Perioperative Strategies in NSCLC: Future Directions and Challenges

In this final part of our recent interview with Ticiana Leal, MD, associate professor and director of the Thoracic Medical Oncology Program, Department of Hematology and Medical Oncology, Emory University School of Medicine, and a board-certified medical oncologist at Winship Cancer Institute, she looks to the future of perioperative care—or the care a patient receives before, during, and after surgery—in the non–small cell lung cancer (NSCLC) arena and the importance of risk-stratifying patients so as not to overlook potential treatment opportunities.

This transcript has been lightly edited for clarity.

Transcript

What unanswered questions remain surrounding perioperative strategies for patients with NSCLC?

I think there are still significant unanswered questions. And again, I think it's critical to work together as a multidisciplinary team so that we can continue to address the real-world questions, but also the questions that are still important from a clinical trial standpoint.

Now, from a clinical trial standpoint, I think key questions that remain are going to be duration of therapy and also whether there is a significant advantage of perioperative vs a neoadjuvant approach with chemoimmunotherapy given the results that we're seeing across these trials, because that also has to do with cost. And I think when you think about a perioperative approach with a full year of immunotherapy in the postoperative setting, that may be a challenge globally as we deliver this therapy to patients, and is there a real gain depending on the results of that postoperative surgical specimen in terms of pathologic response, and so on.

Another key question that I think will be really important for us to understand more about is the role of ctDNA [circulating tumor DNA] and how that can also help us risk-stratify patients and understand duration of therapy. And then certainly, I think it's really key to continue to build upon that backbone of chemoimmunotherapy. Are there additional novel agents that we can use in the adjuvant setting in the perioperative approach for patients who don't achieve a pathCR [pathological complete response]? So some critical questions, a lot of interesting clinical trials and designs that I think will be required to answer those questions.

From the real-world setting, I think it's from the institutions and guidelines, not only in the US but globally, really coming together for consensus in terms of establishing the role of multidisciplinary care for patients. Who are the ideal candidates for multidisciplinary care? And then certainly the critical role of biomarker testing and maybe making sure that we establish a pathway so that patients have access to biomarker testing and that no one is missed.

So I think it's exciting times as we think about improving lung cancer care and improving outcomes for patients with early-stage non–small cell lung cancer. We had a really interesting discussion and a lot of great questions after our talk and so a lot more to come.