Strategies for Neoadjuvant NSCLC Treatment

In season 4, episode 13 of Targeted Talks, Benny Weskler, MBA, MD, FACS, FACCP, professor of cardiothoracic surgery, Drexel University College of Medicine, as well as the system chief of thoracic surgery, Allegheny Health Network, and chief of the Division of Thoracic Surgery at the Department of Cardiothoracic Surgery at Allegheny General Hospital, discusses neoadjuvant therapy for patients with non–small cell lung cancer.

According to Wexler, there is a role for all modalities in the treatment of NSCLC. However, timing of treatment plays an important role in patient outcomes. He explains that neoadjuvant systemic therapy is intended to give patients the best chance before their blood supply is impacted by surgery. Whether patients receive preoperative chemotherapy, radiation, or chemoradiation is dependent upon their disease stage and other factors. But, at AHN, use of radiation neoadjuvantly is reserved for special cases.

Research published in recent years has shown that there is no difference in outcomes between patients with NSCLC treated with neoadjuvant chemotherapy followed by surgery or neoadjuvant chemoradiation plus surgery, according to Weskler. Further, results from the PACIFIC study (NCT02125461), showed improvement in disease-free and overall survival when immunotherapy followed by chemoradiation. He says, this provided proof-of-concept for the use of immunotherapy in the neoadjuvant setting.

“I think the PACIFIC trial opened the door for the immunotherapy in the neoadjuvant setting. Truly after many years of not a lot of evolution in that space we started seeing small trials with preoperative immunotherapy in patients with stage 3 disease, says Weskler. “So, those small trials showed that we could operate patients after immunotherapy, but some of them show that there was a little slightly higher conversion rate to open surgery after immunotherapy.”

After neoadjuvant immune checkpoint inhibitors with chemotherapy or chemoradiation, the next best strategy for improving patient outcomes is the use of minimally invasive surgery. Further, some experts are now taking a trimodal approach to NSCLC treatment, which has been hypothesized to improve outcomes further.