Treatment Strategies for Stage IIIB/N2 and High-Risk Early-Stage NSCLC

Patients with technically resectable stage IIIB disease require individualized treatment approaches that distinguish between different anatomic presentations, with T3/T4 N2 disease potentially more amenable to surgical approaches than N3 disease, which typically represents systemic disease biology. Health care providers increasingly consider surgical resection for carefully selected patients with stage IIIB disease, particularly those with high PD-L1 expression who are likely to respond well to neoadjuvant chemoimmunotherapy. Treatment decisions require careful evaluation of anticipated toxicity and morbidity from both surgical and radiation approaches, with adaptive treatment planning based on response to neoadjuvant therapy.

The management of patients with resectable stage IIIB disease who achieve complete pathologic responses following neoadjuvant therapy demonstrates the evolving understanding of treatment sequencing and adjuvant therapy selection. Health care providers consider multiple factors when determining whether to continue immunotherapy in the adjuvant setting, including the extent of initial nodal involvement, pathologic response, PD-L1 expression levels, and patient tolerance of neoadjuvant treatment. Emerging data suggest that patients achieving pathologic complete responses have unprecedented 5-year survival rates approaching 95%, providing strong rationale for aggressive multimodal approaches in appropriate candidates.

Patient selection for aggressive multimodal approaches requires careful integration of anatomic factors, tumor biology markers, and individual patient characteristics including performance status and treatment preferences. Health care providers must balance the potential for cure through intensive treatment against the risks of treatment-related morbidity and the availability of effective alternative approaches. The decision-making process benefits from multidisciplinary input that considers all available treatment modalities and involves patients as active participants in treatment selection, ensuring that chosen approaches align with individual values and goals while maximizing the potential for long-term disease control.