The Earlier the Better in Lung Cancer: Multispecialty Guidance on Screening, Diagnosis and Management of Resectable NSCLC

Chair, Prof. Sanjay Popat, FRCP, PhD, and presenters Prof. Joachim G. Aerts, MD, PhD, and Prof. Solange Peters, MD, PhD, prepared useful Practice Aids pertaining to NSCLC for this CME activity titled “The Earlier the Better in Lung Cancer: Multispecialty Guidance on Screening, Diagnosis and Management of Resectable NSCLC.” For the full presentation, downloadable Practice Aids, and complete CME information, and to apply for credit, please visit us at https://bit.ly/3Goyt9D. CME credit will be available until October 20, 2026.

1. Lessons and Resources for Lung Cancer
Screening in Europe
Full abbreviations, accreditation, and disclosure information available at
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Diagnosed
in a screening
programme
77% 7% 7%9%
Stage I Stage IIStage IIIStage IV
16% 10% 17% 57%
Diagnosed
outside of a
screening
programme
Stage IVStage IIIStage IIStage I
Stage shift
Low-dose
computed
tomography
Lung Cancer Screening (LCS) Allows
Early Detection and Reduces Lung
Cancer-Related Mortality
1

2. Lessons and Resources for Lung Cancer 
Screening in Europe 
Full abbreviations, accreditation, and disclosure information available at 
PeerView.com/JYH40 In Europe, to date, there are no unifed guidelines on LCS provided
by professional or governmental organisations. European Respiratory
Society and European Society of Radiology task forces were formed
to provide a technical standard for a high-quality LCS programme
and a management protocol for incidental LCS fndings.
ERS Technical Standards and Management 
Protocols for Incidental LCS Findings
2,3

3. Lessons and Resources for Lung Cancer
Screening in Europe
Full abbreviations, accreditation, and disclosure information available at
PeerView.com/JYH40 Lessons to Guide Lung Cancer
Screening Implementation
Ensure adaptability
to local context
and health system
Adapt eligibility
criteria
Optimise risk
prediction
models
Optimise
use of
biomarkers
Understand
barriers to
screening
attendance
Ensure
screening
programme is
geographically
appropriate
Invest in
multidisciplinary
care
Take a
comprehensive
approach to
planning
Integrate
smoking
cessation
Combine with
other screening
programmes
Engage
high-risk
individuals
Try to detect
other diseases
Lesson 4
Ensure the full integration
of lung cancer screening
into health systems
Lesson 1
Tailor eligibility criteria for
screening to reach those at
highest risk of lung cancer
Lesson 3
Amplify the impact of
lung cancer screening by
integrating it into other
public health
initiatives
Lesson 2
Develop targeted outreach
to address potential
barriers to participation
in lung cancer
screening

4. Lessons and Resources for Lung Cancer
Screening in Europe
Full abbreviations, accreditation, and disclosure information available at
PeerView.com/JYH40 1. The Lung Cancer Policy Network. https://www.lungcancerpolicynetwork.com/app/uploads/Lung-cancer-screening-learning-from-implementation.pdf. 2. Baldwin D et al. Eur Respir J.
2023;61:2300128.3. O’Dowd EL et al. Eur J Cardiothorac Surg. 2023;64:ezad302. 4. https://europeanlung.org/solace/.
The multi-national SOLACE project is set to boost lung cancer screenings in Europe.
4

Experiences and lessons from participating countries (Austria, Belgium, Croatia,
Czechia, Estonia, France, Germany, Greece, Hungary, Ireland, Italy, Netherlands,
Poland, Romania, and Spain) are available. Scan the QR code to access additional
project resources.
The multi-national SOLACE project is set to boost lung cancer screenings in Europe.
4

Experiences and lessons from participating countries (Austria, Belgium, Croatia,
Czechia, Estonia, France, Germany, Greece, Hungary, Ireland, Italy, Netherlands,
Poland, Romania, and Spain) are available. Scan the QR code to access additional
project resources.

5. ESMO Clinical Practice Guideline:
Early-Stage NSCLC
1

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Work-Up for Diagnosis and Staging
Mandatory
Scan the QR code to access the
full ESMO guidelines on NSCLC
EGFR mutation status, PD-L1
expression (for unresectable
NSCLC)
Medical history, physical
examination, comorbidity, and PS
General
Blood cell counts, renal function,
liver enzymes
Laboratory
FVC, FEV1, DLCO, ECG; if
indicated, CPET
Cardiopulmonary
function
Molecular testing
Optional
CT thorax and upper abdomen,
PET-CT, MRI brain
Imaging
X-ray thorax, bone scintigraphy,
contrast-enhanced CT brain
Bone parameters
Ejection fraction, CAG
Bronchoscopy, EBUS/EUS
mediastinal nodes,
CT-guided biopsy
Biopsy Mediastinoscopy
ALK fusion status

6. ESMO Clinical Practice Guideline:
Early-Stage NSCLC
1

Full abbreviations, accreditation, and disclosure information available at
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1. Zer A et al. Ann of Oncol.2025; S0923-7534(25)00923-8.
Management of Stage I NSCLC
Stage I NSCLC
Medically
inoperable
Medically
operable
SBRT (II, A)
Surveillance
Local 
progression
Salvage
surgery
[IV, B]
Surveillance
[I, A]
R2
MDT
discussion
R1
R0
Defnitive PORT
(60 Gy in
30 fractions)
[III, C]
T <3 cm
N0
T 3-4 cm
N0
Higher
stage
Refer to the 
Management of
Resectable Stage II-III 
NSCLC Algorithm
EGFR
WT
EGFR exon 19
deletion or
L858R [ESCAT I-A]
Surveillance
[I, A]
Surveillance
[I, A]
Osimertinib for 3 y 
[I, A; MCBS A (AT)]
Preoperative evaluation
and MDT discussion
      Surgery [III, A]
• Sublobar resection
• Lobectomy

7. ESMO Clinical Practice Guideline:
Early-Stage NSCLC
1

Full abbreviations, accreditation, and disclosure information available at
PeerView.com/JYH40 1. Zer A et al. Ann of Oncol.2025; S0923-7534(25)00923-8.
Management of Stage II-III NSCLC
Resectable stage II-III NSCLC
EGFR WT and
ALK WT
ChT-ICI ineligible ChT-ICI eligible
EGFR mutation
or ALK rearrangement
Surgery [III, A]
R1 or R2 R0
MDT
discussion
ChT
eligible
ChT
ineligible
Cisplatin-based
ChT [I, A]
PD-L1 positive PD-L1 negative
Atezolizumab
for 1 y
[I, A; MCBS A (AT)]
Pembrolizumab
for 1 y
[I, A; MCBS A (AT)]
Pembrolizumab
for 1 y
[I, A; MCBS A (AT)]
Surveillance
[I, A]
ChT-ICI
[I, A]
Surgery [III, A]
Immunotherapy
[I, A]
Surgery [III, A]
R1 or R2 R0
MDT
discussion
EGFR exon 19
deletion or
L858R
[ESCAT I-A]
ALK
rearrangement
[ESCAT I-A]
ChT
ineligible
ChT
eligible
Osimertinib
for 3 y [I, A;
MCBS A (AT)]
Cisplatin-
based
ChT [I, A]
Osimertinib
for 3 y
[I, A;
MCBS A (AT)]
Surveillance
[I, A]
EGFR, ALK, and PD-L1 testing
Preoperative evaluation and MDT discussion
ChT [III, C]
Alectinib
for 2 y
[I, A; MCBS A]

8. Immune-Related Adverse Events of Cancer Immunotherapies
1-6 
 
Full abbreviations, accreditation, and disclosure information available at PeerView.com/JYH40 Immune checkpoint inhibitors (ICIs) have transformed treatment of many cancer types.
However, these treatments are associated with immune-related adverse events (irAEs).
fPre-existing autoimmune disease
is a strong risk factor for irAEsf
Diagnostic workup 
of individuals with 
suspected irAEs 
depends on the 
afected organ
SYSTEMIC
Sicca syndr ome 
and vasculitis
irAEs can r ange
in severity and
afect almost
any or gan
Polyneur opathy
Interstitial
lung
disease
Hepatitis
Vitiligo
Myalgia
and
myositis
Enterocolitis 
Thyroiditis
Hypophysiti s
Myocar ditis
Adrenitis
Arthralgia
and
arthritis
Monitoring organ function during ICI 
therapy to enable early detection of 
irAEs is warranted only for some 
organs, such as thyroid and liver
Nephritis
Patterns and Duration of Various irAEs
While onset of irAEs is generally 2 to 16 weeks after ICI initiation, 
 some reports have noted onset within a few days of starting therapy
and >1 year after completion. An irAE that occurs >3 months after 
ICI discontinuation is a delayed/late-onset irAE.
Some irAEs are recurrent (ie, occurring in the same organ or >1 time after
discontinuation), while others are chronic and can be active (ie, requiring
immunosuppression) or inactive (ie, not requiring immunosuppression). 
4 6 8 10 12 14 >30
Duration of Treatment, wk
PD-1/PD-L1 Inhibitors
Toxicity Grade
Colitis
Liver toxicity
Skin toxicity,
rash, or pruritus
PneumonitisEndocrinopathy
Nephritis
Become Aware and Stay Vigilant
Uveitis

9. Immune-Related Adverse Events of Cancer Immunotherapies
1-6 
 
Full abbreviations, accreditation, and disclosure information available at PeerView.com/JYH40 Increasing intensity
of treatment required 
Grade 2Grade 1 Grade 3 Grade 4
ModerateMild Severe Very severe
Symptomatic and suppor tive therapy
Stop treatment
Some irAEs are unresponsive or resistant to treatment with steroids, while others
are steroid-dependent, requiring chronic treatment (≥12 weeks)
Oral steroids  ------------ >
•Referral to specialist
•Strong immune  suppressive treatment
Increasing grade of irAE
Intravenous  steroids
Steroids (PO/IV): 1-2 mg/kg/d
prednisone or equivalent,
slowly taper over 4-6 weeks
For some AEs, treatment can be
restarted after resolution (eg, rash);
generally, ICI can be continued
with endocrinopathies
once managed
Managed in outpatient/
communi ty setting
Generally requires
hospital admission
General Management Recommendations

10. Immune-Related Adverse Events of Cancer Immunotherapies
1-6 
 
Full abbreviations, accreditation, and disclosure information available at PeerView.com/JYH40 Diagnosis and Management of Pulmonary irAEs
 Hold immunotherapy and reassess in 1-2 weeks
 Pulse oximetry rest and ambulation
 Consider chest imaging with CT (with contrast preferred)
 Repeat in 3-4 weeks
Moderate (grade 2): 25%-50% 
lung involved
Severe (grade 3-4)
Grade 3:
all lobes of lung or 
>50% of lung parenchyma; 
limited ADLs, oxygen requirement
Grade 4:
life-threatening
 Hold immunotherapy
 Infectious workup (nasal swab, sputum, blood)
 Consider bronchoscopy and BAL
 Chest imaging with CT contrast
 Repeat in 3-4 weeks
 Consider empiric antibiotics
 Refractory: methylprednisolone 1-2 mg/m
2
/day; if no response in 3-4 days, treat as grade 3
 Permanently discontinue immunotherapy and move to inpatient care
 Infectious workup (nasal swab, sputum, blood)
 Pulmonary and infectious disease consultation
 Bronchoscopy with BAL
 Empiric antibiotics
 Methylprednisolone 1-2 mg/m
2
/day; when grade 1, taper over 6 weeks
 Refractory: infiximab, mycophenolate, or IVIG
 Pneumonitis: focal or difuse infammation of the lung parenchyma (typically identifed on CT imaging)
 Diagnostic workup: CXR, CT, pulse oximetry; for grade ≥2, may include infectious workup
Mild (grade 1): <25% lung 
involved
Additional considerations
•  GI and pneumocystis prophylaxis may be offered to patients on prolonged steroid use (>12 weeks)
•  Consider calcium and vitamin D supplementation with prolonged steroid use 
•  Bronchoscopy and biopsy; if clinical picture is consistent with pneumonitis, no need for biopsy
Supportive care: smoking cessation and vaccinations (infuenza, pneumococcal)

11. Immune-Related Adverse Events of Cancer Immunotherapies
1-6

Full abbreviations, accreditation, and disclosure information available at PeerView.com/JYH40 Guideline Management Recommendations
1. Ramos-Casals M et al. Nat Rev Dis Primers. 2020;6:38. 2. Martins F et al. Nat Rev Clin Oncol. 2019;16:563-580. 3. O’Leary CL et al. J Thorac Oncol. 2023;19:395-408. 4. Naidoo J et al. J Immunother Cancer. 2023;11:e006398. 5. Provided courtesy of Prof. Peter Schmidt, FRCP, MD, PhD.
6. Brahmer JR et al. J Clin Oncol. 2018;36:1714 -178 6 .