David Carbone, MD, PhD: What is the role of neoadjuvant therapy in the current treatment approaches for early-stage lung cancer, and how do you evaluate [whether] patients [are] suitable for this approach?

Patrick Forde, MBBCh: I think the first thing, as Dr Gillaspie mentioned, is that early-stage lung cancer is a high-risk disease. If you look at the numbers over the years, about 50% of patients across stages I to IIIa will experience recurrence of their cancer. The current indication for neoadjuvant chemo-immunotherapy, and that’s an important point when we’re talking about neoadjuvant therapy, our indication is not just immunotherapy. Sometimes patients think we’re just going to give immunotherapy. It also involves chemotherapy. But the current indication is for stage II or stage IIIa, clinical stage. As you mentioned earlier, clinical stage is based on scans and noninvasive staging of the mediastinum. But if the patient has clinical stage II or IIIa, which is generally either node-positive disease or larger node-negative tumors, those are the patients for whom immunotherapy is an option. And as Dr Dietrich mentioned, we’re generally excluding patients who have EGFR [epidermal growth factor receptor] alterations or ALK alterations because in metastatic disease, the efficacy of immunotherapy is minimal and in early-stage disease, we’ve seen perhaps very minimal signals of efficacy, but not as much at all as in the non-EGFR/ALK patients. Those patients, I think, when we see them in clinic, surgeons have the option of bringing them to surgery or referring the patient to a medical oncologist, especially for stage IIIa disease, and discussing that patient in a tumor board. For a medical oncologist it depends largely on the surgeon, whether the surgeon decides to refer the patient to be seen, in some cases, by radiation and medical oncology together if it’s a very locally advanced tumor. But if I do see such a patient, I will discuss the neoadjuvant option, which is either 3 cycles of chemotherapy with nivolumab per the CheckMate 816 [regimen], and then theoretically no further therapy postoperatively. Or we have 2 other studies where we have periods of pre and post. Those are not yet approved, but we expect sometime in the future they will be. But at the moment, for patients with neoadjuvant consideration, I definitely think resectable stage IIIa is a good disease setting to consider it strongly. [For] stage II disease, I think it’s much more individualized, and all of it comes down again to the patient being someone who will have chemotherapy, first of all, who is fit for systemic therapy, and who wishes to maximize their chance of benefit. Because some patients, you tell them [they] have a 50% chance of cure from surgery, and they want to take their odds and have systemic therapy. It’s a complicated discussion, I think, as we all know.

David Carbone, MD, PhD: As you said, this is a really new paradigm in lung cancer. Very few patients, in my experience, got neoadjuvant chemotherapy alone. Historically, it was maybe for pancreas tumors. Chemotherapy regimens for the average patient; the surgeon would operate on it and then refer [the case] to the medical oncologist. This use of neoadjuvant therapy is going to require a paradigm shift toward a multidisciplinary discussion of many of these patients before surgery so that we can optimize their outcomes because I think the signals that we’re seeing now [with] this neoadjuvant therapy are suggesting that the outcomes are going to be much better. We’re having stage III survival at 3 and 4 years of 70% to 80%. This is incredible. This is twice what you might expect historically. How are we going to get surgeons to consider neoadjuvant therapy?

Erin A. Gillaspie, MD, MPH, FACS: I think that’s such an important question, and actually, it’s one of my missions as a surgeon to make sure that we’re being educated about all of these new treatment paradigms that are becoming available and making sure that people who maybe aren’t lucky to spend all of their time in lung cancer like I do [are educated]. That’s my passion, that’s my focus. My nose is in the journals constantly. But for people who perhaps do cardiac and thoracic surgery, [it’s] making sure that we can provide education to say, “Hey, if you are seeing a patient, please, please, please think about sending them to medical colleges. Think about bringing them to our multidisciplinary tumor board so that we can help you.” We struggle, I think, to accomplish the goals that we want to [achieve] surgically nationwide.

David Carbone, MD, PhD: N2 nodes sample—what’s that?

Erin A. Gillaspie, MD, MPH, FACS: That’s exactly what I was going to say. We look at the outcomes data, and only 54% to 56% of patients had an adequate lymph node activity at the time of surgery. To me, that’s a crisis. We have to be sure that if we are taking a patient to the operating room, we’re giving them a great oncologic surgery because that’s so powerful, and helping to guide the next steps in their therapy. Making sure we’re doing the right surgery at the right time is critical. It’s education, education, education, and that goes all the way back to biopsies. Now we have to be educating anybody who’s taking biopsies. We need that biopsy, and we need it to be sent for molecular testing. We need it to be...

David Carbone, MD, PhD: …adequate for molecular testing.

Erin A. Gillaspie, MD, MPH, FACS: Exactly. That’s a huge struggle, too. Asking a patient to wait an additional several weeks to get an additional biopsy and that information back, I think, leads a lot of patients to say, “No, thank you. I’m going to go straight to surgery because I don’t want to wait for the chance that this could progress.”

David Carbone, MD, PhD: It’s why that first biopsy is the most important when you [get] it. It’s the [pressure] on the person doing the biopsy to get adequate samples on that first biopsy and not just get those 10 cells to make a diagnosis, even in the earliest stages of disease.

Erin A. Gillaspie, MD, MPH, FACS: Exactly right.

Transcript is AI generated and reviewed by an AJMC editor.