Managing Side Effects in Patients With NSCLC: Experts Share Strategies

At the 2025 American Society of Clinical Oncology (ASCO) Annual Meeting, a panel of multidisciplinary experts convened to discuss non–small cell lung cancer (NSCLC).

Moderated by medical oncologist Balazs Halmos, MD, of the Montefiore Einstein Comprehensive Cancer Center, the roundtable featured perspectives from thoracic surgeon Jay Lee, MD, of the University of California, Los Angeles (UCLA), nurse practitioner Mary Pasquinelli, DNP, APRN, FNP-BC, of the University of Illinois Chicago (UIC), and interventional pulmonologist Momen Wahidi, MD, MBA, of Northwestern Medicine.

In the sixth segment of this roundtable series, the panel discusses how multidisciplinary teams monitor and manage adverse events in patients undergoing immunotherapy for NSCLC. The panel also discusses the importance of patient education on adverse events and how to best prepare patients for surgery.

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Dr. Halmos: Immunotherapy in general is reasonably safe, but there are certain complications where we need to call on our subspecialist colleagues. So, maybe I can ask you, Momen—pneumonitis is such a feared complication of immunotherapy—what is the role of the pulmonologist to help the team get educated and be able to monitor, intervene for the right patients?

Dr. Wahidi: Immunotherapy-related pneumotoxicity has been hard to predict, so we don’t know which patients will get it. We know we have some data that patients who smoke, patients who have COPD, and patients who have pulmonary fibrosis are at higher risk, potentially, but it’s hard to predict even with the presence of these diseases, who will get immunotoxicity.

Again, education to the patients about symptom development, if they develop respiratory symptoms and obviously, if we see changes on the CT, this is where we need to step in and follow and have an algorithm of how to manage these patients, depending on the grades—pneumonitis has four grades or so based on the radiographic involvement—based on the symptoms, and work closely with our oncologist to follow these patients.

In some cases, we may do a bronchoscopy to try to distinguish if it is an infection, immunotherapy toxicity, or potentially progression of the tumor. Then, for the ones that we think are immunotherapy-related pulmonary toxicity, typically, we initiate steroid treatment early on.

I think it’s a collaborative relationship between the oncologist and the pulmonologist. If you have a high-risk patient that you’re going to do immunotherapy, there might be a role for periodic spirometry checks to detect it early. There’s some not-so-robust data, but some data that suggests high-risk patients, like pulmonary fibrosis patients, may benefit. I would never want to deprive patients of the benefit of immunotherapy. For those patients, we work very closely with our oncologists to mitigate that risk.

Dr. Halmos: Great. Congrats to you.

Jay, immunotherapy adverse events can develop; they do develop. As a surgeon, when you take the patient to the OR [operating room] after nine weeks of immunotherapy, is your heart rate a little high? Is there going to be a perioperative complication?

I have to admit that we had a couple of thyroiditis cases right after surgery, adrenal insufficiency that was difficult to detect post-op because the patient was hypertensive; who’s not hypertensive a little bit?

Dr. Lee: Yes.  I think the adverse event profile for IO [immune-oncology] is different. I think in the neoadjuvant perioperative trials, we have to be careful [with] that, a lot of the data collection is not necessarily long-term, and we don’t always pick up on the delayed immune-related adverse events or even the chronic immune-related adverse events. I think that’s not captured as well. It’s a new complication profile that surgeons may not be familiar with. It’s not just going into surgery, but even in the immediate postoperative [period]—where surgeons are heavily involved in that first 30 to 90 days—we’re seeing some of these adverse events. It’s important to educate the surgical community about that. But I think for the most part, it’s a well-tolerated drug.

I think that when you see renal insufficiency, when you see diarrhea, and you’re thinking colitis, you need to think about, could this be an immune-related colitis? Could this be an immune nephritis, an immune hepatitis? These [are] things that we’re not used to thinking about as surgeons, particularly. A pneumonia patient may be having an immune pneumonitis. I think this requires education among surgeons about the adverse event profile.

Dr. Halmos: Absolutely. Again, generally safe, but there’s such a spectrum of immune adverse events, it makes us relearn different chapters of medicine that we thought we could forget, but now we’re challenged to do so. We’re all so lucky in academic centers such as ours to have so many great subspecialist colleagues—just for example, you, Momen—to be able to call on.

What is your practice as to working with the subspecialist teams—pulmonary, endocrine, dermatology, a bunch of [our] friends we need to keep close?

Dr. Pasquinelli: Everybody has the numbers, and you know who to contact very quickly. Most of it, the medical oncologist can usually handle. But then you have those small subsets of patients that no matter what you do, you do need to get endocrinology involved, or dermatology, doing a lot of education with the patient.

Sometimes you start [a patient] on a treatment and they’re not doing as well as you expected them to, so you need to elevate that with our specialty. Cardiology gets involved too sometimes, and of course, our pulmonologists. It’s important to be able to treat what we can treat, but when it goes beyond our capabilities, we need a specialist.

Dr. Halmos: Fantastic comments.

View the first segment of this roundtable series, titled “Lung Cancer Screening: Multidisciplinary Experts Discuss Barriers, Opportunities.”

View the second segment of this roundtable series, titled “From Biopsy to Biomarkers: Panel Shares Insights on NSCLC Diagnostic Process”

View the third segment of this roundtable series, titled “Treatment for NSCLC: How Multidisciplinary Teams Define Options, Strategies.”

View the fourth segment of this roundtable series, titled “Patient Navigation Strategies in NSCLC: Expert Panel Shares Insights.”

View the fifth segment of this roundtable series, titled “NSCLC Updates: Multidisciplinary Panel Discusses Advances in Treatment.“