Efficacy and safety of neoadjuvant chemoimmunotherapy in elderly patients with resectable non-small cell lung cancer: a network meta-analysis and systematic review

Abstract Purpose This network meta-analysis evaluated neoadjuvant chemoimmunotherapy efficacy and safety in elderly patients with resectable non-small cell lung cancer (NSCLC). Methods We conducted a systematic review and Bayesian network meta-analysis by searching PubMed, Web of Science, Cochrane Library (All Databases), and EMBASE (including MEDLINE). The endpoints for this analysis were event-free survival (EFS), pathological complete response (pCR), and adverse events of grade 3 or higher (AEs ≥ 3). Results We analyzed 8 RCTs, including 6 neoadjuvant plus adjuvant immunotherapy with preoperative chemotherapy (Neo-adj) and 2 neoadjuvant immunotherapy with preoperative chemotherapy (Neo) trials, involving 1,556 elderly patients and covering 7 treatment regimens. In elderly patients, Neo-adj outperformed neoadjuvant chemotherapy (CT) in EFS (HR = 0.60, 95%CI:0.41–0.81) and pCR (OR = 7.29, 95%CI:1.58–34.73). Neo-adj versus Neo demonstrated no significant difference in EFS (HR = 0.86, 95%CI:0.35–1.91) and pCR (OR = 1.11, 95%CI:0.05–25.88). Tislelizumab plus CT showed the greatest pCR benefit (OR = 15.82, 95%CI:1.05–248.39). In patients aged < 65 years, Neo-adj surpassed CT in EFS (HR = 0.54, 95%CI:0.41–0.72) and pCR (OR = 7.44, 95%CI:3.1–17.86). Neo-adj versus Neo demonstrated no significant differences in EFS (HR = 0.96, 95%CI:0.45–2.03) and pCR (OR = 1.98, 95%CI:0.22–14.91). Nivolumab plus CT demonstrated notably higher pCR versus CT (OR = 7.05, 95%CI:1.01–49.66). In the overall population, no significant differences were observed in AEs ≥ 3 between Neo-adj and Neo, as well as among different regiments. Conclusion Neo-adj may be optimal treatment strategy for resectable NSCLC in both younger (< 65 years) and elderly patients. In elderly patients, tislelizumab plus chemotherapy seems to offer the best therapeutic effect. Nivolumab plus chemotherapy appears more effective in younger patients. Notably, Safety profiles remain clinically manageable despite adverse events.