The Case for Neoadjuvant Immunotherapy in Resectable NSCLC

At the Great Debates & Updates meeting in New York, New York, Jamie Chaft, MD, Memorial Sloan Kettering Cancer Center, New York, New York, debated in favor of using neoadjuvant immunotherapy vs adjuvant immunotherapy for the treatment of resectable non-small cell lung cancer.

Transcript:

Hi I am Jamie Chaft, a Thoracic Medical Oncologist at Memorial Sloan Kettering Cancer Center, New York, New York, here at the Great Debates & Updates in Lung Cancer 2023.

I had the pleasure today at the Great Debates to debate Dr Patrick Ford, [MD, Johns Hopkins, Baltimore, Maryland] on the topic of perioperative therapy. My argument is that neoadjuvant therapy is the way to go for patients with non-small cell lung cancer. Now, there are a few caveats to my opinion–the first is that we can only appropriately prescribe neoadjuvant therapy when our predictive biomarkers are known, our staging has been completed, and the patient has been defined to have resectable disease by the thoracic surgeon and medically-operable disease by the cardiologist and the pulmonologist.

Now, if the patient comes to me with resectable non-small-cell lung cancer clinical stages 2 or 3 and they're both medically-operable and technically resectable, their tumors have PD-L1 expression known —ideally PD-L1-positive disease for chemoimmunotherapy— and no known driver mutations then almost always I would favor neoadjuvant chemoimmunotherapy over adjuvant therapy for many reasons: the opportunity to see the tumor shrink, the ability to offer a potentially lesser surgical resection by shrinking the tumor adequately away from margins, and better tolerability. There is some data in melanoma suggesting that perioperative therapy is more successful than postoperative therapy. However, in lung cancer we don't have that data set yet.

For patients with operable and resectable non-small-cell lung cancer who are not at high risk of complications from chemotherapy, there's certainly hints that preoperative therapy is going to be superior to postoperative therapy and unfortunately, that comparative study to prove that hint is probably never going to be done.

Source:

Chaft J. Debate: Neoadjuvant vs adjuvant therapy – neoadjuvant. Presented at Great Debates & Updates in Lung Cancer; September 21-23; New York, NY.