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NCCN 2025: Immune Checkpoint Inhibitors Expand Treatment Options for Early-Stage NSCLC
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Key Takeaways
- Neoadjuvant ICIs improve event-free survival and pathological response in NSCLC, with CheckMate816 showing significant benefits in resectable cases.
- Adjuvant ICI therapy, as seen in IMpower010 and KEYNOTE-091, enhances disease-free survival, particularly in patients with high PD-L1 expression.
PD-L1 immune checkpoint inhibitors are now standard for early-stage non-metastatic non-small cell lung cancer (NSCLC), with neoadjuvant, adjuvant, and perioperative strategies improving survival and outcomes.
Neoadjuvant, adjuvant, or perioperative treatment with PD-L1 immune-checkpoint inhibitors (ICIs) such as nivolumab (Opdivo; Bristol Myers Squibb), atezolizumab (Tecentriq; Genentech), pembrolizumab (Keytruda; Merck), and durvalumab (Imfinzi; AstraZeneca) represent standard of care options for patients with early-stage non-metastatic non-small cell lung cancer (NSCLC), according to a presentation at the National Comprehensive Cancer Network 2025 Annual Conference in Orlando, Florida.1
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The presentation, titled “Advances in the Treatment of Non-Metastatic Non-Small Cell Lung Cancer” and led by Jonathan W Riess, MD, MS, UC Davis Comprehensive Cancer Center, aimed to highlight advances in targeted therapies and immunotherapies in NSCLC that have improved patient outcomes as treatment options have expanded. Specifically, Riess spoke to the discourse among clinicians and providers regarding the use of adjuvant, neoadjuvant, and perioperative options, which continue to expand as more options are investigated in clinical trials.1
Given the differences in benefits and possible complications with each form of therapy, it is crucial for members of a patient’s care team to properly evaluate each treatment and determine whether a patient could benefit from such therapy. With any of these treatments, the management of side effects to keep patients on treatment remains critical, and molecular testing is imperative to implement so clinicians know which patients to treat with targeted therapy and which may not benefit from immunotherapy, Riess explained.1
Neodjuvant Regimens for NSCLC
Neoadjuvant treatment brings numerous potential benefits, according to Riess. A patient’s pathological response could be utilized as a fast efficacy readout and surrogate outcome marker for survival and as guidance for further treatment decisions, while neoadjuvant treatment induces a stronger and more broad T cell response. Additionally, adjuvant therapy facilitates easier surgery if that is an option for patients, Riess explains. In CheckMate816 (NCT02998528), the first phase III trial to evaluate neoadjuvant NSCLC treatment, these benefits can be observed.1,2
In CheckMate816, neoadjuvant nivolumab plus chemotherapy was found to significantly improve event-free survival (EFS) and pathological complete response (pCR) compared with chemotherapy alone at 4 years in patients with newly diagnosed, resectable, stage IB through IIIA NSCLC (EFS: 43.8 months vs 18.4 months; HR: 0.66; 95% CI, 0.49-0.90). Furthermore, there was a favorable trend in overall survival (OS) in patients with resectable NSCLC, with median OS not reported (NR) in patients administered neoadjuvant nivolumab plus chemotherapy (HR: 0.71; 98.36% CI, .47-1.07; P = .0451).1
Moving to 3-year updates of CheckMate816 in patients with PD-L1 data, Riess noted that there seemed to be an observed correlation between higher PD-L1 expression and better responses with nivolumab and chemotherapy. Among patients with a PD-L1 expression of 1% or more, median EFS (NR vs 26.7 months; HR: 0.46; 95% CI, 0.28-0.77) and median OS (NR vs NR; HR: 0.37; 95% CI, 0.20-0.71) were both heightened when treated with the nivolumab-chemotherapy combination.1
“PD-L1 expression matters and is important,” Riess explained. Overall, CheckMate816 demonstrated the feasibility of neoadjuvant treatment with ICIs in NSCLC, though Riess cautioned that only 3 cycles of nivolumab and chemotherapy were administered.1
Adjuvant Regimens for NSCLC
Riess shifted to a discussion on adjuvant therapies for NSCLC. Theoretical benefits of adjuvant ICI therapy were discussed, including the fact that every patient gets surgery, allowing for the disease-free survival (DFS) end point to be assessed. Furthermore, driver mutations become known by the investigators with adjuvant ICI therapy, allowing for more optimized and targeted treatment. Two clinical trials—IMpower010 (NCT02486718) and KEYNOTE-091 (NCT02504372), which evaluated atezolizumab and pembrolizumab, respectively—were highlighted as examples of trials showing the effectiveness of adjuvant NSCLC therapy.1,3,4
In IMpower010, 1280 patients with completely resected stage IB through IIIA NSCLC were randomized to either atezolizumab for 1 year or best supported care (BSC), after which, a survival follow-up was conducted. Key end points were DFS; specifically, DFS in patients with PD-L1 levels of 1% or more in the stage II through IIIA population and DFS in the all-randomized, stage II through IIIA population.1
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Median DFS in patients with 1% PD-L1 levels or higher in the stage II through IIIA population treated with adjuvant atezolizumab was improved compared with BSC (68.5 months vs 37.3 months; HR: 0.70; 95% CI, 0.55-0.91). Similarly positive results were observed regarding median OS, with lengthier survival in patients treated with adjuvant atezolizumab compared with BSC (not estimable (NE) vs 87.1 months; HR: 0.77; 95% CI, 0.56-1.06).1
In a critical observation, patients considered PD-L1 high—those with 50% or more PD-L1 levels—had the greatest benefit (HR: .48; 95% CI, 0.32-0.72). The significant benefits of adjuvant ICI treatment seen in this population were reaffirmed when analyzing 5-year OS rates in patients with PD-L1 of 50% or higher. Although no OS benefit was observed in patients with stage II to IIIA disease, substantial OS and DFS benefits were observed in the PD-L1-high population (OS and DFS were NE).1
The results of KEYNOTE-091 bolster the clinical significance of adjuvant ICI therapy. In this trial, adjuvant pembrolizumab was compared with placebo in patients with NSCLC; critically, patients were not mandated to receive chemotherapy prior to adjuvant pembrolizumab, though many still opted to do so, according to Riess.1
Once again, a statistically significant response was observed in patients treated with adjuvant ICI—in this case, pembrolizumab. Patients treated with pembrolizumab had a median DFS of 53.6 months compared with 42.0 months among those treated with placebo. Unlike the results of IMpower010, though, PD-L1 status did not seem to be a determining factor in response to treatment, as many patients with a high PD-L1 status had DFS events; however, like IMpower010, patients with PD-L1 of 50% or more had one of the highest response rates (HR: .82; 95% CI, 0.57-1.18).1
Riess, despite the possible benefits of adjuvant ICI treatment, cautions that PD-L1 results can be confusing across trials due to inadequate specimen collection. Given the novel nature of the field, future directions should focus on minimum-residual disease (MRD) and risk stratification, with possible approaches now in the clinical pipeline—including vaccine-based approaches—that look particularly exciting, Riess says.1
Perioperative Regimens for NSCLC
To conclude the presentation, Riess showcased 3 clinical trials that highlight the effects of perioperative ICI regimens that combine neoadjuvant and adjuvant treatment for patients with NSCLC. The 3 trials—AEGEAN (NCT03800134), KEYNOTE-671 (NCT03425643), and CheckMate 77T (NCT03425643)—collectively indicate the positive benefits in EFS with perioperative ICI treatment in this population, with highly statistically significant results.1,5-7
In AEGEAN, KEYNOTE-671, and CheckMate 77T, patients were treated with durvalumab and chemotherapy followed by adjuvant durvalcumab; pembrolizumab and chemotherapy followed by adjuvant pembrolizumab; and nivolumab and chemotherapy followed by adjuvant nivolumab, respectively. In each trial, median EFS was NR in patients treated with perioperative ICI therapy compared with placebo (AEGEAN: NR vs 25.9 months, HR: 0.68, 95% CI, 0.53-0.88; KEYNOTE-671: NR vs 17.0 months, HR: 0.58; 95% CI, 0.46-0.72; CheckMate 77T: NR vs 18.4 months, HR: 0.58; 97.36% CI, 0.42-0.81).1
As observed in other previously discussed clinical trials, the higher a patient’s PD-L1, the more survival benefit they derived. In each of the 3 trials, patients with PD-L1 of 50% or higher had the most robust EFS reported, compared with patients with 1% to 49% PD-L1 or those with 1% or less PD-L1. Accordingly, benefits were seen in patients across all stages of NSCLC.1
Despite these positive results, Riess elaborated on the potential burdens associated with perioperative treatment, including both neoadjuvant and adjuvant regimens, emphasizing the increased toxicity, heightened financial difficulties, and more comprehensive treatment management that come with receiving more therapy. Additionally, many patients do not make it to the surgery stage of this treatment strategy. There have also been concerns raised by the FDA regarding the overuse of immunotherapy in this population, according to Riess.1
Ultimately, more work is needed to investigate novel biomarkers of response, and comparative trials are necessary for more thorough analyses and evaluations, Riess explains. In addition, novel agents should be sought out and studied for patients who may not achieve pCR with ICI treatment, according to Riess.1
