Resectable stage I to III non-small-cell lung cancer: the decisions you may face

Cancer page →Second-opinion finder →

5 treatment settings, 3 with more than one named option. Each section lays out the options the standard of care names, what each is for, the trials behind them with their recorded results, the side effects and cautions on record, and questions to ask. Built from the cancer page's standard-of-care rows; nothing here is advice for your case.

Other settings

Stage IA, peripheral, 2 cm or less

2 options

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.

Guideline

NCCN Guidelines: Non-Small Cell Lung Cancer

The options, in plain words

Robotic & minimally invasive surgeryStandard of care

Surgeons operate through small incisions using robotic arms with tremor-free precision and 3D vision.

Precision, shorter stay
Enables complex minimally invasive resections

SBRT / SABR (stereotactic radiotherapy)Standard of care

Stereotactic body radiotherapy converges multiple beams with sub-millimetre accuracy to deliver tumour-destroying doses in one to five outpatient sessions, doing the job of surgery for inoperable early lung cancer and for metastases in liver, spine and brain. Tumour size and location limit its use, and late toxicity is a concern near the central airways.

Ablative doses with minimal recovery
Outpatient

Also referenced:LobectomySegmentectomy (sublobar resection)Minimally invasive surgery (laparoscopic, robotic, VATS)

The evidence behind it

CALGB 140503 (Alliance)Phase 3 NCT00499330 2023697 peopleevidence 83
Tests Robotic & minimally invasive surgery
Peripheral clinical stage IA non-small-cell lung cancer 2 cm or smaller with negative hilar and mediastinal nodes: sublobar resection (wedge or segmentectomy) versus lobectomy
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.
5-year disease-free survival 63.6% (sublobar) vs 64.1% (lobectomy), non-inferior; 5-year overall survival 80.3% vs 78.9%.
Disease-free survival at 5 years (%): Sublobar resection 63.6 (n=340) vs Lobectomy 64.1 (n=357) · HR 1.01 · source
CHISEL (TROG 09.02)Phase 3 NCT01014130 2019101 peopleevidence 63
Tests SBRT / SABR (stereotactic radiotherapy)
Inoperable stage I non-small-cell lung cancer: stereotactic ablative radiotherapy versus conventionally fractionated radiotherapy
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.
Local failure hazard ratio 0.32 favouring SABR; median overall survival 5 years vs 3 years.
Local treatment failure (freedom from local failure was the primary endpoint) (%): SABR 14 (n=66) vs Standard radiotherapy 31 (n=35) · HR 0.32 · source
JCOG0403 Phase 2 2015169 peopleevidence 61
Tests SBRT / SABR (stereotactic radiotherapy)
Stage IA non-small-cell lung cancer, operable and inoperable patients: stereotactic body radiotherapy 48 Gy in four fractions
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.
3-year overall survival 76.5% (operable) and 59.9% (inoperable) after 48 Gy in 4 fractions.
Overall survival at 3 years (%): Operable patients, SBRT 48 Gy in 4 fractions 76.5 (n=64) vs Inoperable patients, SBRT 48 Gy in 4 fractions 59.9 (n=100) · source

The main trade-offs on record

Robotic & minimally invasive surgery

Cost
Loss of haptic feedback
Not superior for every indication

SBRT / SABR (stereotactic radiotherapy)

Size and location limits
Late toxicity near central airways

Questions to ask about this decision

Between Robotic & minimally invasive surgery and SBRT / SABR (stereotactic radiotherapy), which do you recommend for me, and what about my case would make you choose differently?
Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?
Why: The aim shapes how much side effect and disruption is worth accepting.
How closely do I match the people in CALGB 140503 (Alliance) and CHISEL (TROG 09.02), and does that change what the results mean for me?
Why: Trial populations are selected; age, fitness, prior treatment and biomarkers all affect how far results carry.
What happens if I delay, or decline this step for now? Is the decision reversible?
Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
Does your recommendation follow the current guideline (NCCN Guidelines: Non-Small Cell Lung Cancer), and if it departs from it, why?
Why: Departures from guidelines are sometimes right for an individual; they should be explained.
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.

Add these to your appointment list, or take the full question set for this cancer.

Other settings

Stage IB to IIIA without EGFR or ALK alteration

7 optionsCompare side by side →

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).

Guideline

NCCN Guidelines: Non-Small Cell Lung Cancer

The options, in plain words

NivolumabApprovedMonoclonal antibody (anti-PD-1)

Nivolumab was the second PD-1 blocker and is often combined with ipilimumab. Long-term data show about half of advanced melanoma patients alive at 10 years on the combination.

PembrolizumabApprovedMonoclonal antibody (anti-PD-1)

Pembrolizumab is a PD-1 blocking antibody approved in more than 40 settings, from melanoma and lung cancer to the first tumour-agnostic approval for mismatch-repair-deficient tumours in 2017, and before and after surgery in triple-negative breast cancer. A subcutaneous form arrived in 2025, and it is the backbone partner for ADCs and personalised neoantigen vaccines.

DurvalumabApprovedMonoclonal antibody (anti-PD-L1)

A PD-L1 blocker that became standard after chemoradiation for stage III lung cancer, and now in bladder, biliary, and gastric cancers.

AtezolizumabApprovedMonoclonal antibody (anti-PD-L1)

A PD-L1 blocker used in lung, liver, and bladder cancer. In 2026 it became the first drug approved based on a blood test showing leftover cancer after bladder surgery.

CisplatinApprovedCytotoxic chemotherapy (platinum)

Cisplatin is the original platinum chemotherapy, discovered by accident in 1965; it cures testicular cancer and makes radiation work better in cervical and head and neck cancer.

CarboplatinApprovedCytotoxic chemotherapy (platinum)

Carboplatin is a platinum chemotherapy that crosslinks DNA; it is part of the standard pre-surgery regimen for triple-negative breast cancer.

PemetrexedApprovedCytotoxic (antifolate)

Pemetrexed is the chemotherapy that, with a platinum drug, became the first approved treatment for mesothelioma in 2004, and is still the backbone today.

Also referenced:Neoadjuvant / adjuvant / perioperativePathologic complete response (pCR)Major pathological response (MPR)

The evidence behind it

CheckMate 816 Phase 3 NCT02998528 2022358 peopleevidence 81
Tests Nivolumab
Resectable stage IB-IIIA NSCLC: neoadjuvant nivolumab + platinum chemotherapy (3 cycles) vs chemotherapy
EFS HR 0.63; OS HR 0.72.
Pathologic complete response (%): Nivolumab + chemotherapy 24 (n=179) vs Chemotherapy 2.2 (n=179) · source
KEYNOTE-671 Phase 3 NCT03425643 2023797 peopleevidence 89
Tests Pembrolizumab
Resectable stage II-IIIB NSCLC: neoadjuvant pembrolizumab + chemotherapy then adjuvant pembrolizumab vs placebo
EFS HR 0.58; OS HR 0.72.
Event-free survival (months): Pembrolizumab + chemotherapy → pembrolizumab 47.2 (n=397) vs Placebo + chemotherapy → placebo 18.3 (n=400) · HR 0.59 · source
A Study of Neoadjuvant/Adjuvant Durvalumab for the Treatment of Patients With Resectable Non-small Cell Lung Cancer Phase 3 NCT03800134825 peopleevidence 50
Tests Durvalumab, Cisplatin, Carboplatin, Pemetrexed
A Phase III, Double-blind, Placebo-controlled, Multi-center International Study of Neoadjuvant/Adjuvant Durvalumab for the Treatment of Patients With Resectable Stages II and III Non-small Cell Lung Cancer (AEGEAN)
No headline result recorded yet.
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 NCT04025879461 peopleevidence 48
Tests Nivolumab, Cisplatin, Carboplatin, Pemetrexed
A Phase 3, Randomized, Double-blind Study of Neoadjuvant Chemotherapy Plus Nivolumab Versus Neoadjuvant Chemotherapy Plus Placebo, Followed by Surgical Resection and Adjuvant Treatment With Nivolumab or Placebo for Participants With Resectable Stage II-IIIB Non-small Cell Lung Cancer
No headline result recorded yet.
Study to Assess Safety and Efficacy of Atezolizumab (MPDL3280A) Compared to Best Supportive Care Following Chemotherapy in Patients With Lung Cancer [Phase 3 NCT024867181,280 peopleevidence 51
Tests Atezolizumab, Cisplatin, Pemetrexed
A Phase III, Open-Label, Randomized Study to Investigate the Efficacy and Safety of Atezolizumab (Anti-PD-L1 Antibody) Compared With Best Supportive Care Following Adjuvant Cisplatin-Based Chemotherapy in Patients With Completely Resected Stage IB-IIIA Non-Small Cell Lung Cancer
No headline result recorded yet.

The main trade-offs on record

Nivolumab all recorded rates →

Side effect	Any grade	Grade 3+
Colitis with ipilimumab (1+3 mg/kg) · Monotherapy pooled unless stated	25%	14.4%
Hepatitis with ipilimumab · Monotherapy pooled unless stated	15%	13.4%
Colitis · Monotherapy pooled unless stated	2.9%	1.7%
Hepatitis · Monotherapy pooled unless stated	1.8%	1.5%

Rates from the label or pivotal trial as recorded on the product page; each grade 3+ figure links to its source.

Pembrolizumab all recorded rates →

Side effect	Any grade	Grade 3+
Hypothyroidism (immune-mediated) · Pooled monotherapy data, >2,800 patients	8%	-
Pneumonitis (immune-mediated) · Pooled monotherapy data, >2,800 patients	3.4%	-
Colitis (immune-mediated) · Pooled monotherapy data, >2,800 patients	1.7%	-
Hepatitis (immune-mediated) · Pooled monotherapy data, >2,800 patients	0.7%	-

No pharmacokinetic interactions expected (antibody). See the irAE guide for toxicity management.

Rates from the label or pivotal trial as recorded on the product page; each grade 3+ figure links to its source.

Durvalumab all recorded rates →

Side effect	Any grade	Grade 3+
Pneumonitis (any cause, PACIFIC) · vs 12.8% placebo; 1.1% fatal	18.3%	-

Rates from the label or pivotal trial as recorded on the product page; each grade 3+ figure links to its source.

Atezolizumab all recorded rates →

Side effect	Any grade	Grade 3+
Pneumonitis (immune-mediated) · Monotherapy pooled	3%	0.8%
Hepatitis (immune-mediated) · Monotherapy pooled	1.8%	0.7%
Colitis (immune-mediated) · Monotherapy pooled	1%	0.5%
Hypothyroidism (immune-mediated) · Monotherapy pooled	4.9%	0.2%

Rates from the label or pivotal trial as recorded on the product page; each grade 3+ figure links to its source.

Cisplatin all recorded rates →

Dose reduce or avoid for CrCl below 60 (carboplatin is the alternative).

Carboplatin all recorded rates →

Dose by Calvert formula using GFR (see the calculators).

Pemetrexed all recorded rates →

Not recommended for CrCl below 45.

Questions to ask about this decision

Between Nivolumab, Pembrolizumab, Durvalumab and the other options, which do you recommend for me, and what about my case would make you choose differently?
Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?
Why: The aim shapes how much side effect and disruption is worth accepting.
How closely do I match the people in CheckMate 816 and KEYNOTE-671, and does that change what the results mean for me?
Why: Trial populations are selected; age, fitness, prior treatment and biomarkers all affect how far results carry.
Which side effects of Nivolumab or Pembrolizumab are most likely for me, which are reversible, and which would make us stop?
Why: The recorded rates below come from labels and trials; your own risk depends on dose, other medicines and your health.
What happens if I delay, or decline this step for now? Is the decision reversible?
Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
Does your recommendation follow the current guideline (NCCN Guidelines: Non-Small Cell Lung Cancer), and if it departs from it, why?
Why: Departures from guidelines are sometimes right for an individual; they should be explained.
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.

Add these to your appointment list, or take the full question set for this cancer.

Other settings

Resected EGFR-mutated stage IB to IIIA

One path named

Adjuvant platinum chemotherapy where indicated, then three years of osimertinib (ADAURA).

Guideline

NCCN Guidelines: Non-Small Cell Lung Cancer

The path, in plain words

OsimertinibApprovedSmall-molecule kinase inhibitor (EGFR)

Osimertinib (Tagrisso) is the standard pill for EGFR-mutant lung cancer, now also given after surgery and with chemotherapy or after chemoradiation.

Also referenced:EGFR exon 19 deletion & L858R

The evidence behind it

ADAURA Phase 3 NCT02511106 2020682 peopleevidence 78
Tests Osimertinib
Adjuvant osimertinib 3 years after resection of stage IB-IIIA EGFR-mutant NSCLC
OS HR 0.49.
Disease-free survival, stage II to IIIA (months): Placebo 19.6 (n=237) · HR 0.17 · source

The main trade-offs on record

Osimertinib all recorded rates →

Side effect	Any grade	Grade 3+
Decreased appetite · FLAURA	20%	2.5%
Diarrhoea · FLAURA	58%	2.2%
Fatigue · FLAURA	21%	1.4%
Rash · FLAURA	58%	1.1%

Known QT prolongation. Avoid other QT-prolonging drugs where possible; check ECG and correct potassium and magnesium before and during treatment.
No adjustment for mild or moderate impairment; not studied in severe.

Rates from the label or pivotal trial as recorded on the product page; each grade 3+ figure links to its source.

Questions to ask about this decision

Is Osimertinib the only reasonable path for me, or is there a trial, a different sequence or a wait-and-see option?
Why: A single standard does not mean a single choice; timing and trials are decisions too.
What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?
Why: The aim shapes how much side effect and disruption is worth accepting.
How closely do I match the people in ADAURA, and does that change what the results mean for me?
Why: Trial populations are selected; age, fitness, prior treatment and biomarkers all affect how far results carry.
Which side effects of Osimertinib are most likely for me, which are reversible, and which would make us stop?
Why: The recorded rates below come from labels and trials; your own risk depends on dose, other medicines and your health.
What happens if I delay, or decline this step for now? Is the decision reversible?
Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
Does your recommendation follow the current guideline (NCCN Guidelines: Non-Small Cell Lung Cancer), and if it departs from it, why?
Why: Departures from guidelines are sometimes right for an individual; they should be explained.
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.

Add these to your appointment list, or take the full question set for this cancer.

Other settings

Resected ALK-positive stage IB to IIIA

One path named

Two years of adjuvant alectinib in place of chemotherapy (ALINA).

Guideline

NCCN Guidelines: Non-Small Cell Lung Cancer

The path, in plain words

AlectinibApprovedSmall-molecule kinase inhibitor (ALK)

Alectinib is a well-tolerated ALK pill, standard first line for years and, since 2024, the first targeted therapy given after surgery for ALK-positive lung cancer.

The evidence behind it

ALINA Phase 3 NCT03456076 2023257 peopleevidence 86
Tests Alectinib
Adjuvant alectinib 2 years vs platinum chemotherapy after resection of stage IB (≥4 cm)-IIIA ALK-positive NSCLC
DFS HR 0.24.
Disease-free survival, stage II to IIIA (months): Platinum chemotherapy 44.4 (n=115) · HR 0.24 · source

The main trade-offs on record

Alectinib all recorded rates →

Take with food; exposure roughly triples with a high-fat meal, and the trials dosed with food.
Start at 450 mg twice daily in severe impairment (Child-Pugh C).

Questions to ask about this decision

Is Alectinib the only reasonable path for me, or is there a trial, a different sequence or a wait-and-see option?
Why: A single standard does not mean a single choice; timing and trials are decisions too.
What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?
Why: The aim shapes how much side effect and disruption is worth accepting.
How closely do I match the people in ALINA, and does that change what the results mean for me?
Why: Trial populations are selected; age, fitness, prior treatment and biomarkers all affect how far results carry.
What happens if I delay, or decline this step for now? Is the decision reversible?
Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
Does your recommendation follow the current guideline (NCCN Guidelines: Non-Small Cell Lung Cancer), and if it departs from it, why?
Why: Departures from guidelines are sometimes right for an individual; they should be explained.
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.

Add these to your appointment list, or take the full question set for this cancer.

Screening, prevention and diagnosis

Staging and surveillance

3 options

PET-CT and mediastinal sampling before surgery; CT every six months for two years then yearly; circulating tumour DNA surveillance in trials.

Guideline

NCCN Guidelines: Non-Small Cell Lung Cancer

The options, in plain words

PET/CTStandard of care

PET and CT in one machine, so hot spots on the PET are pinned to exact locations on the CT.

Anatomy plus biology
Standard for lymphoma, lung, melanoma, head and neck staging

CT (computed tomography)Standard of care

A CT scan is a fast 3D X-ray that shows the size and shape of tumours and whether they have spread.

Fast, ubiquitous
Sub-millimetre resolution
Standard for RECIST response

MRD / molecular residual disease testingEstablished

An ultra-sensitive blood test after surgery that detects leftover cancer months before a scan would.

Months of lead time over imaging
Enables escalation and de-escalation trials

Also referenced:Bronchoscopy (EBUS, robotic navigation)Circulating tumour DNA (ctDNA)TNM staging

The evidence behind it

No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.

The main trade-offs on record

PET/CT

CT radiation added to PET dose

CT (computed tomography)

Anatomic only; cannot distinguish scar from live tumour
Radiation dose
Poor for brain, marrow, and small peritoneal disease

MRD / molecular residual disease testing

Sensitivity limited by cfDNA quantity
Lead time without proven intervention causes anxiety

Questions to ask about this decision

Between PET/CT, CT (computed tomography) and MRD / molecular residual disease testing, which do you recommend for me, and what about my case would make you choose differently?
Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?
Why: The aim shapes how much side effect and disruption is worth accepting.
What happens if I delay, or decline this step for now? Is the decision reversible?
Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
Does your recommendation follow the current guideline (NCCN Guidelines: Non-Small Cell Lung Cancer), and if it departs from it, why?
Why: Departures from guidelines are sometimes right for an individual; they should be explained.
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.

Add these to your appointment list, or take the full question set for this cancer.

How to read this page. Options and results come from OnCo records with their sources; the settings are the standard-of-care rows on the cancer page, and the lines of therapy are on the sequencing grid. Where a setting names one path, the choice is usually about timing, trials and where to be treated: see expert centres. OnCo is orientation, not medical advice.