluation process maximizes the likelihood of treatment completion and surgical success while minimizing dropout rates.
Current surgical recommendations support neoadjuvant chemoimmunotherapy for all patients with stage II and III disease deemed surgically resectable, regardless of PD-L1 expression levels or most molecular characteristics (excluding EGFR and ALK alterations). The emphasis has shifted from patient exclusion criteria to optimization of treatment delivery, with surgeons playing crucial roles in initial patient evaluation, interim assessment after neoadjuvant therapy, and final surgical decision-making. This evolution reflects the maturation of multidisciplinary care models that prioritize evidence-based treatment selection over traditional specialty-specific approaches.
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