In the National Cancer Database, adjuvant chemotherapy remained efficacious when started 7 to 18 weeks after non-small-cell lung cancer resection. Patients who recover slowly from non-small-cell lung cancer surgery may still benefit from delayed adjuvant chemotherapy started up to 4 months after surgery.

Overall and relative survival in younger patients with NSCLC is better than in older patients, with greater benefit seen in earlier stages. Despite having fewer comorbidities and undergoing more aggressive treatment, younger patients with advanced-stage NSCLC have only marginally better overall and relative survival than older patients.

In an ongoing, open-label, single-arm phase II study (NCT02927301), 181 patients with untreated, resectable, stage IB–IIIB non-small cell lung cancer received two doses of neoadjuvant atezolizumab monotherapy. The primary end point was major pathological response (MPR; ≤10% viable malignant cells) in resected tumors without EGFR or ALK alterations. Of the 143 patients in the primary end point analysis, the MPR was 20% (95% confidence interval, 14–28%). With a minimum duration of follow-up of 3 years, the 3-year survival rate of 80% was encouraging. The most common adverse events during the neoadjuvant phase were fatigue (39%, 71 of 181) and procedural pain (29%, 53 of 181), along with expected immune-related toxicities; there were no unexpected safety signals. In exploratory analyses, MPR was predicted using the pre-treatment peripheral blood immunophenotype based on 14 immune cell subsets. Immune cell subsets predictive of MPR in the peripheral blood were also identified in the tumor microenvironment and were associated with MPR. This study of neoadjuvant atezolizumab in a large cohort of patients with resectable non-small cell lung cancer was safe and met its primary end point of MPR ≥ 15%. Data from this single-arm, non-randomized trial suggest that profiles of innate immune cells in pre-treatment peripheral blood may predict pathological response after neoadjuvant atezolizumab, but additional studies are needed to determine whether these profiles can inform patient selection and new therapeutic approaches.

Key Points Question What information may motivate the US public to travel to safer hospitals for complex cancer surgery, what barriers to traveling do they face, and what solutions may facilitate appropriately changing hospitals? Findings In this nationally representative survey study, 92% of respondents would be motivated to travel to a specialty cancer hospital for superior safety or oncologic outcomes, but 74% also reported barriers to traveling, although most of the barriers could be overcome with proposed solutions. Specific socioeconomic subsets were less likely to travel. Meaning It appears that most of the US public could be motivated to travel to safer hospitals for complex cancer surgery, yet most would require some support to move. Further efforts to ensure that benefits from regionalization are equitable across sociodemographic strata are indicated.

The 1995 Lung Cancer Study Group consensus recommending lobectomy for stage I non-small cell lung cancer (NSCLC) has directed lung cancer resections since its publication. However, enhancements in imaging technology over the last decade have produced larger cohorts of patients presenting with localized, early-stage disease. Today, multislice computer tomography is widely available, capable of detecting NSCLC at smaller sizes, with improved spatial resolution, and is used in screening programs for high-risk individuals. Furthermore, the maturation of minimally invasive surgical resection (video-assisted thoracoscopic surgery) has reduced perioperative morbidity and mortality, improved postoperative lung function, and demonstrated equivalent oncologic effectiveness to open surgery. The mandatory use of lobectomy for patients with small stage IA NSCLC is now being challenged. Numerous single-institution trials have demonstrated that well-selected use of sublobar resection can afford comparable survival and recurrence rates to lobectomy, particularly in high-risk patients. Currently, a prospective, randomized multi-institutional phase III trial is being conducted by the Cancer and Lymphoma Group B (CALGB 140503) to determine whether patients with small (< or =2 cm) peripheral NSCLC tumors can safely undergo sublobar resection while maintaining rates of survival and recurrence that are comparable to lobectomy. This review summarizes the literature from the past 15 years to assist in applying those conclusions to future research innovation.