Favorable Outcomes With Perioperative Immunotherapy in Resectable NSCLC
Large real-world study finds neoadjuvant and adjuvant chemoimmunotherapy improve survival in stage II–IIIA lung cancer
Topline
A nationwide retrospective cohort study of over 1,300 patients with resectable stage II–IIIA NSCLC found that perioperative chemoimmunotherapy significantly improves 18-month distant metastasis–free survival (DMFS), yet remains underused, with fewer than 30% of eligible patients receiving it.
Study Details
Non–small cell lung cancer (NSCLC) remains a leading cause of cancer-related deaths, even in early stages. While perioperative immunotherapy has shown survival benefits in clinical trials, this study aimed to assess its real-world application and outcomes.
Using data from the Flatiron Health database, researchers analyzed the records of 1,334 adults with stage II–IIIA resectable NSCLC who received either neoadjuvant or adjuvant chemoimmunotherapy following FDA approvals between 2021 and 2023.
Methodology
This retrospective cohort study leveraged deidentified electronic health records from over 280 cancer clinics across the U.S. Patients included had undergone surgery and received either:
Neoadjuvant chemoimmunotherapy: immunotherapy (nivolumab or pembrolizumab) + platinum-based chemotherapy before surgery
Adjuvant chemoimmunotherapy: atezolizumab or pembrolizumab, with or without chemotherapy, within 12 weeks post-surgery
Primary outcome was clinical DMFS. Secondary outcomes included biomarker testing rates, time-to-treatment, and metastatic patterns.
Key Findings
18-month DMFS was 80.2% for neoadjuvant and 83.0% for adjuvant cohorts.
Biomarker testing (PD-L1, EGFR, ALK) was significantly lower in neoadjuvant patients (e.g., PD-L1 testing: 52.6% vs. 72.2%).
Longer adjuvant immunotherapy durations (≥12 months) correlated with higher survival rates (95.2% DMFS).
Patterns of metastasis were consistent across cohorts, with brain, bone, and pleura most commonly affected.
Uptake of chemoimmunotherapy increased from 2022 to 2023 but remained below 30% of eligible patients.
Implications for Practice
This study reinforces the benefit of perioperative immunotherapy in resectable NSCLC. However, several critical gaps were highlighted:
Low adoption: Despite FDA approvals and guideline endorsements, chemoimmunotherapy is underutilized.
Biomarker testing gaps: Inadequate testing for EGFR and ALK may result in inappropriate therapy selection.
Stage-based strategies: While adjuvant therapy may be preferred in stage II disease, stage IIIA cases benefit more from neoadjuvant approaches.
For clinicians, multidisciplinary evaluation (including pulmonology, oncology, surgery, and pathology) and integration of molecular testing are essential for optimal treatment planning.
For patients, especially those with resectable stage II–IIIA NSCLC, understanding the timing and type of immunotherapy can significantly influence long-term outcomes.