For patients who received neoadjuvant chemotherapy and found to have an EGFR sensitizing mutation at time of R0 surgical resection, would you offer still offer adjuvant osimertinib?

This question has several nuances to address with the rapidly evolving therapeutic landscape for early-stage lung cancer, specifically patients with EGFR mutation. First is the question of neoadjuvant therapy and whether genomic testing should be done prior to offering neoadjuvant treatment. With the approval of nivolumab with chemotherapy in the neoadjuvant setting and the potential for increased risk of ILD with osimertinib in EGFR mutant NSCLC, it should be considered. There are also a number of neoadjuvant trials to provide precision oncology prior to surgery. In this scenario, neoadjuvant therapy was given so we will move forward with this assumption.

In this case, the patient with EGFR NSCLC had neoadjuvant therapy, although the type of neoadjuvant therapy was not specified. With an R0 resection, depending on the stage before and after neoadjuvant therapy, further adjuvant therapy could be considered. If the patient had stage II or III disease, I would provide the data regarding the ADAURA trial and consider adjuvant osimertinib. If stage I disease following neoadjuvant therapy, I might opt for surveillance. 

The final caveat is related to immunotherapy. As noted above, patients who have EGFR NSCLC and receive immunotherapy can have a higher risk of developing ILD on osimertinib so this risk must be considered in decision making. Recent data presented at ELCC 2022 by Felip and colleagues as a subset analysis of the IMpower010 trial in patients with PDL1 greater or equal to 50%, the small number of patients with EGFR mutant NSCLC had similar benefit to other patients with high PDL1. Given this information, I would still favor osimertinib as adjuvant therapy for EGFR NSCLC.