The first 60 days: 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. Below, week by week, is what OnCo's record of Resectable stage I to III non-small-cell lung cancer says about the first two months: the order is typical, the timing is yours to ask about. Sections appear only where the record has something to say. Orientation, not medical advice.
What happens now
Staging tests establish exactly what and where the cancer is. Everything else follows from the answers.
PET-CT and mediastinal sampling before surgery; CT every six months for two years then yearly; circulating tumour DNA surveillance in trials.
Ask which of these were tested and what the results were; see the report reader for what each value means.
These specialties appear in the standard of care for this cancer. In most centres they meet weekly as a tumour board to agree each plan; you can ask when yours was discussed and what was decided.
- PathologistNamed in the standard of care for: Stage IB to IIIA without EGFR or ALK alteration, Staging and surveillance.
- RadiologistNamed in the standard of care for: Staging and surveillance.
- SurgeonNamed in the standard of care for: Stage IA, peripheral, 2 cm or less, Stage IB to IIIA without EGFR or ALK alteration, Staging and surveillance.
- Medical oncologistNamed in the standard of care for: Stage IA, peripheral, 2 cm or less, Stage IB to IIIA without EGFR or ALK alteration, Resected EGFR-mutated stage IB to IIIA, Resected ALK-positive stage IB to IIIA.
- Clinical oncologist (radiotherapy)Named in the standard of care for: Stage IA, peripheral, 2 cm or less.
A second opinion from a centre that treats many similar cases is normal, not rude; the standard of care tells you what to compare it against.
Each row is a setting from the standard of care, in the order it usually arises. Not all will apply to you; your stage and biomarkers decide which do. The guideline grade, where recorded, says how strong the evidence is.
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).
CheckMate 816NivolumabKEYNOTE-671PembrolizumabA Study of Neoadjuvant/Adjuvant Durvalumab for the Treatment of Patients With Resectable Non-small Cell Lung CancerDurvalumabA 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 CancerStudy to Assess Safety and Efficacy of Atezolizumab (MPDL3280A) Compared to Best Supportive Care Following Chemotherapy in Patients With Lung Cancer [AtezolizumabCisplatinCarboplatinPemetrexedNeoadjuvant / adjuvant / perioperativePathologic complete response (pCR)Major pathological response (MPR)Adjuvant platinum chemotherapy where indicated, then three years of osimertinib (ADAURA).
Two years of adjuvant alectinib in place of chemotherapy (ALINA).
Generated from this cancer's standard of care, biomarkers and open problems. Take the group that matches where you are. To tick, add your own and print, open the one-page appointment sheet.
Newly diagnosed
- What is my exact diagnosis, stage, and grade, and which tests established them?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?These results decide eligibility for targeted therapy, immunotherapy, and trials.
- Which subtype is my cancer, and does that change the recommended treatment?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?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?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?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?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?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?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?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?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of ADAURA apply to someone like me?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?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?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of ALINA apply to someone like me?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?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?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?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?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?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?Open problems are where trials and second opinions matter most.
Trials open now for this cancer in OnCo, largest phase first. Joining a trial is a decision like any other: ask what the comparison arm is, whether a placebo is used, and what happens if you leave. The cancer page searches ClinicalTrials.gov live for more.
- 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 CancerPhase 3 · active · NCT04025879A 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
- A Study of Neoadjuvant/Adjuvant Durvalumab for the Treatment of Patients With Resectable Non-small Cell Lung CancerPhase 3 · active · NCT03800134A 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)
- Study to Assess Safety and Efficacy of Atezolizumab (MPDL3280A) Compared to Best Supportive Care Following Chemotherapy in Patients With Lung Cancer [Phase 3 · active · NCT02486718A 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
- ALCHEMIST (Adjuvant Lung Cancer Enrichment Marker Identification and Sequencing Trials)Phase platform · active · NCT02194738Completely resected stage IB to IIIA non-small-cell lung cancer: central testing for EGFR mutations, ALK rearrangements and later PD-L1 feeds randomised adjuvant trials of erlotinib, crizotinib and nivolumab against observation or placebo
Much of what helps in the first weeks is free if you know to ask: testing, helplines, rides and lodging, second opinions, trial travel.
- Resectable stage I to III non-small-cell lung cancer: the full pageLung 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.
- One-page appointment sheetYour questions, the words you may hear, what to bring, and space for the answers. Print it.
- Treatment sequencingWhich treatment tends to follow which, line by line.
- NavigatorStandard of care for your stage, what you have tried, and trials near you.
- Stage: How far a cancer has spread, from stage I (small and confined) to stage IV (spread to distant organs).
- Minimally invasive surgery (laparoscopic, robotic, VATS): Any operation done through small incisions with cameras and long instruments, including robot-assisted surgery; the cancer operation is the same, the wound is smaller.
- Segmentectomy (sublobar resection): Removing only a segment or wedge of a lung lobe rather than the whole lobe, sparing breathing capacity.
- TNM staging: TNM staging is the universal system describing tumour size (T), lymph node spread (N), and distant metastasis (M).
- EGFR exon 19 deletion & L858R: Exon 19 deletion and L858R are the two common EGFR mutations, together ~85% of EGFR-mutant lung cancer, and both respond to EGFR pills.
- Major pathological response (MPR): When, after pre-surgery treatment, the removed tumour contains little or no living cancer: 10% or less viable cells.
- Pneumonectomy: Removing an entire lung.
- Lobectomy: Removing one lobe of the lung (the right lung has three, the left two).
- Bronchoscopy (EBUS, robotic navigation): Passing a camera down the windpipe into the lungs to biopsy tumours and lymph nodes without surgery.
- Event-free / disease-free survival (EFS, DFS, iDFS, RFS): In early-stage cancer: how long patients stay free of recurrence, progression, or death.
Every term links to the glossary.