Jaspal Singh, MD, MHS: This is a tough one. It’s a great case. The other part of it is what you said very nicely: you’re an oncologist first and a surgeon second. I’m a pulmonologist first and an oncologist second. With this perspective, this is chronic disease management at this point. I started thinking through his lung function, which is marginal. Now comes the point that I start predicting what his postoperative lung function will look like at best, knowing that you can’t predict that exactly. I’m also thinking of the physiology and quality of life, and how that will impact him depends partly on that.

If you can, think of what this might look like for him surgically. He’ll be treated from a cancer perspective, but it will leave him as a pulmonary cripple or severely debilitated. We’ve got to start thinking about quality-of-life vectors. That’s where it gets tricky. That’s where it gets exciting, however. If you’re on the fence of using chemoradiation or neoadjuvant therapy, if you want to wait and see, this is where our heads come together and we start thinking that through.

We don’t put a lot of emphasis on the patient decision in the multidisciplinary tumor board. We don’t have patients [participate]. This is where I’d probably think there are 2 or 3 options out there. Let’s think it through, take it back to the patient, and say what we think will be your best chance of surviving with the best chance of treatment of cancer. But let’s know that the risk of potential low quality-of-life issues might come into play, not to mention surgical complications. We might say, “Let’s try this for now.”

The important part is [knowing] that what we decide today may not be what we decide 6 months or a year from now. Start thinking about this as a maze of choices, as we move from chronic disease management. If you can go either way, as a pulmonologist, I’d go to the patient and say, “These are your 2 options. Let’s compartmentalize this a little and think this through collectively.”

David Spiegel, MD: What would you end up doing, David?

David H. Harpole Jr, MD: I brought up the PACIFIC regimen because that N2 node we saw on PET [positron emission tomography] was negative by EBUS [endobronchial ultrasound] in a patient without the greatest function. Is this a reasonable [patient] to give definitive, nonoperative therapy? We ended up putting him on a CheckMate 816 regimen.

Cisplatin/pembrolizumab/nivolumab is [the regimen] where we used mediastinoscopy [MED] to help us to see—because this is a central tumor—if we thought those nodes were positive. Because they hadn’t had a MED and they did not get radiation, we did a MED. Then I VATS [video-assisted thoracic surgery] explored this patient…and we were able to resect it.

The patient was not a pathCR [pathologic complete response]. They had a major pathologic response—I didn’t show the slides—but they still were level 11 microscopically positive, although the tumor was quite a bit smaller. [The patient] did well. We’ve got somebody who had a short course of up-front chemoimmunotherapy, but now still has persistent disease. What are you going to think about?

David Spiegel, MD: I have a woman like this. These are the nightmares of the CheckMate 816 dilemma, because they responded but still have disease. Sometimes I’ve had the opposite occur: I’ve given them 3 cycles, but there’s more disease than we thought. By the letter of the law, you wouldn’t give more systemic chemotherapy. You can test for EGFR; that’s fair. I don’t think there’s a role for radiation therapy. That would be it: EGFR testing. If they don’t have it, you’d [monitor].

But what would I do? This sounds silly because you shouldn’t work based on what you think’s going to happen, but I think other trials are going to emerge shortly that are going to show us the value of neoadjuvant and adjuvant I/O [immuno-oncology]. The IMpower010 study led to the FDA approval of atezolizumab after chemotherapy in patients with stage II and III cancer with at least 1% PD-L1 expression for a year. To make myself feel better, I might do PD-L1 testing in this patient. If it’s 1% or higher, then I’d consider giving this patient a year of adjuvant I/O—mixing trials together. I want to emphasize that the right answer is to test for EGFR. That should be the only intervention you’d give if they’re positive. The real-world answer is that I’d probably give a little more. For me, that would probably be I/O.

Transcript edited for clarity.