Neoadjuvant, perioperative, or adjuvant immunotherapy in resectable non-small cell lung cancer: How do I choose? Importance of immune biomarkers and molecular testing

Feature Editor's ' s Introduction-The treatment of patients with advanced non-small cell lung cancer is a quintessential illustration of what is meant by precision medicine. Upon diagnosis, non-small cell lung cancer tumor tissues are analyzed for genomic alterations to select effective Food and Drug Administration-approved molecular therapies that are designed specifically to target the resultant drivers of oncogenesis; and for their expression of a protein that reveals tumor vulnerability to immune checkpoint immunotherapy. In early stage non-small cell lung cancer, our techniques for resection (and for biopsy) are also continuously evolving toward improved technical precision; however, the failure of surgical is rarely surgical-it is biological. Even among patients with tumors who have been generally considered to have the lowest risk for recurrence (<= 2 cm, peripheral, pathologically confirmed hilar, and mediastinal node negative), X 30 % of individuals will experience recurrence and more than 50% % of these recurrences are systemic in nature (Cancer and Leukemia Group B 140503). Consequently, the field of thoracic surgical oncology has naturally progressed to incorporate some of our most effective systemic therapies into neoadjuvant and adjuvant regimens that are recently considered standard. By combining surgery with systemic therapies that combat the offending tumor biology, we are beginning to witness exciting shifts in the unfavorable survival curves to which we have become accustomed. For the practicing surgeon, paradigm- changing clinical trials are resulting swiftly, are highly nuanced, and are not without challenges to assimilate. At this time, among the most widely debated matters is the choice between preoperative, postoperative, and perioperative immunotherapy. In the following Feature Expert Opinion article, we are privileged to have an expert in our field dissect for you recent relevant evidence, and distill for you its complexities into usable assertions. .