Treatment for NSCLC: How Multidisciplinary Teams Define Options, 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 third segment of this roundtable discussion, the panel discusses how multidisciplinary teams collaborate to treat patients with lung cancer and how decisions are made about surgery, radiation, and medical oncology treatment strategies.

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

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Dr. Halmos: Now that we’ve made a diagnosis, thanks to Momen’s help and you [Mary] helped us communicate it to the patient, how do we define the next steps? Who is primary resectable? Who should take a different approach? And if somebody is resectable, maybe still discuss some alternative options, such as radiation, with our patients.

Dr. Lee: Surgeons think about two issues. One is medical operability of the patient, which is performance status-driven, and cardiovascular and pulmonary status-driven. It’s more [about] the fitness of the patient.

Medical operability pertains to the patient. Then, there’s surgical resectability of the tumor and the lymph nodes. To the surgeon, these are two entirely separate issues. You could have resectable disease but be medically inoperable and not make it to surgery. You need both to be aligned.

Those issues of who’s medically operable and surgically resectable are highly variable, depending on the institution and the surgeon. Among different surgeons at the same institution, there are different thresholds. There isn’t one good way to pinpoint a fine black-and-white line of who’s medically operable and who’s surgically resectable.

I think the greatest controversy comes in the invasive T4 patients, the multistage and N2 patients, and then, the pneumonectomy patients, all of which have been included in all the neoadjuvant or perioperative trials except for AEGEAN, which, at the time of screening, were excluded. But if they ultimately need a pneumonectomy, they were they were allowed to get it. But I think it’s important to recognize that those are probably the three subsets of patients that are most controversial.

Dr. Halmos: Great. I think that, on this team, I’m perhaps the closest to radiation oncology, so I’d like to stand up for our fantastic specialty. Certainly, in inoperable patients, we now have fantastic modalities that can potentially achieve a high rate of cure, particularly with the use of stereotactic radiosurgery. Of course, radiation-based treatments can be appropriate for multistage node-positive patients where maybe the surgical approach is not ultimately the right one.

But let’s come back to this resectability and multimodal treatment. Nowadays, with neoadjuvant approaches coming into the foreground, it’s even more important to stage patients correctly. It’s one thing to diagnose, one thing to have a sense of the stage, but now we need more accuracy. Because if somebody’s not positive, it’s so important to at least consider that a neoadjuvant approach would be more helpful.

Maybe I can throw this question to Momen: The mediastinum is now your organ. How do you make sure that we’re not missing out on the option of better treatments for occult node-positive disease? Do you do an EBUS [endobronchial ultrasound]on each patient who will go for resection? What’s the current standard of care?

Dr. Wahidi: I think this is such an important topic. We know that even if the mediastinum is negative on CT and PET scans, there’s about a 10% chance that metastasis may still be present in the mediastinum.

So really, the push has been to try to look at the mediastinum always before resection. It could be done with mediastinoscopy, or it could be done with endobronchial ultrasound with bronchoscopy. It’s routine now when we’re trying to diagnose cancer [and detect a] lung nodule, lung mass, even if the mediastinum is clean radiographically, we look with endobronchial ultrasound, and any lymph node that’s higher than 5mm in size gets sampled. Obviously, we do it systematically from the contralateral side to the side of the primary. I think we are now seeing that being utilized more.

We had studies 20 years ago that showed that we did not do well in staging. We rely too much on radiographic studies and PET scans. We know that PET can be false positive or false negative. I think there’s been a push to be more aggressive in sampling the mediastinum.

I mean, we have the tools now; endobronchial ultrasound, that’s not very invasive. Anytime a patient’s getting a diagnostic procedure, they’re usually getting a look at their mediastinum to ensure that there’s no metastasis.

Dr. Halmos: Fantastic. A study from Australia just a couple of months ago highlighted that even in patients who undergo primary radiation, the EBUS procedure may still be beneficial, as it helps upstage some cases, allowing patients to receive more effective treatment than just definitive radiation. Is that becoming routine as well?

Dr. Wahidi: Yes. There are different thresholds for different programs in the country, but, increasingly, we advocate for that approach. If you’re going to do SBRT [stereotactic body radiation therapy] for a stage I lung cancer, it would be beneficial to look at the mediastinum. We need to balance the invasiveness of the procedure—it’s anesthesia and bronchoscopy versus the likelihood of metastasis—so, if it’s a 1-centimeter, very peripheral lung nodule, it’s probably OK to not look at the mediastinum.

But the more central the nodule or the primary is, the bigger size or the presence of hilar lymph node potentially, that all pushes us toward [saying] “Let’s look at the mediastinum.”

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”