Outcome of stage-eligible patients not receiving neoadjuvant chemo-immunotherapy for clinical or procedural reasons: a real practice analysis.

[BACKGROUND] We aimed to assess the outcome of patients who were stage-eligible for neoadjuvant chemo-immunotherapy but did not start the treatment and received surgery upfront.

[METHODS] All consecutive patients undergoing lung resection with or without prior neoadjuvant chemo-immunotherapy (nivolumab) for clinical stage II and III NSCLC (April 2023 through December 2024) were included in this analysis. The main reasons for not receiving the neoadjuvant treatment were described. Subgroup analyses were performed to assess outcomes by presence of neoadjuvant treatment.

[RESULTS] 129 patients were included. 47 % received neoadjuvant nivolumab in combination with platinum-based chemotherapy (IO group), whereas 53 % did not receive neoadjuvant treatment and proceeded to surgery upfront (S group). There was no difference in minimally invasive approach between procedures performed after neoadjuvant treatment and those without (75 % vs. 73.9 %, p = 0.88). Neoadjuvant treatment was not associated with increased risk of postoperative cardiopulmonary complications (IO = 35 % vs. S = 38 %, p = 0.75) or prolonged hospital stay (IO = 5 days vs. S = 6, p = 0.24). The most frequent reason for not starting neoadjuvant treatment was the lack of adequate tissue sampling for molecular testing or diagnosis/nodal staging confirmation (32 %), followed by the presence of actionable genetic alterations (16 %), patient choice (11.5 %) and underlying immune-related disease (11.5 %).

[CONCLUSIONS] A large proportion of patients who could qualify for neoadjuvant systemic anticancer treatment never started it. Our findings may inform future discussions on how to improve the treatment pathway of patients with NSCLC and candidates to neoadjuvant or perioperative immunotherapy.