Induction or neoadjuvant therapy in resectable non-small cell lung cancer

Many patients with stage I-IIIA non-small cell lung cancer (NSCLC) resected for cure will experience distant relapse. Results of adjuvant chemotherapy trials after surgery have generally been negative. Neoadjuvant or induction chemotherapy before surgery offers several theoretical advantages; the results of neoadjuvant chemotherapy or combined chemoradiation therapy followed by surgery in resectable and potentially resectable NSCLC are reviewed in this report. In resectable NSCLC, the results of two small trials have yielded positive trends in favor of neoadjuvant chemotherapy. However, neither of these trials was flawless; therefore, firm conclusions cannot yet be drawn. In selected patients with initially nonresectable NSCLC, several phase II studies have demonstrated the potential utility of induction chemotherapy or combined chemoradiation therapy. A relatively high proportion of these patients were rendered resectable. Pathologic complete remissions were observed in up to 25% of patients and survival rates improved significantly, particularly in patients achieving pathologic complete remission. A current intergroup trial will ultimately assess the utility of surgery after induction chemoradiation in this group of patients. The advent of newer agents with demonstrated activity in advanced NSCLC has led to the design of potentially more effective but also more toxic neoadjuvant regimens. Some of these are under investigation in large randomized phase III trials, which should ultimately elucidate the role of induction therapy with "modern" agents in potentially curable NSCLC.