Using Immunotherapy Before and After Lung Cancer Surgery
When you’re facing surgery for non-small cell lung cancer, it’s natural to ask if more can be done before and after the operation to improve your odds. That’s where immunotherapy comes in, working with your immune system to attack cancer cells that surgery alone might miss. You may have heard names like nivolumab or pembrolizumab, but what matters most is how, when, and if they fit into your specific treatment plan…
How Immunotherapy Fits Before and After Surgery
Although surgery remains the cornerstone for treating operable non-small cell lung cancer (NSCLC), care is becoming more integrated, with immunotherapy now playing a key role before and after the operation. In clinical practice, patients may receive immune checkpoint inhibitors such as nivolumab or pembrolizumab alongside chemotherapy prior to surgery, followed by continued immunotherapy during recovery to help address any remaining cancer cells. This perioperative approach aims to improve surgical outcomes while reducing the risk of recurrence over time.
Evidence continues to support this strategy. In the CheckMate 77T trial, adding nivolumab both before and after surgery reduced the risk of recurrence or death by around 40% compared with standard treatment alone. It also improved rates of complete tumor clearance, particularly in patients with N2 nodal involvement, and demonstrated benefit even among those with low PD-L1 expression.
Because treatment decisions at this stage are highly individualized, working with a specialist who understands both the latest research and the nuances of local care pathways can make a meaningful difference. A clinician familiar with regional healthcare systems can help coordinate surgery, systemic therapy, and follow-up care more seamlessly, ensuring that each phase of treatment is appropriately timed and tailored.
Key Questions to Ask Your Care Team About Pre- and Post-Surgery Immunotherapy
Someone considering lung cancer surgery with immunotherapy benefits from clear, specific information from their care team.
One key point is to clarify whether the plan is neoadjuvant-only (treatment before surgery only) or perioperative (treatment before and after surgery).
Ask how strongly they recommend continuing immunotherapy after surgery and how they interpret data suggesting substantially lower risk of recurrence or death when at least one postoperative nivolumab dose is given.
It is also useful to ask which specific regimen they recommend (for example, a CheckMate 77T–type approach with 4 preoperative and 13 postoperative cycles versus a CheckMate 816–type approach with 3 preoperative cycles only) and the reasons behind that choice, such as evidence strength, side‑effect profile, and practical considerations.
Discuss your PD-L1 status and how it may influence the expected benefit from immunotherapy.
Ask about realistic goals for pathologic response (such as major pathologic response or pathologic complete response) and how your staging, including any N2 lymph node involvement, might affect prognosis and the potential benefit of adding or continuing immunotherapy around the time of surgery.
Seeking input from a multidisciplinary team is crucial to making well-informed decisions. This may include a medical oncologist, a radiation oncologist, and a thoracic surgeon, who specializes in the treatment of lung and chest conditions. Consulting experienced specialists, such as Marco Scarci, a trusted thoracic surgeon operating in London, can help ensure that treatment recommendations are aligned with the latest evidence and tailored to the individual patient’s clinical situation.
Mr Marco Scarci is a strong choice with experience in both surgical and perioperative cancer management. Check out his website here:
Immunotherapy Before Lung Cancer Surgery: How It Helps
Before lung cancer surgery, immunotherapy can be combined with chemotherapy to help shrink tumors and improve surgical planning. In clinical trials such as CheckMate 816, patients received three cycles of nivolumab with chemotherapy before surgery.
This approach was associated with a higher rate of major pathologic response and complete tumor clearance in the removed tissue compared with chemotherapy alone.
Nivolumab is a PD-1 inhibitor. Many lung tumors express PD-L1, which binds to PD-1 on immune cells, reducing their ability to attack cancer cells.
By blocking PD-1, nivolumab can restore some immune activity against the tumor. As a neoadjuvant (pre-surgery) treatment, this may help the immune system target both the main tumor and microscopic disease that isn't visible on scans.
Evidence from CheckMate 816 and similar studies indicates that these benefits occur across a range of resectable non–small cell lung cancer (NSCLC) stages.
However, appropriateness of this strategy depends on individual factors such as tumor stage, molecular profile, overall health, and potential side effects, and should be evaluated in discussion with an oncology team.
Immunotherapy After Surgery: Why Add More Treatment?
Even when immunotherapy shrinks a lung tumor before surgery, many clinicians recommend continuing it afterward to further reduce the chance that the cancer returns.
Clinical studies indicate that adding nivolumab after surgery, even for a limited duration, can reduce the risk of recurrence or death by roughly 40% compared with observation alone.
Postoperative immunotherapy is thought to address residual microscopic disease, including micrometastases and tumor cells that may have evaded both surgery and preoperative treatment.
The benefit appears more pronounced in certain groups, such as patients whose tumors show low PD-L1 expression (less than 1%) and those who don't achieve a complete pathologic response to preoperative therapy.
In patients with N2 lymph node involvement, continued nivolumab after surgery has been associated with a notable improvement in event-free survival in clinical trials.
CheckMate 816 and 77T: What the Trials Show
When considering whether to add immunotherapy in the perioperative setting for resectable non–small cell lung cancer (NSCLC), two trials, CheckMate 816 and CheckMate 77T, provide key data.
CheckMate 816 evaluated three cycles of nivolumab plus platinum-based chemotherapy before surgery, compared with chemotherapy alone, in 358 patients with resectable NSCLC. The addition of nivolumab improved pathologic complete response rates and event-free survival, indicating better long-term outcomes versus chemotherapy alone.
CheckMate 77T enrolled over 450 patients with resectable NSCLC and tested a perioperative regimen: nivolumab plus chemotherapy before surgery, followed by adjuvant nivolumab after surgery. With follow-up approaching four years, the perioperative approach reduced the risk of recurrence or death by roughly 40% compared with preoperative chemo-immunotherapy alone, with particular benefit seen in patients with PD-L1 expression <1% or with residual disease at the time of surgery.
Together, these trials support the use of neoadjuvant chemo-immunotherapy (CheckMate 816) and suggest that extending nivolumab into the postoperative period (CheckMate 77T) can provide additional benefit in selected patients.
What These Results Mean for Your Risk of Recurrence
Taken together, the CheckMate 816 and 77T results suggest a meaningful change in expected outcomes after surgery. When nivolumab is given both before and after an operation, the overall risk of the cancer returning or of death is reduced by about 40% compared with receiving it only before surgery.
This effect is seen across different initial disease stages, not only in patients with earlier, operable cancer. The reduction in risk appears greater in patients whose tumors have PD-L1 expression below 1%. In addition, for patients in whom surgery doesn't remove all cancer cells, continuing immunotherapy after surgery still provides a measurable reduction in the risk of recurrence.
What If Cancer Has Reached Your N2 Lymph Nodes?
Although learning that cancer has reached the N2 lymph nodes can be concerning, newer evidence indicates this doesn't automatically mean a substantially worse outlook or an inability to benefit from perioperative immunotherapy.
In the CheckMate 77T trial, patients with N2 disease had outcomes broadly similar to those without N2 involvement.
When nivolumab was given before and after surgery, 1‑year event‑free survival in patients with N2 disease was about 70%, compared with roughly 45% for those who received chemotherapy alone.
Pathologic complete response rates also increased, including in patients with cancer in multiple N2 lymph node stations.
In addition, patients who didn't achieve a complete response still appeared to gain benefit from continuing nivolumab after surgery.
How PD-1 and PD-L1 Test Results Can Shape Treatment
Because checkpoint inhibitors don't have the same effect in all individuals, PD-1 and PD-L1 test results can provide your care team with additional information about how likely you are to benefit from perioperative immunotherapy. These tests estimate how much your tumor relies on the PD-L1 pathway, often described as a biological “brake”, to avoid being recognized and attacked by the immune system.
In clinical studies of perioperative treatment strategies, patients whose tumors had PD-L1 levels below 1% still experienced a meaningful reduction in the risk of cancer recurrence or death after surgery, and in some analyses, this reduction was relatively pronounced.
This suggests that perioperative immunotherapy may offer benefit even when PD-L1 expression is low and even if surgery doesn't completely remove all cancer cells.
The observed benefit has been reported across different disease stages, indicating that PD-1/PD-L1 test results add another layer of insight on top of traditional staging, rather than replacing it.
Side Effects, Safety, and Daily Life on Immunotherapy
Knowing how PD-1 and PD-L1 results guide treatment is only part of the picture. It's also important to understand how immunotherapy may affect your body and daily routine.
In clinical trials such as CheckMate 77T and CheckMate-816, adding nivolumab before and/or after surgery didn't substantially increase the overall rate of side effects, and most planned surgeries were completed without major delays or complications, which is consistent with maintaining recovery.
Treatment usually follows a structured schedule, with regular visits for nivolumab or pembrolizumab infusions and routine blood tests to monitor safety and response.
Daily activities may need to be adjusted around these appointments, including work, family responsibilities, and rest.
Because PD-1 blockade can lead to immune-related side effects involving organs such as the skin, lungs, intestines, liver, or endocrine glands, it's important to report new or worsening symptoms promptly so that they can be evaluated and managed early.
Conclusion
When you’re facing surgery for non-small cell lung cancer, it helps to know you’ve got options that target the cancer from every angle. Using immunotherapy before and after surgery can shrink tumors, lower your risk of recurrence, and improve long-term outcomes, even when lymph nodes are involved. Ask your team how trial results like CheckMate 816 and 77T apply to you, and whether perioperative immunotherapy should be part of your treatment plan.