Efficacy and safety of the optimal immunochemotherapy regimen for resectable non-small cell lung cancer: A network meta-analysis of randomized controlled trials

Depending on the timing of surgery, immunochemotherapy regimen can be classified into neoadjuvant, perioperative, and adjuvant models, all of which demonstrate great clinical efficacy; however, the optimal regimen remains uncertain. Our study encompassed phase Ⅱ/Ⅲ randomized controlled trials (RCTs) that involved immunochemotherapy or chemotherapy for resectable NSCLC. The primary outcomes included disease free survival (DFS), overall survival (OS), incidences of adverse events (AEs) and event-free survival (EFS). Subgroup analyses for EFS were stratified by race, gender, PD-L1 expression levels, and histological types. A total of 22 eligible trials involving 12,351 patients were analyzed. Compared with chemotherapy or surgery alone, immunochemotherapy in both neoadjuvant, perioperative and adjuvant models was notably effective in prolonging DFS without increasing AEs risk. Neoadjuvant immunochemotherapy was identified as the optimal regimen for DFS improvement. Perioperative immunochemotherapy was associated with the greatest OS and EFS benefits. Adjuvant immunochemotherapy was associated with the highest AE risk. In EFS subgroup analysis, neoadjuvant immunochemotherapy showed superior outcomes in population with high sensitivity including, Asian, stage III, PD-L1>50 % subgroups. The insensitive population was more likely to benefit from perioperative immunochemotherapy. This study underscores the superiority of immunochemotherapy over chemotherapy alone in terms of efficacy and safety. It also highlights the necessity for personalized treatment strategies. These findings provide critical insights for clinical decision-making in resectable NSCLC management.