Dr Donington on the Effects of Targeted Therapy on Surgical Planning in Early-Stage Lung Cancer

“It’s been fun for the past 20 years to watch the medical oncologist tackle biomarkers and biomarker-directed therapy. It is exciting that it has finally made it to the surgical space, [but] it does complicate what we do. There is no doubt about it.”

Jessica Donington, MD, MSCR, professor of surgery and chief of the Section of Thoracic Surgery at UChicago Medicine, reflected on the growing integration of biomarker testing into surgical oncology, noting that advances in precision medicine are increasingly reshaping how surgeons evaluate and manage patients.

Over the past two decades, biomarker-driven therapy has transformed medical oncology, and its influence is now extending into the surgical setting, Donington said. Traditionally, surgical decision-making was centered on disease staging and physiologic fitness, determining the extent of resection required and whether a patient could safely tolerate the procedure. However, this paradigm has evolved to incorporate a deeper understanding of tumor biology. Surgeons are now tasked not only with assessing anatomy and operability, but also with considering what molecular insights may inform treatment strategy, Donington explained.

This shift has introduced new complexities into the preoperative workflow. Biomarker testing, often performed via next-generation sequencing (NGS), has become an important component of the diagnostic workup. As a result, patients may require additional procedures, such as needle biopsies, to obtain sufficient tissue for molecular analysis. These smaller, minimally invasive samples reflect broader trends in cancer diagnosis but can present challenges in ensuring adequate material for comprehensive testing.

From a surgical perspective, one of the primary frustrations is the added time required to complete biomarker analysis, Donington expressed. Surgery has historically been a field driven by efficiency and rapid progression from diagnosis to intervention. In contrast, molecular testing introduces delays that must be balanced against the potential benefits of more informed, personalized treatment planning.

A key tension arises in how limited biopsy tissue is allocated. Comprehensive approaches such as NGS can maximize the detection of actionable alterations but often require longer turnaround times. Alternatively, more rapid, point-of-care testing may provide quicker results but can consume more tissue, potentially limiting the ability to perform broader genomic profiling. This creates an ongoing push-pull dynamic among surgeons, pathologists, and institutional teams as they work to optimize both diagnostic yield and timeliness, Donington stated.

Ultimately, the integration of biomarker testing into surgical oncology underscores a broader shift toward multidisciplinary, biology-driven care. Although it introduces logistical challenges, it also offers the opportunity to better align surgical decision-making with the molecular characteristics of each patient’s disease.