Bridging evidence and practice: international multidisciplinary consensus on non-metastatic NSCLC
Journal of Thoracic Oncology, pp. 104111
Abstract
BACKGROUND: The management of non-metastatic non-small-cell lung cancer (NSCLC) has become increasingly complex with the integration of multimodality strategies and biomarker-driven approaches. Several clinically relevant areas remain insufficiently defined by current evidence and international guidelines. We conducted an international multidisciplinary consensus to address major areas of uncertainty in real-world practice. METHODS: A modified Delphi process was conducted during a 3-day in-person meeting in Barcelona, Spain (3-5 September 2025). Eighty-nine thoracic oncology experts independently rated predefined clinical statements developed by working groups and refined by a steering committee. Agreement was assessed using a 9-point Likert scale. Consensus was predefined as ≥75% of ratings in the 7-9 range; rejection as ≥75% in the 1-3 range. RESULTS: Ninety-six statements were evaluated. Consensus was achieved for 62 statements (64%), 31 (32%) remained without consensus, and 3 (3%) were rejected. Consensus supported routine FDG PET-CT for staging, histologic confirmation of suspicious mediastinal nodes, reflex PD-L1 testing and DNA-based next-generation sequencing at diagnosis, standardized post-neoadjuvant pathologic assessment, and sublobar resection with systematic nodal evaluation for selected peripheral node-negative tumors ≤2 cm. Consolidation durvalumab after definitive chemoradiotherapy was supported irrespective of PD-L1 expression in unresectable stage II-III disease. Persistent areas of controversy included brain MRI in stage I disease, mediastinal restaging after induction therapy, routine RNA-based testing, and the use of circulating tumor DNA/minimal residual disease to guide perioperative decisions. CONCLUSIONS: This international consensus provides structured expert guidance in areas of uncertainty in non-metastatic NSCLC and highlights priorities for future prospective research.
Authors 89
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May‐Lucie Meyer corresponding
Centre Hospitalier Universitaire Vaudois · Hôpital Orthopédique de la Suisse Romande
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CHUV, Lausanne University Hospital, Lausanne, Switzerland. Electronic address: May-Lucie.Meyer@chuv.ch
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Centre Hospitalier Universitaire Vaudois
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CHUV, Lausanne University Hospital, Lausanne, Switzerland
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Fox Chase Cancer Center, Philadelphia, PA, USA
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The University of Texas MD Anderson Cancer Center
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MD Anderson Cancer Center, Houston, TX, USA
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Yale School of Medicine, New Haven, CT, USA
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University of Manchester · The Christie NHS Foundation Trust
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The Christie NHS Foundation Trust/University of Manchester, Manchester, UK
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Princess Margaret Cancer Centre
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Princess Margaret Cancer Centre, Toronto, Canada
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Hospital Universitario 12 De Octubre
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Hospital Universitario 12 de Octubre, Madrid, Spain
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Erasmus MC · Erasmus MC Cancer Institute
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Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
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University of Pennsylvania, Philadelphia, PA, USA
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Hanyang University Medical Center
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Hanyang University Medical Center, Hanyang University, Seoul, South Korea
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Memorial Sloan Kettering Cancer Center
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Memorial Sloan Kettering Cancer Center, New York, NY, USA
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University of Bologna, Bologna, Italy
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Instituto Nacional de Cancerología
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Thoracic Oncology Unit, Instituto Nacional de Cancerología (INCan), Mexico City, Mexico
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Memorial Sloan Kettering Cancer Center
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Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Tel Aviv University · Sheba Medical Center
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Jusidman Cancer Center, Sheba Medical Center, Tel Aviv, Israel; The Gray Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
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Inserm · Université Paris-Saclay · Prédicteurs moléculaires et nouvelles cibles en oncologie
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Université Paris-Saclay, Gustave Roussy, Inserm, Prédicteurs Moléculaires et Nouvelles Cibles en Oncologie (U981), F-94805, Villejuif, France
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Affiliation as printed
UC San Diego Moores Cancer Center, San Diego, CA, USA
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Inserm · Université Paris-Saclay · Prédicteurs moléculaires et nouvelles cibles en oncologie
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Université Paris-Saclay, Gustave Roussy, Inserm, Prédicteurs Moléculaires et Nouvelles Cibles en Oncologie (U981), F-94805, Villejuif, France
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Memorial Sloan Kettering Cancer Center
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Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Yonsei Cancer Center, Seoul, South Korea
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University of Fribourg · HFR Freiburg Kantonsspital
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University of Fribourg, Switzerland and HFR Fribourg, Switzerland
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Maastricht University Medical Centre · Erasmus MC · Erasmus MC Cancer Institute · Maastro Clinic
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Radiation Oncology Department, MaastroClinic, Maastricht UMC, GROW-Research Institute for Oncology and Reproduction, Maastricht, Netherlands; Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, Netherlands
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Erasmus MC · Erasmus MC Cancer Institute
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Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
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Medical University of Gdańsk, Poland
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Universitat Autònoma de Barcelona · Vall d'Hebron Hospital Universitari
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Vall d'Hebron University Hospital, Universitat Autónoma de Barcelona, Spain
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Johns Hopkins University, Baltimore, MD, USA
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UC Davis Comprehensive Cancer Center
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UC Davis Comprehensive Cancer Center, Sacramento, CA, USA
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University of Chicago, Chicago, IL, USA
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Hospital Universitario A Coruña (SERGAS), Spain
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Instituto Ramón y Cajal de Investigación Sanitaria · Hospital Universitario Ramón y Cajal
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Instituto Ramón y Cajal de Investigación Sanitaria, (IRYCIS) and Hospital Universitario Ramón y Cajal, Madrid, Spain
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Luzerner Kantonsspital, Lucerne, Switzerland
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Institut Curie, Paris, France
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National Cancer Center Hospital East
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National Cancer Center Hospital East, Japan
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Moffitt Cancer Center, Tampa, FL, USA
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Maastricht University Medical Centre · Maastricht University
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Maastricht University Medical Center, The Netherlands
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Tisch Cancer Institute · Icahn School of Medicine at Mount Sinai
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Icahn School of Medicine and Center for Thoracic Oncology, Tisch Cancer Center, Mount Sinai, New York, NY, USA
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The University of Sydney · University of Hong Kong
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Centre of Cancer Medicine, LKS Faculty of Medicine, University of Hong Kong, Hong Kong, and Faculty of Medicine and Health, University of Sydney, Australia
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Dana-Farber Cancer Institute, Boston, MA, USA
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National Cancer Institute, Cairo, Egypt
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Gustave Roussy (Radiation Oncology), France
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Emory University, Atlanta, GA, USA
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Massachusetts General Hospital
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Massachusetts General Hospital/Harvard, USA
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Metropolitan Hospital, Athens, Greece
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Georgetown University, Washington, DC, USA
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Minia University/Military Medical City, Egypt
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University of Naples Federico II
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Department of Public Health, University Federico II of Naples, Naples, Italy
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Instituto Nazionale Tumori Regina Elena
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Instituto Nazionale Tumori IRCCS Regina Elena, Roma, Italy
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Kindai University, Japan
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Chinese University of Hong Kong
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Chinese University of Hong Kong
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Henry Dunant Hospital Center, Athens, Greece
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Royal College of Surgeons in Ireland · Beaumont Hospital
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Beaumont Hospital / RCSI, Dublin, Ireland
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Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori
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IRST IRCCS, Meldola, Italy
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University of Turin, Italy
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IPO Porto, Portugal
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Ospedale Sacro Cuore Don Calabria
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IRCCS Ospedale "Sacro Cuore - Don Calabria", Negrar di Valpolicella VR, Italy
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Campus Bio-Medico University, Rome, Italy
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Centre Léon Bérard, Lyon, France
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Memorial Cancer Institute/Florida Atlantic University (FAU), FL, USA
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Campus Bio-Medico University, Rome, Italy
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University Hospital Mútua de Terrassa · Mútua Terrassa
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Hospital Universitari Mútua Terrassa and Network of Centres for Biomedical Research in Respiratory Diseases (CIBERES) Lung Cancer Group, Terrassa, Barcelona, Spain
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Cedars-Sinai Medical Center, USA
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Hospital Clinic Barcelona, Spain
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Inserm · Université Paris-Saclay · Prédicteurs moléculaires et nouvelles cibles en oncologie
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Université Paris-Saclay, Gustave Roussy, Inserm, Prédicteurs Moléculaires et Nouvelles Cibles en Oncologie (U981), F-94805, Villejuif, France
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University of Turin, Italy
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Dana-Farber Cancer Institute, Boston, MA, USA
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Hospital Universitario Insular de Gran Canaria
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Hospital Universitario Insular de Gran Canaria, Spain
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Dana-Farber Cancer Institute, Boston, MA, USA
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Oncology Institute of Hope and Innovation
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The Oncology Institute of Hope and Innovation, USA
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Yale School of Medicine, New Haven, CT, USA
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Amsterdam University Medical Centers
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Amsterdam University Medical Centers, The Netherlands
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National Hospital Organization Kyushu Cancer Center
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NHO Kyushu Cancer Center, Japan
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The University of Texas MD Anderson Cancer Center
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MD Anderson Cancer Center, Houston, TX, USA
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Egbert Frederik Smit Aachen
Leiden University Medical Center
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Leiden University Medical Center, The Netherlands
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IPO Porto, Portugal
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Fondazione IRCCS Istituto Nazionale dei Tumori
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Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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Peter MacCallum Cancer Centre, Melbourne, Australia
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National University Cancer Institute, Singapore
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National University Cancer Institute, Singapore
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University Hospital Zurich, Switzerland
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Montefiore Medical Center, New York, NY, USA
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University Hospital Antwerp, Belgium
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Vita-Salute San Raffaele University · IRCCS Ospedale San Raffaele
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a: Vita-Salute San Raffaele University, Milan, Italy; b: Department of Thoracic Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
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The University of Texas MD Anderson Cancer Center
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MD Anderson Cancer Center, Houston, TX, USA
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University Hospital Cologne, Germany
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Guangdong Provincial People's Hospital
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Guangdong Lung Cancer Institute, Guangdong Provincial People's Hospital, China
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Rambam Health Care Campus, Israel
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Ohio State University, Columbus, OH, USA
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Instituto Nazionale Tumori Regina Elena
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Instituto Nazionale Tumori IRCCS Regina Elena, Roma, Italy
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Instituto Nazionale Tumori Regina Elena
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Instituto Nazionale Tumori IRCCS Regina Elena, Roma, Italy
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