Assessing Guideline-Directed Care in the New Era of Neoadjuvant Therapy in Early-Stage Resectable Non-small Cell Lung Cancer (NSCLC): A Retrospective Review.

INTRODUCTION: Neoadjuvant chemoimmunotherapy (NAT) has become standard of care for select patients with resectable non-small cell lung cancer (NSCLC). Accurate and timely preoperative staging with positron emission tomography and computed tomography (PET-CT) ± invasive mediastinal staging (IMS) is essential to identify patients who may benefit from NAT prior to curative-intent surgery. We sought to evaluate the real-world implementation of guideline-informed staging and treatment decisions in early-stage NSCLC. METHODS: We conducted a retrospective chart review of patients with stage IA-IIIB NSCLC who underwent surgical resection within our medical center between April 1, 2023 and January 1, 2026. We compared clinical stage at diagnosis with pathologic stage at surgery and assessed barriers to NAT utilization. RESULTS: In total, 212 patients met inclusion criteria. Sixteen patients received NAT and most were downstaged. However, based on surgical pathologic staging, there were 39 patients (71% of all NAT-eligible patients) staged as Stage IIA or higher who had not received NAT, 35 of whom did not meet criteria for NAT prior to surgery. Mean time to surgery was 69 days in patients who did not undergo biopsy and 99 days in those who did. CONCLUSION: Nearly 3 quarters of eligible patients were found to have advanced disease at the time of surgery, representing missed opportunities for the consideration of standard-of-care NAT. These findings highlight limitations in the current diagnostic staging and delays between imaging and surgery. Improved accuracy and timeliness of preoperative staging are critical to ensure appropriate multidisciplinary evaluation and optimal delivery of NAT for eligible patients.