Resectable stage I to III non-small-cell lung cancer
Lung cancer caught before it has spread is treated with surgery, now often keyhole or robotic and sometimes removing only part of a lobe. Immunotherapy given before and after the operation, or a targeted pill afterwards for EGFR or ALK tumours, cuts the chance of the cancer coming back by between a third and four fifths.
Overview
Surgery has cured lung cancer since Evarts Graham's pneumonectomy in 1933, and lobectomy with mediastinal node dissection became the standard after the 1995 Lung Cancer Study Group trial found more recurrences with lesser resections. Staging rests on PET-CT and, for central or node-suspicious tumours, endobronchial ultrasound sampling of the mediastinum; brain MRI is added from stage II. Two trials in 2022 and 2023, JCOG0802 and CALGB 140503, showed that segmentectomy or wedge resection is as good as lobectomy for peripheral tumours of 2 cm or less, the tumours that screening finds, and most resections are now by video-assisted or robotic thoracoscopy. Stereotactic radiotherapy cures most stage I tumours in patients who cannot have surgery (CHISEL, JCOG0403). Adjuvant cisplatin doublet chemotherapy, established by the LACE meta-analysis in 2008, adds about 5 percent to five-year survival in stage II and III.
The decade since 2020 has added systemic therapy on both sides of the operation. ADAURA (2020) showed that three years of adjuvant osimertinib in EGFR-mutated stage IB to IIIA cut recurrence by 83 percent and improved five-year survival from 78 to 88 percent, and ALINA (2024) did the same for two years of alectinib in ALK-positive disease (hazard ratio 0.24). For the majority without a driver, IMpower010 (2021) showed adjuvant atezolizumab improved disease-free survival in PD-L1-positive stage II to IIIA (hazard ratio 0.66), CheckMate 816 (2022) showed that three cycles of nivolumab with chemotherapy before surgery raised pathological complete response from 2 to 24 percent and improved event-free and, later, overall survival, and the perioperative trials that give immunotherapy before and after surgery, KEYNOTE-671 (pembrolizumab, event-free survival hazard ratio 0.58, overall survival hazard ratio 0.72), AEGEAN (durvalumab, hazard ratio 0.68) and CheckMate 77T (nivolumab, hazard ratio 0.58), all followed, with approvals between 2022 and 2024.
The open questions are practical: whether the adjuvant phase adds anything for patients who already had a complete pathological response, whether circulating tumour DNA after surgery can pick out who needs more treatment and who needs none, how to avoid immunotherapy toxicity that prevents an operation, and how to stage patients accurately enough to give the right group neoadjuvant treatment. Driver testing before any neoadjuvant immunotherapy is now essential because EGFR- and ALK-positive tumours gain little and should go to targeted adjuvant therapy instead.
State of the art
- Perioperative chemoimmunotherapy (CheckMate 816, KEYNOTE-671, AEGEAN, CheckMate 77T) cuts recurrence by about 40 percent and improves survival in driver-negative disease.
- Targeted adjuvant therapy for EGFR (ADAURA) and ALK (ALINA) tumours with hazard ratios of 0.17 and 0.24 for recurrence.
- Sublobar resection is an accepted standard for small peripheral tumours.
- Low-dose CT screening is shifting diagnoses toward stage I.
Red cards
From the labels and guidelines behind the standard of care. Your team's thresholds win.- Emergency services nowHypophysitis or adrenal crisis
Persistent headache with extreme tiredness, nausea, dizziness on standing or low blood pressure. Vomiting, severe weakness or collapse is adrenal crisis.
- Emergency services nowBleeding or bruising
Bleeding that will not stop, black or bloody stools, or unexplained bruising when platelets are expected to be low.
- Emergency services nowFainting or palpitations
Fainting, near-fainting, or an irregular or racing heartbeat; several kinase inhibitors prolong the QT interval and the labels require ECG and electrolyte monitoring.
- Check before combiningFood and drink: Alectinib
Take with food; exposure roughly triples with a high-fat meal, and the trials dosed with food.
- Check before combiningFood and drink: Pembrolizumab
No pharmacokinetic interactions expected (antibody). See the irAE guide for toxicity management.
- Check before combiningHeart rhythm (QT): Osimertinib
Known QT prolongation. Avoid other QT-prolonging drugs where possible; check ECG and correct potassium and magnesium before and during treatment.
See all on the product pages:AlectinibAtezolizumabCarboplatinCisplatinDurvalumabNivolumabOsimertinibPembrolizumabPemetrexed·Printable cards in the navigator
Anatomy and lymph node drainage
- Central airways (squamous, small-cell)
- Periphery (adenocarcinoma)
- Apex (Pancoast)
- Pleura (mesothelioma)
- Thymus (anterior mediastinum)
- Nodes: hilar (N1)
- Nodes: mediastinal (N2)
- Nodes: supraclavicular (N3)
Central tumours arise in the large airways, peripheral ones in the alveoli; both drain to hilar then mediastinal nodes, and the pleural lining is a separate cancer site.
- Central airways (squamous, small-cell)Stage IB to IIIA adenocarcinoma or squamous cell carcinoma without a driver (perioperative or neoadjuvant chemoimmunotherapy)
- Periphery (adenocarcinoma)Stage IA peripheral adenocarcinoma 2 cm or less (sublobar resection or lobectomy) · Stage IB to IIIA adenocarcinoma or squamous cell carcinoma without a driver (perioperative or neoadjuvant chemoimmunotherapy) · Resected EGFR-mutated adenocarcinoma (adjuvant osimertinib) · Resected ALK-positive adenocarcinoma (adjuvant alectinib)
- Apex (Pancoast)
- Pleura (mesothelioma)
- Thymus (anterior mediastinum)Stage IA peripheral adenocarcinoma 2 cm or less (sublobar resection or lobectomy) · Stage IB to IIIA adenocarcinoma or squamous cell carcinoma without a driver (perioperative or neoadjuvant chemoimmunotherapy) · Resected EGFR-mutated adenocarcinoma (adjuvant osimertinib) · Resected ALK-positive adenocarcinoma (adjuvant alectinib)
- hilar (N1)
- mediastinal (N2)
- supraclavicular (N3)
Same organ: Non-small-cell lung cancer, Lung cancer (all types), Small-cell lung cancer, Mesothelioma, Pleural mesothelioma, Thymoma and thymic carcinoma, Childhood lung and airway tumours (pleuropulmonary blastoma, tracheobronchial tumours), Inflammatory myofibroblastic tumour (IMT), EGFR-mutated non-small-cell lung cancer, ALK-positive non-small-cell lung cancer, KRAS G12C-mutant non-small-cell lung cancer, ROS1-positive non-small-cell lung cancer, MET exon 14 and MET-amplified non-small-cell lung cancer, RET fusion-positive non-small-cell lung cancer, BRAF V600E-mutant non-small-cell lung cancer, HER2-mutant non-small-cell lung cancer, NTRK fusion-positive non-small-cell lung cancer, PD-L1-high non-small-cell lung cancer without a driver mutation, Unresectable stage III non-small-cell lung cancer, Limited-stage small-cell lung cancer, Extensive-stage small-cell lung cancer, Lung neuroendocrine tumours (typical and atypical carcinoid)
Show survival figures (1)
Averages across everyone diagnosed, often years ago. Your stage, subtype, age, fitness and the treatment you receive matter more than the average, and the numbers are improving quickly.
- About a quarter to a third of non-small-cell lung cancers are found while still resectable, a share rising with low-dose CT screening; five-year survival ranges from over 80 percent for screen-detected stage IA tumours to about 40 percent for stage IIIA.
- Low-dose CT lung screeningStandard of care
- MRIStandard of care
Nothing recorded yet.
Also on OnCo: Symptoms and red flags · Early detection roadmap.
Cases by country
No country-level case numbers. This cancer is not mapped to a GLOBOCAN site.
One section per setting: the options named, what each is for, the trials behind them, the recorded trade-offs and the questions to ask.
Segmentectomy or lobectomy by video-assisted or robotic thoracoscopy with node dissection (CALGB 140503, JCOG0802); no systemic therapy; stereotactic radiotherapy if not fit for surgery.
Neoadjuvant nivolumab plus platinum chemotherapy for three cycles (CheckMate 816) or perioperative pembrolizumab (KEYNOTE-671), durvalumab (AEGEAN) or nivolumab (CheckMate 77T) with chemotherapy before and immunotherapy for a year after surgery; or surgery first then adjuvant cisplatin doublet and atezolizumab or pembrolizumab if PD-L1-positive (IMpower010).
Adjuvant platinum chemotherapy where indicated, then three years of osimertinib (ADAURA).
Two years of adjuvant alectinib in place of chemotherapy (ALINA).
PET-CT and mediastinal sampling before surgery; CT every six months for two years then yearly; circulating tumour DNA surveillance in trials.
Subtypes & biomarkers
top- Stage IA peripheral adenocarcinoma 2 cm or less (sublobar resection or lobectomy)
- Stage IB to IIIA adenocarcinoma or squamous cell carcinoma without a driver (perioperative or neoadjuvant chemoimmunotherapy)
- Resected EGFR-mutated adenocarcinoma (adjuvant osimertinib)
- Resected ALK-positive adenocarcinoma (adjuvant alectinib)
- Medically inoperable stage I (stereotactic radiotherapy)
- Superior sulcus (Pancoast) tumour (chemoradiation then surgery)
- TNM stage by PET-CT, brain MRI (stage II and above) and mediastinal sampling by endobronchial ultrasound or mediastinoscopy
- EGFR and ALK status before any systemic treatment (targeted adjuvant therapy; neoadjuvant immunotherapy avoided)
- PD-L1 tumour proportion score (adjuvant atezolizumab and pembrolizumab eligibility)
- Pathological complete and major pathological response after neoadjuvant therapy
- Circulating tumour DNA after surgery (molecular residual disease; under study)
- Pulmonary function and cardiac fitness for surgery
How often this target appears
- 1933Evarts Graham performs the first successful pneumonectomy for lung cancer
- 1995Lung Cancer Study Group: lobectomy beats limited resection, setting the standard for 30 years
- 2008LACE meta-analysis: adjuvant cisplatin chemotherapy adds about 5 percent to five-year survival
- 2011NLST: low-dose CT screening cuts lung cancer mortality by 20 percent, finding more early-stage tumours
- 2020ADAURA: adjuvant osimertinib for EGFR-mutated disease
- 2021IMpower010: adjuvant atezolizumab improves disease-free survival in PD-L1-positive stage II to IIIA
- 2022CheckMate 816: neoadjuvant nivolumab plus chemotherapy raises pathological complete response from 2 to 24 percent
- 2023KEYNOTE-671 and AEGEAN: perioperative pembrolizumab and durvalumab; CALGB 140503: sublobar resection non-inferior
- 2024ALINA: adjuvant alectinib for ALK-positive disease; CheckMate 77T perioperative nivolumab approved
Dated changes read from the records linked to this cancer: approvals, regulatory steps, reported trials, guideline versions and milestones. Newest first; no date is inferred.
All 19 changes by month →- 2026-09-17This recordResectable stage I to III non-small-cell lung cancerFacts on this page last checked
When this page itself was last checked or edited.
- 2024MilestoneALINAALINA: adjuvant alectinib for ALK-positive disease; CheckMate 77T perioperative nivolumab approved
A milestone in how this cancer is treated.
- 2023-10-16RegulatoryPembrolizumabPembrolizumab: approval (US)
Perioperative NSCLC (KEYNOTE-671)
- 2023Trial resultALINAALINA reported
DFS HR 0.
- 2023Trial resultCALGB 140503 (Alliance)CALGB 140503 (Alliance) reported
5-year disease-free survival 63.
- 2023Trial resultKEYNOTE-671KEYNOTE-671 reported
EFS HR 0.
What is in development for Resectable stage I to III non-small-cell lung cancer, drawn from the whole corpus: 14 items. Drugs are grouped by the most advanced trial phase they have reached anywhere; approved treatments sit under standard of care. Technologies are the methods being tested for this cancer, trials are the studies recorded here, and ideas are proposals not yet in a trial.
Trials under way · 4
- A Study of Neoadjuvant Chemotherapy Plus Nivolumab Versus Neoadjuvant Chemotherapy Plus Placebo, Followed by Surgical Removal and Adjuvant Treatment With Nivolumab or Placebo for Participants With Surgically Removable Early Stage Non-small Cell Lung Cancer · phase 3 · Bristol-Myers Squibb
- A Study of Neoadjuvant/Adjuvant Durvalumab for the Treatment of Patients With Resectable Non-small Cell Lung Cancer · phase 3 · AstraZeneca
- ALCHEMIST (Adjuvant Lung Cancer Enrichment Marker Identification and Sequencing Trials) · phase platform · National Cancer Institute with the Alliance, ECOG-ACRIN, SWOG and NRG Oncology
- Study to Assess Safety and Efficacy of Atezolizumab (MPDL3280A) Compared to Best Supportive Care Following Chemotherapy in Patients With Lung Cancer [ · phase 3 · Hoffmann-La Roche
Trials reported · 7
- ADAURA · phase 3 · 2020 · positive
- ALINA · phase 3 · 2023 · positive
- CALGB 140503 (Alliance) · phase 3 · 2023 · positive
- CheckMate 816 · phase 3 · 2022 · positive
- CHISEL (TROG 09.02) · phase 3 · 2019 · positive
- JCOG0403 · phase 2 · 2015 · positive
- KEYNOTE-671 · phase 3 · 2023 · positive
Ideas not yet in a trial · 3
Open problems and what is being done
Whether adjuvant immunotherapy adds anything after neoadjuvant treatment and surgery, especially for complete pathological responders, has not been tested directly.
Circulating tumour DNA after surgery identifies high-risk patients but no trial yet shows that acting on it improves survival.
About a fifth of patients given neoadjuvant therapy never reach surgery, from progression, toxicity or decline.
and how the field plans to fix it →What is being done about thisSide effects and quality of lifeAvailable now- Cytotoxic chemotherapyStandard of care
- Immune checkpoint inhibitorsStandard of care
- Robotic & minimally invasive surgeryStandard of care
- SBRT / SABR (stereotactic radiotherapy)Standard of care
In trialsNothing recorded yet.
Ideas and roadmapsNothing recorded yet.
Also on OnCo: Side effects by symptom · Immune-related side effects · Toxicity compare · Survivorship planner.
Screening uptake is low in most countries, so most lung cancers are still found late.
and how the field plans to fix it →What is being done about thisFinding cancer earlierAvailable now- Low-dose CT lung screeningStandard of care
- MRIStandard of care
In trialsIdeas and roadmapsNothing recorded yet.
Also on OnCo: Symptoms and red flags · Early detection roadmap.
Trials
topTrials recruiting now
Country and place are remembered in this browser only. A postcode is sent to OpenStreetMap's Nominatim service to find coordinates when you press the button; nothing else leaves your device.
Landmark trials
Expert centres
topExpert centres
Houston · cancer center | United States | 0 | 6,724 | 95,007 | #2 | ||
Baltimore · cancer center | United States | 0 | 2,955 | 41,449 | #10 | ||
Seoul · hospital | South Korea | none recorded | 0 | 464 | 3,248 | #22 | |
Barcelona · cancer center | Spain | none recorded | 0 | 966 | 23,221 | none recorded | #28 |
Stanford · university | United States | 0 | 3,000 | 50,162 | #30 | ||
Amsterdam · cancer center | Netherlands | none recorded | 0 | 1,451 | 25,873 | #45 | |
Bethesda, MD · government | United States | none recorded | 2 | 2,905 | 47,715 | - | |
Chicago, IL · consortium | United States | none recorded | 2 | 42 | 482 | - | |
Guangzhou · hospital Programme: Guangdong Lung Cancer Institute | China | none recorded | 1 | 704 | 7,832 | - | |
Philadelphia, PA · consortium | United States | none recorded | 1 | 87 | 2,130 | none recorded | - |
Portland, OR · consortium | United States | none recorded | 1 | 42 | 1,880 | none recorded | - |
Philadelphia, PA · consortium | United States | none recorded | 1 | 15 | 142 | - | |
Guangzhou · consortium | China | none recorded | 1 | not matched | - | none recorded | - |
Tokyo · consortium | Japan | none recorded | 1 | not matched | - | none recorded | - |
Shanghai · hospital | China | none recorded | 0 | 2,872 | 31,534 | - |
These are the things we can measure; they are not a ranking of quality. Each column is a field on the institution record or a count over what OnCo has linked; a centre that treats many patients with Resectable stage I to III non-small-cell lung cancer but is thinly recorded here will look small.
Not known: OnCo holds no case-volume or outcome figures for centres, so none are shown. Where a national audit or registry publishes them, the centre's page links to it. Default order: Newsweek rank, then trials for this cancer, then research output.
Questions to ask
topQuestions to ask your oncologist about Resectable stage I to III non-small-cell lung cancer
Newly diagnosed
- What is my exact diagnosis, stage, and grade, and which tests established them?Why: Everything else follows from an accurate stage and subtype.
- Which biomarkers have been tested on my tumour (for example TNM stage by PET-CT, brain MRIand mediastinal sampling by endobronchial ultrasound or mediastinoscopy, EGFR and ALK status before any systemic treatment, PD-L1 tumour proportion score, Pathological complete and major pathological response after neoadjuvant therapy, Circulating tumour DNA after surgery), and what were the results?Why: These results decide eligibility for targeted therapy, immunotherapy, and trials.
- Which subtype is my cancer, and does that change the recommended treatment?Why: Recognised subtypes for this cancer include Stage IA peripheral adenocarcinoma 2 cm or less, Stage IB to IIIA adenocarcinoma or squamous cell carcinoma without a driver, Resected EGFR-mutated adenocarcinoma.
- Is germline (inherited) genetic testing recommended for me or my family?Why: Inherited variants can change treatment and matter for relatives.
Stage IA, peripheral, 2 cm or less
- For my situation (stage ia, peripheral, 2 cm or less), which of the standard options do you recommend and why?Why: Guideline options include: Segmentectomy or lobectomy by video-assisted or robotic thoracoscopy with node dissection (CALGB 140503, JCOG0802); no systemic therapy; stereotactic radiotherapy if not fit for surgery.
- How do the results of CALGB 140503 (Alliance) and CHISEL (TROG 09.02) apply to someone like me?Why: Trial populations differ from individual patients; ask how closely you match.
Stage IB to IIIA without EGFR or ALK alteration
- For my situation (stage ib to iiia without egfr or alk alteration), which of the standard options do you recommend and why?Why: Guideline options include: Neoadjuvant nivolumab plus platinum chemotherapy for three cycles (CheckMate 816) or perioperative pembrolizumab (KEYNOTE-671), durvalumab (AEGEAN) or nivolumab (CheckMate 77T) with chemotherapy before and immunotherapy for a year after surgery; or surgery first then adjuvant cisplatin doublet and atezolizumab or pembrolizumab if PD-L1-positive (IMpower010).
- Am I a candidate for Nivolumab, Pembrolizumab, Durvalumab or related drugs, and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of CheckMate 816 and KEYNOTE-671 apply to someone like me?Why: Trial populations differ from individual patients; ask how closely you match.
Resected EGFR-mutated stage IB to IIIA
- For my situation (resected egfr-mutated stage ib to iiia), which of the standard options do you recommend and why?Why: Guideline options include: Adjuvant platinum chemotherapy where indicated, then three years of osimertinib (ADAURA).
- Am I a candidate for Osimertinib, and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of ADAURA apply to someone like me?Why: Trial populations differ from individual patients; ask how closely you match.
Resected ALK-positive stage IB to IIIA
- For my situation (resected alk-positive stage ib to iiia), which of the standard options do you recommend and why?Why: Guideline options include: Two years of adjuvant alectinib in place of chemotherapy (ALINA).
- Am I a candidate for Alectinib, and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of ALINA apply to someone like me?Why: Trial populations differ from individual patients; ask how closely you match.
Staging and surveillance
- For my situation (staging and surveillance), which of the standard options do you recommend and why?Why: Guideline options include: PET-CT and mediastinal sampling before surgery; CT every six months for two years then yearly; circulating tumour DNA surveillance in trials.
Any stage
- Are there clinical trials I could join, for example of MRD / molecular residual disease testing, Circulating tumour DNA (ctDNA), A Study of Neoadjuvant Chemotherapy Plus Nivolumab Versus Neoadjuvant Chemotherapy Plus Placebo, Followed by Surgical Removal and Adjuvant Treatment With Nivolumab or Placebo for Participants With Surgically Removable Early Stage Non-small Cell Lung Cancer, Formally qualify tumour-DNA blood tests as a surrogate endpoint for adjuvant trials?Why: Trials are how the next standard of care is set; asking early keeps options open.
- Would a second opinion at a high-volume centre change anything, and can you help arrange it?Why: Rare or high-stakes decisions benefit from a centre that treats many similar patients.
- What supportive care (symptom control, nutrition, exercise, mental health, financial help) is available from the start?Why: Supportive care improves quality of life and helps patients complete treatment.
- I read that “Whether adjuvant immunotherapy adds anything after neoadjuvant treatment and surgery, especially for complete pathological responders, has not been tested directly”. How does that affect my plan?Why: Open problems are where trials and second opinions matter most.
- I read that “Circulating tumour DNA after surgery identifies high-risk patients but no trial yet shows that acting on it improves survival”. How does that affect my plan?Why: Open problems are where trials and second opinions matter most.
Newly diagnosed? Read the first 60 days with Resectable stage I to III non-small-cell lung cancer, then print the one-page appointment sheet with room for the answers.
Print this page for your appointment (your browser's print command). These prompts are for discussion; your clinical team knows your case.
Direct links plus the targets, companies, and technologies of this cancer's products.
technologies
12targets
4drugs
11companies
6institutions
3pathways
1terms
13trials
12ideas
3people
8key papers
3Patients with operable stage II-III lung cancer without EGFR or ALK alterations should have chemo-immunotherapy discussed before surgery rather than only afterwards. Three pre-operative cycles do not compromise the operation and improve cure rates. Whether to continue immunotherapy after surgery, as the perioperative trials do, and whether patients with pCR need any further treatment, remain open questions.
Every resected non-squamous lung cancer should be tested for EGFR mutations, because patients who carry one live longer if they take osimertinib for three years after surgery. The trial does not tell us whether adjuvant chemotherapy can be omitted, nor what happens on relapse after osimertinib, and the three-year duration was chosen empirically.
For people with a heavy smoking history, an annual low-dose CT scan is one of the few screening tests proven to reduce cancer deaths. Most abnormal scans are not cancer, so screening must be paired with careful nodule management. It does not apply to never-smokers or light smokers.
Latest papers
topQuery for this cancer: (TITLE:"Resectable stage I to III non-small-cell lung cancer" OR ABSTRACT:"Resectable stage I to III non-small-cell lung cancer" OR TITLE:"Early-stage non-small-cell lung cancer" OR ABSTRACT:"Early-stage non-small-cell lung cancer" OR TITLE:"Operable lung cancer" OR ABSTRACT:"Operable lung cancer" OR TITLE:"Stage I, II and IIIA NSCLC" OR ABSTRACT:"Stage I, II and IIIA NSCLC" OR TITLE:"Perioperative NSCLC" OR ABSTRACT:"Perioperative NSCLC") AND (treatment OR therapy OR trial OR survival OR diagnosis). Results are unfiltered search hits about Resectable stage I to III non-small-cell lung cancer, not a curated reading list.
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