Post-surgery immunotherapy may not benefit specific lung cancer patients

A new real-world observational study has found that adding adjuvant immunotherapy after surgery does not significantly improve survival outcomes in patients with resectable non-small cell lung cancer (NSCLC) who have already achieved a pathological complete response (pCR) following neoadjuvant chemoimmunotherapy. The research, published in the Chinese Medical Journal, suggests that the excellent prognosis associated with a pCR may render further postoperative immune checkpoint inhibition unnecessary for many patients.

The study, conducted at Xiangya Hospital and Hunan Cancer Hospital, enrolled 145 patients with stage IB-IIIB NSCLC who attained a pCR after three cycles of preoperative chemoimmunotherapy. Of these, 81 patients (55.9%) received adjuvant PD-1 inhibitors post-surgery, while 64 (44.1%) did not. With a median follow-up of 39.0 months, the study's primary endpoint of disease-free survival (DFS) showed no significant difference between the two groups, even after rigorous adjustment for confounding factors using inverse probability of treatment weighting (IPTW). The 3-year DFS rates were 92.3% in the adjuvant group and 91.2% in the neoadjuvant-only group, while overall survival (OS) rates were similarly comparable at 94.7% and 97.7%, respectively.

"Achieving pCR is a critical milestone and a strong predictor of long-term survival," the authors note. "However, our findings suggest that the additional benefit of extending immunotherapy into the adjuvant phase may be limited in this population, as these patients may already derive the maximum benefit from neoadjuvant therapy alone." The safety profile was tolerable, with no significant increase in severe treatment-related adverse events (TRAEs) in the adjuvant group, though the researchers emphasize that the non-significant results do not rule out a potential benefit and call for larger, more definitive trials.

The study contributes to a growing debate in the field regarding the optimal duration of perioperative immunotherapy. While trials like AEGEAN and KEYNOTE-671 have shown the value of perioperative immunotherapy overall, the question of whether adjuvant therapy is needed specifically for patients who achieve a pCR remains unresolved. The current study, with its real-world data and direct comparison of the two strategies, provides preliminary evidence that de-escalating treatment in this favorable-risk subgroup may be a viable approach, potentially sparing patients from unnecessary costs, inconvenience, and toxicity.

The authors acknowledge several limitations, including the observational design, small sample size, and a low number of endpoint events, which restrict statistical power. They also note that molecular biomarkers such as PD-L1 expression and minimal residual disease (MRD) were not available for all patients, limiting stratified analyses. Future research focusing on biomarker-driven selection and longer follow-up is essential to confirm these findings and refine perioperative management strategies for resectable NSCLC.