NEW CHEST clinical guidelines provide updated, evidence-based recommendations for managing Stage I and II non-small cell lung cancer (NSCLC), with a focus on improving survival outcomes through surgical precision and adjuvant therapy.
Lung cancer remains the leading cause of cancer-related death worldwide, prompting continued evaluation of optimal treatment strategies. To inform clinical practice, an expert panel conducted a systematic review of 578 studies on primary treatment options for patients with Stage I and II NSCLC. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework was used to evaluate evidence certainty, and a modified Delphi method helped the panel reach consensus on 17 formal recommendations.
For operable patients with Stage I NSCLC, surgical resection remains the standard of care, with minimally invasive approaches preferred over open thoracotomy due to improved overall survival, as confirmed by a new meta-analysis. Notably, sublobar resection demonstrated equivalent survival to lobectomy for peripheral tumours ≤2 cm, offering a less extensive option for selected patients. Importantly, the panel emphasised the need for systematic mediastinal and hilar lymph node assessment during surgery for both Stage I and II NSCLC to ensure appropriate staging and management.
In resected Stage II NSCLC, adjuvant chemotherapy combined with checkpoint inhibitors was shown to improve survival, including in patients with node-negative tumours ≥4 cm. For patients with EGFR-mutant Stage IB (≥3 cm) and Stage II NSCLC, adjuvant targeted therapy further enhanced overall survival. For patients unfit for surgery, stereotactic body radiotherapy remains the preferred modality for Stage I disease, reaffirming its role as a high-precision, non-surgical alternative.
These updated CHEST guidelines highlight the importance of surgical technique, precise staging, and personalised adjuvant therapies in improving survival for early-stage NSCLC. Clinicians are encouraged to integrate minimally invasive surgery and molecular-guided therapies into standard practice where appropriate.
Reference
Howington J et al. Management of patients with early-stage non-small cell lung cancer: an American college of chest physicians clinical practice guideline. Chest. 2025; DOI: 10.1016/j.chest.2025.06.023.
