Table 3.

Prioritizing Treatment Options for NSCLC

Clinical Scenario	Treatment Recommendation	Initial Delay, wk	Workup	Comments
Stage I, II, and resectable IIIA
Stage I and II, untreated	Surgery SBRT for selected stage I	2–8	Repeat CT scan if baseline CT >8 wk
Stage I and II, resected	Observation (adjuvant therapy for a subset of stage II disease)	>8	Expand interval for CT scans up to 4– 6 mo if asymptomatic with 4 y, then annually after y 5	Consider CT scan but perform remote follow-up
Stage IIIa resectable single station	Surgery followed by chemo +/- radiation	<2	CT scan every 4 mo
Stage III
Stage III untreated	Concurrent chemotherapy and radiotherapy but may start with chemotherapy for two cycles	<2	Same	Consider cisplatin/ pemetrexed Consider G-CSF if administering chemotherapy alone
Stage III completed chemoradiotherapy Immune therapy		<2	Usual workup for immune checkpoint therapy	May delay up to 7 wk per the study, but the sooner the better
Stage II completed treatment	Observation	>8	Ct scan every 4 mo	Consider CT scan but perform remote follow-up
Stage IV
Stage IV with actionable targets
Untreated	Targeted therapy	<2		Start on time, perform safety assessments as laboratory or ECG, but do phone clinic instead of in-person visit. Consider performing response assessment after 2 mo
On treatment with disease control targeted therapy		<2	May expand the disease assessment for 3 mo if clinically stable or longer if on treatment for a long period of time	Do virtual clinics for toxicity notation, management, and any sign of disease progression
Stage IV wild-type
Untreated	Chemotherapy alone	<2	Standard	Consider less immune suppressive agents and use of growth factors or dose reduction as appropriate
	Chemotherapy and immune therapy combination	<2	Standard	Need to be very selective
	Immune therapy single agent	<2	Standard	Preferred if PD-L1 score >50% consider the approved longer interval of dosing
On treatment first line	Chemotherapy
	Chemotherapy and immunotherapy	<2	May do imaging every 3 cycles, if stable	Consider growth factor, aim for a lesser number of cycles (4, if disease stable), and switch to maintenance
	Immune therapy	<2	May do imaging every 3 mo, if stable	Consider switching to maintenance as early as indicated, use a longer interval of administration. Skip cycles if appropriate
		<2	May do imaging every 3 cycles, if stable.	Use approved longer dosing intervals and stop at 2 y.
On treatment beyond first-line	Chemotherapy	<2 or 2–8	Extend CT scan to 3 or 4 cycles, if clinically stable	Consider chemotherapy holidays for 2–3 cycles interval.
	Immunotherapy	<2 or 2–8	Extend disease assessment interval	Use approved longer dosing intervals
Completed treatment
No evidence of disease	Observation	>8	Extend interval of workup	refer to survival clinics
Presence of disease	Observation	2–8	Extend the interval of workup	per phone clinic

CT computed tomography; ECG, electrocardiogram; G-CSF, granulocyte-colony stimulating factor; PD-L1, programmed death-ligand 1; SBRT, stereotactic body radiation therapy.