Optimal management of early-stage lung cancer in 2026

The most important developments in the field of lung cancer in the past decade have been: 1) the implementation of lung cancer screening using low-dose CT in many countries, 2) the introduction and validation of chemoimmunotherapy combinations before surgery, improving long-term survival dramatically, 3) the introduction and validation of adjuvant therapy with tyrosine kinase inhibitors following cancer resection (i.e osimertinib) in patients with oncogene-addicted non small cell lung cancer (EGFR mutations, Alk translocation essentially) improving long-term survival and reducing relapse in the central nervous system (brain metastases, essentially).

Screening ex or active smokers using low-dose CT allows many lung cancers to be detected early at a stage where they can be treated radically and cured. Schematically, more than 80% of patients with early-detected and resected lung cancer are still alive 10 years later and considered cured. In the past, only 20 to 25% of patients with lung cancer could benefit from a curative operation plus or minus chemotherapy. With the implementation of CT screening, the idea is to diagnose more than 75% of patients with early-stage lung cancer and to offer them curative therapy i.e. minimally-invasive surgical resection using keyhole surgery or robotic surgery, or stereotactic radiotherapy. We have seen the benefit of this approach in our practice and many of our patients have benefited from CT screening and curative surgery in the past few years.

The second most important development in lung cancer has been the introduction of neoadjuvant chemoimmunotherapy before surgery in patients with locally advanced (but still curable) lung cancer. Patients whose lung cancer has spread into local lymph nodes (N1 or N2) or which size exceeds 4cm have benefited greatly from this approach. Surgery is typically delayed by a few weeks, allowing patients to receive 3 or 4 injections of chemotherapy AND immunotherapy drugs (i.e. nivolumab or pembrolizumab) before their operation. The lung cancer is then removed using minimally invasive techniques. In our experience, more than 1 in 5 of our patients had a complete pathological response, which means the tumour was totally destroyed by treatment and no active cancer cells could be found in the resected specimen. Many other patients had more than 90% of tumour destroyed by treatment and those probably require continuation of immunotherapy for a couple of years after surgery to improve long-term survival (but this remains to be proven!). Those not responding to treatment generally have aggressive cancers and others kind of therapies have to be tried to control the disease.

At present, we offer chemoimmunotherapy to all patients with locally-advanced lung cancer (and sometimes even to those with more extensive lymph node spread -called N3- or a single metastasis) and re-stage their disease after 2 or 3 injections. When patients show a good response on repeat imaging (PET scanning) we offer them curative-intent surgery.

Finally, for the subgroup of patients -often never smokers- who are diagnosed with oncogene-addicted lung cancer (i.e. mutation in the EGFR gene or Alk fusion, Her2, Kras,...), large clinical trials have showed that continuing tyrosine kinase inhibitor therapy (i.e osimertinib in EGFR-mutant) for several years after surgery improved survival significantly and reduced the risk of developing brain metastases. Several clinical trials are presently evaluating the role of tyrosine kinase inhibitors given before surgery to improve further cancer-free survival and increase operability in those patients.

For thoracic surgeons, there is an ongoing debate as to whether less is more: should we remove an entire pulmonary lobe when the cancer is small (less than 2 cm) and has not spread into local lymph nodes, or should we resect just the involved lung segment (one fourth to one fifth of a lobe) ? Results of two large clinicall trials conducted in Japan and in the western world are not clear-cut: survival at 5 years is essentially similar with a slightly better lung function preservation in those who had less lung removed (as one would expect!), but the local cancer relapse rate at 10 year is double in those who had only a segment removed (in the Japanese trial, approximately 11% versus 5.5%). Further analyses of outcomes and results are in progress, but in our practice we offer lobectomy, which is associated with less relapse at 10 years and similar survival, over segmentectomy in fit patients with early-stage lung cancer. We do offer segmentectomies to older patients with impaired lung function, those with multiple lung cancers (sometimes bilateral) and those with less invasive types of lung cancer (pure ground-glass nodules, cancers in-situ or minimally-invasive lung cancers). We perform lung cancer surgery using keyhole surgical techniques (VATS) or robotic-assisted technique (Da Vinci Xi robot). When surgery is not possible because the patient is unfit, has too many co-morbidities or just does not wish to have surgery, we use stereotactic radiotherapy often combined with other systemic therapies if the cancer is more than 4cm in diameter or if local lymph nodes are found involved by cancer.

Altogether, the past decade has seen a huge transformation of lung cancer therapy. It is essential for thoracic surgeons to work as part of a network with thoracic oncologists and radiation oncologists, interventional radiologists, nuclear physicians, as well as specialized pathologists to guarantee quality and to be able to offer the best therapies and highest chances of cure.

We work in specialized thoracic network offering world-class treatment within Swiss Medical Network clinics and hospitals. We have weekly tumor board meetings where we discuss each patient case individually. We have access to all molecular tests within our network (i.e liquid biopsy, advanced genomic analyses, ...) and we offer the full-range of lung cancer therapies from the simplest to the most complex.