Dr Forde on Selecting Neoadjuvant and Perioperative Immunotherapy in Resectable NSCLC

“We do know that patients who have a [pathological complete response], so no residual viable cancer at the time of surgery, [are] destined to do quite well.”

Patrick Forde, MBBCh, PhD, the Patrick Prendergast Professor of Clinical Immuno-Oncology at the Trinity St James’s Cancer Institute, Trinity College Dublin, a consultant medical oncologist at St James’s Hospital in Dublin, and a professor at Johns Hopkins University, discussed how he selects among neoadjuvant, perioperative, and adjuvant immunotherapy approaches for patients with resectable non–small cell lung cancer (NSCLC), and whether the adjuvant phase of perioperative immunotherapy adds benefit beyond neoadjuvant treatment alone at the 44th Annual PER® Chemotherapy Foundation Symposium.

Management of resectable NSCLC has changed considerably in recent years, Forde said. Approximately 7 to 8 years ago, the main option was upfront surgery followed by adjuvant chemotherapy; since then, neoadjuvant therapy has been increasingly adopted, he explained.

For most patients with resectable stage II or III NSCLC without an actionable genomic alteration, Forde said he favors neoadjuvant chemoimmunotherapy. The central question is whether to proceed with a perioperative regimen, which adds adjuvant treatment after surgery, he noted. According to Forde, pathological complete response (pCR) currently serves as a rough indicator: patients who achieve a pCR may not require further adjuvant treatment, whereas outside of a clinical trial he generally favors continued, perioperative treatment for those who do not.

There are no randomized trials comparing neoadjuvant-only treatment with a perioperative approach, Forde said. When survival is marked at the time of surgery, patients who receive adjuvant immunotherapy after neoadjuvant treatment tend to do better, he explained. Although, he added that some of that benefit could reflect a lasting influence from the neoadjuvant component.

Patients with a pCR have 5-year survival rates ranging from 93% to 100%, depending on the clinical trial, Forde noted. For these patients, he said he is less inclined to give further adjuvant treatment.

For patients without a pCR, who represent approximately 75% to 80% of patients, Forde said enrollment in a clinical trial that intensifies treatment may make sense. Outside of that setting, he said he tends to continue the adjuvant component for these patients.