Immunotherapy Moves to the Early-Stage Setting in Non-Small Cell Lung Cancer: Emerging Evidence and the Role of Biomarkers

SIMPLE SUMMARY: In recent years there has been a trend towards an increase in the proportion of non-small cell lung cancer patients diagnosed with localized stage instead of advanced. However, 5-year survival rates continue to be low, even among patients diagnosed at early stages. In recent years major advances have been made in the treatment of advanced NSCLC, in large part due to the irruption of immunotherapy. PD-1 axis blocking-based immunotherapy is already a well-established standard of care treatment for patients with advances NSCLC, in frontline setting and in pretreated patients. Our greatest challenge now is to move the benefit of immunotherapy to patients with early-stage NSCLC so as to increase 5-year survival rate. The aim of this manuscript is to make a comprehensive review of available evidence, make a critical review of the results of published and ongoing studies, and analyze the role of biomarkers, main areas of controversy and future challenges. ABSTRACT: Despite numerous advances in targeted therapy and immunotherapy in the last decade, lung cancer continues to present the highest mortality rate of all cancers. Targeted therapy based on specific genomic alterations, together with PD-1 and CTLA-4 axis blocking-based immunotherapy, have significantly improved survival in advanced non-small cell lung cancer (NSCLC) and both therapies are now well-established in this clinical setting. However, it is time for immunotherapy to be applied in patients with early-stage disease, which would be an important qualitative leap in the treatment of lung cancer patients with curative intent. Preliminary data from a multitude of studies are highly promising, but therapeutic decision-making should be guided by an understanding of the molecular features of the tumour and host. In the present review, we discuss the most recently published studies and ongoing clinical trials, controversies, future challenges and the role of biomarkers in the selection of best therapeutic options.