Updated clinical guidelines for the management of patients with early-stage non–small cell lung cancer (NSCLC) from the American College of Chest Physicians (CHEST) recommend use of more minimally invasive procedures and methods where possible.
The guidelines, published in the journal CHEST, suggest use of minimally invasive surgery—such as a sublobar resection for a peripheral ≤ 2 cm lesion—over thoracotomy for patients with stage I lung cancer, as these approaches have now been proven to lead to greater overall survival benefits. When surgical resection is not possible for patients with stage I NSCLC, stereotactic body radiotherapy is instead recommended.
“In the time since the last guideline on this topic was published by CHEST, there have been several landmark trials that have taught us a lot about treating early-stage lung cancer,” said lead guideline author John Howington, MD, MBA, FCCP, the 2025 President of CHEST. “As an example, we knew that there were short-term benefits to minimally invasive surgeries because of shorter hospital stays—less pain, and the like—but now we have the evidence to show that minimally invasive surgery for stage I lung cancer is also associated with better long-term survival.”
An expert panel conducted a systematic review of literature that addresses treatment options for patients with stage I or II NSCLC. They looked at 578 studies with an applied Grading of Recommendations, Assessment, Development, and Evaluations approach, and pulled together a list of 17 evidence-based recommendations.
For patients with completely resected stage II NSCLC, the guidelines recommend treatment with adjuvant chemotherapy. The addition of checkpoint inhibitors could also improve overall survival for patients with ≥ 4 cm, node-negative tumors. For patients with resected stage IB (≥ 3 cm) and stage II NSCLC and with EGFR exon 19 del/L858R mutations, adjuvant targeted therapy is suggested as it improves overall survival.
In medically fit patients with a peripheral ≤ 2 cm solid or mostly solid clinical stage I NSCLC, the expert panel suggested either lobectomy, segmentectomy, or sublobar nonanatomic (wedge) resection as equivalent alternatives to thoracotomy.
For all patients with stage I and II NSCLC, it is recommended to perform systematic intraoperative mediastinal and hilar lymph node sampling or dissection for greater confidence in the guidelines and results.
The guidelines also include three flowchart graphs to guide treatment for medically inoperable, high-operative risk, and average-risk patients.
“As with the release of any new guideline, our goal is to help standardize the approach to treatment and management of care,” said Dr. Howington, who is also a practicing thoracic surgeon at Virginia Mason Franciscan Health, St. Michael Medical Center, Silverdale, Washington. “Variable care is often associated with lower-quality care, and guidelines are a great way to share best practices far and wide to improve patient outcomes.”
Disclosure: For full disclosures of the study authors, visit journal.chestnet.org.
