Perioperative Chemoimmunotherapy in Early-Stage NSCLC: From Concept to Clinic With Juliet Meir, MD, and Wint Yan (Arthur) Aung, MD
Expert Perspectives · Keira Smith · 2026-03-26
Perioperative chemoimmunotherapy has rapidly moved from clinical trials into practice for patients with resectable non–small cell lung cancer (NSCLC), yet implementation is often suboptimal. In this discussion, Dr. Wint Yan (Arthur) Aung, Hematology/Oncology Fellow at Northwell Health, sits down with his co-fellow, Dr. Juliet Meir, who is leading a quality improvement initiative focused on optimizing perioperative strategies for NSCLC within the Northwell Health system. Dr. Meir outlines the clinical rationale, common concerns, and practical steps that institutions can take to implement these strategies safely and effectively.
Clinical Rationale and Demonstrated Benefits
Dr. Meir emphasizes that the numerous advantages of perioperative chemoimmunotherapy, explaining that “the benefit is multi-fold for improving the major pathologic response rate, which is the rate of complete response following resection.” Beyond local disease control, there is a systemic rationale: “There's also a benefit in terms of controlling micrometastatic disease at the time prior to resection and determining how the disease itself responds to systemic chemoimmunotherapy.”
Crucially for clinicians weighing risk-benefit tradeoffs, perioperative strategies are now supported by robust evidence. As Dr. Meir highlights, “The reason this approach is exciting is because we now have evidence from major randomized trials that have shown overall improvement in survival with this strategy.”
Surgical Timing, Technical Complexity, and Patient Selection
Despite the emerging data, integrating neoadjuvant or perioperative chemoimmunotherapy is a new paradigm, and teams may be hesitant to adopt it broadly. Dr. Meir acknowledges that “the most common concern is delayed or missed surgery—there may be delays in resection with 15% to 25% of patients not getting to resection across neoadjuvant trials, most commonly due to disease progression, treatment, toxicity, or functional decline.”
Surgeons, in particular, may be apprehensive about operative difficulty. “Surgeons may also be concerned regarding treatment-related fibrosis,” she notes, “which is reported at rates of 40% at Cornell. At MD Anderson, 40% of surgeons reported that the surgery was more difficult following perioperative chemoimmunotherapy.”
Another key concern is biologic heterogeneity. “There's also a concern about patient selection,” Dr. Meir explains. “Patients with actionable driver mutations such as EGFR or ALK may not necessarily benefit from perioperative chemoimmunotherapy strategies. Ongoing studies are looking at incorporating targeted treatment instead for those patients.”
Still, she stresses that “when care is coordinated through multidisciplinary programs, many of these concerns can be mitigated.”
Multidisciplinary Coordination: The Cornerstone of Safe Implementation
To translate trial data into real-world benefit, Dr. Meir underscores that “the key is multidisciplinary coordination.” She advocates for early, coordinated assessment: “Patients should be evaluated jointly by thoracic oncologists or surgeons, medical oncologists, and pulmonology early in this process. This allows structured care pathways for staging, molecular testing, and treatment planning before therapy begins.”
Equally important is what happens during treatment. “Close monitoring during the neoadjuvant treatment also helps ensure that these patients proceed to surgery within the intended timeframe,” she notes. Done properly, these programs can improve R0 resection rates and pathologic response while maintaining surgical feasibility.
Building Institutional Pathways: The Northwell Experience
Implementation requires both culture change and infrastructure. “We need both education and system-level support. It goes beyond academic practice,” Dr. Meir stresses. Across institutions, “many centers are developing care pathways and navigation programs to identify patients early and coordinate referral between surgery and medical oncology.”
At Northwell Health, Dr. Meir describes a focused quality initiative: “At Northwell, we have currently partnered with Lilly for a quality improvement initiative to increase rates of referral for perioperative chemoimmunotherapy. We are currently working with our surgical colleagues to educate them on this benefit and working with navigation to determine these patients and offer these navigation services to help their referral to medical oncology prior to resection.” Dr. Aung frames this as a promising opportunity to improve care, aligning improved screening and earlier detection with optimized perioperative management.
Future Directions: Biomarkers and Personalized Perioperative Therapy
Looking ahead, the field is rapidly moving toward more nuanced patient selection. “Future work will focus on refining patient selection and biomarkers,” Dr. Meir says. “We are learning that not all patients derive the same benefit from immunotherapy. Molecular alterations, circulating tumor DNA, and pathologic response may eventually help guide risk-adapted perioperative strategies.” The overarching aim, she adds, is “to integrate these tools to deliver personalized perioperative therapy while maintaining the curative potential of surgery.”
Dr. Aung reflects on the broader trajectory of thoracic oncology: “This has been an amazing time to be in thoracic oncology, especially in early-stage non-small cell lung cancer. As we improve our screening and detect earlier-stage lung cancer, we have a duty and responsibility to really improve the outcomes for these patients and make sure patients are able to enjoy their expected life expectancy and be cancer-free.”
Key Takeaways
Perioperative chemoimmunotherapy improves outcomes: This approach improves major pathologic response rates and has shown overall improvement in survival in randomized trials.
Risks are real but manageable: Delayed or missed surgery, treatment-related fibrosis, and functional decline are key concerns; 15%-25% of trial patients may not reach resection.
Multidisciplinary coordination is essential: Joint evaluation by thoracic surgery, medical oncology, and pulmonology, with structured staging and molecular workflows, is critical to safe implementation.
Patient selection must be nuanced: Patients with EGFR, ALK, or other actionable alterations may be better served with targeted strategies rather than chemoimmunotherapy.
Institutional pathways drive success: Navigation programs, surgeon education, and formal referral pathways—such as Northwell’s quality improvement initiative with industry partners—are central to scaling perioperative strategies.
Biomarker-driven personalization is on the horizon: Molecular alterations, ctDNA, and pathologic response are emerging tools to risk-stratify and tailor perioperative therapy while preserving the curative intent of surgery.
About the Speakers
Juliet Meir, MD, is a second-year Hematology/Oncology Fellow at Zucker School of Medicine at Hofstra/Northwell Health. She is interested in lung cancer and is currently leading a quality improvement initiative focused on optimizing perioperative strategy for NSCLC within the Northwell Health system.
Wint Yan (Arthur) Aung, MD, is a second-year Hematology/Oncology Fellow at Zucker School of Medicine at Hofstra/Northwell Health. He is interested in lung cancer and head and neck cancer, including immunotherapy and clinical trial development.