Should we optimise or revise the management of initially unresectable stage III non-small cell lung cancer: rethinking consolidation therapy.

Despite the PACIFIC trial transforming unresectable stage III non-small cell lung cancer (NSCLC) management, survival gains remain modest and heterogeneous. Current consolidation strategies are fragmented, with redundant "me-too" designs, underuse of dynamic biomarkers, and little consensus on optimal sequencing of chemoradiotherapy (CRT), surgery, and next-generation systemic agents. We synthesise emerging evidence across immune checkpoint inhibitors (ICIs), genotype-directed tyrosine kinase inhibitors (TKIs), antibody-drug conjugates (ADCs), bispecific antibodies, and advanced radiotherapy techniques, identifying critical gaps: lack of head-to-head CRT-first vs systemic-first comparisons, inconsistent central nervous system (CNS) management, unclear optimal integration of stereotactic body radiotherapy (SBRT) boosts, and minimal integration of dynamic biomarkers such as circulating tumour DNA (ctDNA) to guide escalation or de-escalation. We further examine the potential of early ADC integration to maximise initial tumour eradication, the role of salvage and planned surgery within trimodality strategies, and the need for harmonised CNS management. Finally, we address the economic sustainability of intensification, advocating value-based pricing, outcome-linked reimbursement, and biomarker-driven duration limits.