NSCLC Updates: Multidisciplinary Panel Discusses Advances in Treatment

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

In the fifth segment of this roundtable discussion, the panel discusses critical advances in the treatment of NSCLC in the adjuvant, neoadjuvant, and perioperative settings, and what surgeons consider when determining operative strategies.

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Dr. Halmos: A lot of advances we’ve seen lately have been about perioperative treatment. We know that we can cure early-stage lung cancers quite well with surgery and radiation, but the intermediate stage has not been satisfying for many, many, many years.

Lately, we’ve seen a lot of advances, both in terms of adjuvant targeted therapy for EGFR-mutated patients and the neoadjuvant chemoimmunotherapy for patients with EGFR-negative tumors. Now that information is impacting [decisions], [teams are] having it to work through the tumor board.

We spoke about the mediastinum work-up—that’s even more important than in the past— and biomarker testing, but tell us, Momen, how does the patient’s lung function and other elements of their illness come into play when we think about those modalities?

Dr. Wahidi: Obviously, patients with lung cancer have the risk factors for heart disease and lung disease. Our job is to optimize their respiratory function.

We often see patients right after diagnosis or ahead of upcoming treatment, whether it’s surgery or immunotherapy. We know immunotherapy can potentially cause pneumonitis. For those patients, our job is to optimize them. We make sure that if they have COPD, they’re on the optimal medical regimen. We encourage smoking cessation prior to surgery because it contributes to better outcomes. We have pulmonary rehab that we can enroll patients in, but it gets challenging because patients have a lot of other obligations when they have cancer treatment. Our job is to get them to a standard treatment that’s best for their outcome.

Dr. Halmos: Yes. After staging is done and the decision is made to go at with neoadjuvant therapy—the data now is very robust, [showing] that neoadjuvant treatment with three to four cycles of chemotherapy and immunotherapy, can achieve a great improvement in outcomes, to the point that in certain biomarker-positive patients—with just nine weeks of therapy— 50% of the tumors go away by the time the surgeon removes where the tumor used to be.

It’s just so exciting for me as a medical oncologist to look over to the surgeon to say, “This time, I got it out of there.” They might enjoy my comments too. Really exciting advances, but not everybody’s a candidate. Immunotherapy certainly has some potential for immune adverse events. Patients with autoimmune disease, patients after transplantation, might not be the perfect candidates. But there are also some challenges after neoadjuvant treatment, as normal flares, maybe some surgical complexity.

Jay, can you tell us how this shifted your practice in the past? Every one of these patients, you might have taken to the OR [operating room] right away; now, you must wait three months anxiously to see in what shape the medical oncologist delivers the patient back to you. How is that process working out?

Dr. Lee: In the US, we’re accustomed to saying that if someone’s medically operable and has resectable disease with stage III disease, that they should get neoadjuvant therapy, regardless of whether it’s single-station N2 or multistation N2.

I think stage II is where there’s more controversy in the US. My personal belief is, even with stage II patients, your recurrence rates are 60%, so to me, that’s still a systemic problem. I prefer neoadjuvant therapy in stage II. But I know surgical colleagues who would say that stage II is more controversial, and some may prefer to take that patient upfront.

In terms of the surgical complexity, we haven’t prospectively collected that data. We’ve put out grading systems. I wrote a review paper about this in JTO [Journal of Thoracic Oncology] about grading systems for nodal lymphadenopathy and perihilar fibrosis, but it has not been prospectively collected in the phase 3 trials. It’s hard to get a grasp of. Is that locally advanced disease and expectant, or is that attributed to the chemo-IO [chemoimmunotherapy]?

It’s not entirely clear. Now that we’re going to the neoadjuvant targeted therapy trials, that level of fibrosis, we’re seeing in neoadjuvant targeted therapy trials. And again, is that due to the target therapy or is that just inherent to the disease? It’s not so easy to decipher.

Dr. Halmos: There’s a lot to learn. However, some of these studies also suggest that we may be able to perform fewer surgeries—for some patients as a result of the neoadjuvant treatment—such as pneumonectomies, potentially reducing the rate. Do you see that in practice?

Dr. Lee: That data first came out with CheckMate 816 with neoadjuvant chemo and nivolumab for up to three cycles. When you looked at the types of operations that were done, there were less pneumonectomies in the chemo-nivo arm.

But when you look at the perioperative trials with IO on both ends, you don’t see that difference, so I’m not sure that’s a real difference.

Dr. Halmos: Got it. There’s a lot of talk about these aspirational neoadjuvant candidates. Where do we draw the line? Are we able to push the boundaries to offer neoadjuvant and surgery? Or are some patients still better off with a more definitive chemoradiation immunotherapy program, like PACIFIC, where you see that boundary lying today?

Dr. Lee: I think it’s important that the surgeon is decisive upfront about medical operability and resectability, because you want that patient to have the best chance of completing either pathway.

[You can have them] going on neoadjuvant chemo-IO, then surgery; or if you’re a perioperative institution, then finish off the adjuvant IO; or go the non-operative route with definitive chemo XRT [chemoradiation], then consolidation durvalumab; either pathway that you think the patient will most likely complete.

Then, these borderline medically operable patients, I don’t think those patients are the aspirational stage 3 patients we’re talking about, because when you look at CheckMate 816 and you look at the patients that didn’t make it to surgery, and what happens to them, very few got the PACIFIC trial regimen.

Is it really feasible to think that we’re going to go from chemo IO, neoadjuvant [treatment] for three to four cycles and then switch gears to PACIFIC? That may not be a feasible or practical route in a pathway for the patient.

Dr. Halmos: There’s a learning curve for us to figure out the right path for each patient. A huge, huge amount of progress has been made. Where do you guys see this in your practices?

Is there a lot of this aspirational, “let’s just give a few rounds of chemo IO and let’s just see what happens?”

Dr. Pasquinelli: We have a couple clinical trials in the early stage. We’re following the NCCN [National Comprehensive Cancer Network] guidelines, and we are seeing such great benefit from doing the IO. It’s been an interesting time.

Dr. Halmos: It’s hard not to catch the excitement and just give things a try. But we’ll learn a little bit more as to how to use these new tools. But again, in that neoadjuvant space, [we need] to make sure that the patient is actually healthy by the time the surgery needs to be performed. Where’s the nursing perspective, where’s the nursing need in that phase?

Dr. Pasquinelli: We do a lot of teaching around IO. So, if it’s neoadjuvant, we discuss the differences between chemotherapy and immunotherapy. We have a lot of written information about that, and there’s a notable difference in the side effect profile. It’s important for patients to understand the side effects.

We talk to them about what to expect: what are the possible side effects, and what are the more concerning symptoms that they may have that they need to call us right away. We practice that.

I would rather a patient call me too many times than not enough in those situations. We have a form that we give them, it [says] these symptoms may happen and this is what you do; these are more concerning, and these are ones that you need to call us right away. But we would rather have them call us.

Then, we go over everything because a lot of things can be treated, and it’s better to treat it early on rather than it getting [worse]. This is such an important message, and it’s not just about creating that line of communication—but also about ensuring the patient understands that you want them to communicate. Our lung cancer navigator receives many of these calls, and then she knows what is acceptable and what needs to be escalated, so she can contact us or the position directly.

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.”