How do you choose between neoadjuvant and adjuvant chemo-immunotherapy for patients with resectable stage II-IIIA NSCLC?

The billion dollar question. For patients with resectable stage II-IIIA NSCLC, how do you choose between neoadjuvant and adjuvant chemo-immunotherapy in light of the recent FDA approval of the CheckMate-816 regimen? Of course, this approval quickly followed in the footsteps of the FDA approval of atezolizumab for patients with PD-L1 positive stage IB-III NSCLC as well as the recent ESMO presentation on the first readout of the eagerly awaited KN091 study. Out with the old, in with the new? Or let’s not throw out the baby with the bathwater? This is a very important issue for all of us to carefully discuss with our multidisciplinary thoracic teams as well as patients to ensure that appropriate decisions could be made for each potentially eli...

Important to keep in mind that we've had no head-to-head comparison of neoadjuvant versus adjuvant immunotherapy, nor has there been an appetite to address this important question thus far. In parsing the existing data, it is important that we remember what we don't know, to avoid extinguishing interest in seeking answers to important residual questions. Although the results of CheckMate 816 are impressive, from comments made in our Tumor Boards, the growing impression in community practices seems to be that primary surgical resection (and subsequent use of adjuvant therapy as appropriate) has somehow become inappropriate, indefensible, or ethically insecure. I find myself having to remind colleagues repeatedly that the design of CheckMate ...

In potentially resectable non-small cell lung cancer (NSCLC) patients, phase 3 randomized studies in the adjuvant setting (IMpower010 and KEYNOTE-091), neoadjuvant setting (CheckMate 816) and perioperative setting (KEYNOTE-671, AEGEAN, and CheckMate 77T) have shown statistically significant and clinically meaningful improvement in disease free survival (DFS) and event free survival (EFS) with HR (0.58-0.76) leading to about 40% relative risk reduction in DFS/EFS in favor of adding immune checkpoint inhibitors compared to chemotherapy alone. This led to the FDA approval of all 3 approaches in patients with stage II and III NSCLC. The main question is which approach leads to better outcomes and fewer side effects for this patient population.

T...