The emerging perioperative treatment paradigm for non-small cell lung cancer: a narrative review

The management of resectable non-small cell lung cancer (NSCLC) has relied on surgery and adjuvant chemotherapy for the past two decades, but is now radically changing through the introduction of immunotherapy and targeted drugs. This review was conducted to summarize recent developments and highlight future directions.

A literature search for randomized phase 2/3 trials on the treatment of early-stage NSCLC was performed based on PubMed and the content on major oncology congresses during the last 3 years.

Perioperative strategies with 3-4 cycles of neoadjuvant chemoimmunotherapy and 1 year of adjuvant programmed cell death (ligand) 1 [PD-(L)1] blockade combine the efficacy of purely adjuvant [effective for both stage II and stage III tumors with event-free survival hazard ratios (HR) of approximately 0.70] and the purely neoadjuvant strategies (effective only for stage III with a lower EFS HR of approximately 0.50), show benefit across the entire spectrum of PD-L1 tumor expression levels, and significantly improve overall survival, as the NADIM-2 and Keynote-671 studies recently showed. Once approved, they will probably dominate the landscape of management for resectable NCSLC based on two main advantages: first, compared to purely adjuvant treatments, like those of the IMpower010 and Keynote-091 trials, they allow for evaluation of response in the surgical specimen and permit adjustment of the postoperative management accordingly; second, compared to the purely neoadjuvant treatment of Checkmate-816, their postoperative component appears to additionally improve the outcome of patients failing to achieve a pathologic complete remission (pCR). Further improvements in the near future will likely include intensified postoperative therapy for non-pCR patients, e.g., with addition of chemotherapy, antibody-drug conjugates, or next-generation immunotherapeutics; broader use of circulating tumor DNA assays for improved monitoring of minimal residual disease; as well as routine availability of further tyrosine kinase inhibitors (TKI) against oncogenic drivers beyond classic EGFR mutations, like adjuvant alectinib for tumors with ALK fusions, whose approval is expected soon based on the recent success of the ALINA trial, and adjuvant selpercatinib for tumors with RET fusions, if the ongoing LIBRETTO-432 trial is also positive. The availability of both TKI and neoadjuvant chemoimmunotherapy in the routine setting renders molecular tumor profiling imperative for potentially resectable tumors already at initial diagnosis.

Perioperative immunotherapy is becoming the dominant treatment paradigm for resectable NSCLC, while increasing use of targeted drugs for actionable alterations necessitates upfront molecular profiling of early tumors for patient selection.