Adjuvant or neoadjuvant chemotherapy for NSCLC

Philip McElnay, Eric Lim


In functionally fit patients with localized disease surgical resection remains the treatment of choice. There is also good evidence to support the use of chemotherapy in stages II-III. However, whether to use neoadjuvant or adjuvant therapy has been the topic of much debate. With its strong evidence base, adjuvant chemotherapy has been adopted in the European Society of Medical Oncology clinical practice guidelines for early and locally advanced stages II-III non-small-cell lung cancer (NSCLC), with consideration of adjuvant therapy in those with stage IB but with tumours >4 cm in size. There are fewer trials comparing neoadjuvant therapy plus surgery with surgery alone. Even less has been carried out directly comparing neoadjuvant with adjuvant therapy. The NATCH trial demonstrated no difference in survival between adjuvant and neoadjuvant arms, whilst others have yet to be completed. Meta-analysis also demonstrates no appreciable difference between the two methods. With such a strong body of evidence, however, postoperative delivery of chemotherapy remains the timing of choice in NSCLC.