From the Guidelines
Neoadjuvant therapy in lung cancer is primarily indicated for locally advanced non-small cell lung cancer (NSCLC), particularly stage IIIA and select stage IIIB disease, where the goal is to downstage the tumor before surgery, as supported by recent evidence 1.
Indications for Neoadjuvant Treatment
The indications for neoadjuvant treatment in lung cancer include:
- Locally advanced NSCLC, particularly stage IIIA and select stage IIIB disease
- Resectable stage II disease with high-risk features
Neoadjuvant Approach
The standard neoadjuvant approach typically involves:
- Platinum-based chemotherapy combinations such as cisplatin/carboplatin with pemetrexed, paclitaxel, or gemcitabine for 3-4 cycles before surgical resection
- Targeted therapies may be incorporated for patients with EGFR mutations, ALK rearrangements, or other targetable mutations
- Recent evidence supports adding immunotherapy (such as nivolumab, pembrolizumab, or atezolizumab) to neoadjuvant chemotherapy regimens, particularly for patients with PD-L1 expression 1
Rationale for Neoadjuvant Therapy
The rationale for neoadjuvant therapy includes:
- Potential tumor downstaging
- Early treatment of micrometastatic disease
- Better tolerance compared to adjuvant therapy
- Ability to assess treatment response pathologically, which provides prognostic information
Pre-Treatment Evaluation
Patients should undergo comprehensive staging with PET-CT and brain imaging, as well as pulmonary function testing to ensure they can tolerate subsequent surgery after neoadjuvant treatment 1.
Special Considerations
Neoadjuvant chemoradiation may be considered for superior sulcus tumors or other cases where local control is particularly challenging. The most recent and highest quality study 1 provides the strongest evidence for the indications and approach to neoadjuvant therapy in lung cancer.
From the FDA Drug Label
for the treatment of patients with resectable (tumors ≥4 cm or node positive) NSCLC in combination with platinum-containing chemotherapy as neoadjuvant treatment, and then continued as a single agent as adjuvant treatment after surgery. (1. 2) The indications for neoadjuvant treatment in lung cancer using pembrolizumab are:
- Resectable NSCLC with tumors ≥4 cm or node positive
- In combination with platinum-containing chemotherapy as neoadjuvant treatment, followed by continued use as a single agent as adjuvant treatment after surgery 2
From the Research
Indications for Neoadjuvant Treatment in Lung Cancer
- Neoadjuvant treatment is considered for patients with locally advanced non-small cell lung cancer (NSCLC) to improve survival outcomes and increase the chances of complete resection 3, 4, 5.
- The use of neoadjuvant chemotherapy, such as docetaxel, cisplatin, and carboplatin, has shown promising results in improving response rates and survival outcomes 3, 5.
- Neoadjuvant immunotherapy strategies, including the use of immune checkpoint blockers, have also shown evidence of clinical benefit in resectable NSCLC, with improved pathologic complete response and major pathologic response rates 6.
- The selection of patients who are most likely to benefit from neoadjuvant treatment remains a challenge, and ongoing trials are exploring biomarkers, molecularly targeted agents, and postoperative radiation therapy to optimize treatment strategies 4, 6.
- Neoadjuvant treatment is often considered for patients with stage IIIA and IIIB NSCLC, with the goal of downstaging the disease and improving surgical outcomes 5, 7.
- The role of neoadjuvant chemotherapy in the treatment of NSCLC remains controversial, with some studies showing improved survival outcomes and others showing no significant benefit 7.
- Future studies are needed to define the optimal neoadjuvant treatment strategies for NSCLC and to identify the patients who are most likely to benefit from these approaches 3, 4, 6, 5, 7.