Due to major advances in the field of radiation oncology, patients with lung cancer (LC) can now receive technically individualised radiotherapy treatments. However, in the era of precision oncology, radiotherapy-based treatment selection needs to be improved as many patients do not benefit or are not offered optimum therapies. Cost-effective robust biomarkers can address this knowledge gap and lead to individuals being offered more bespoke treatments leading to improved outcome. This narrative review discusses some of the current achievements and challenges in the realisation of personalised radiotherapy delivery in patients with LC.

There is an unmet need in patient monitoring between the end of radiotherapy and the first follow-up appointment during which patients may experience severe side effects. Personalised follow-up has the potential to tailor healthcare to individual needs. ePROMs enable remote monitoring and identification of those needing earlier intervention. To assess the feasibility of integrating ePROMs into personalised follow-up of patients after radiotherapy. Patients with lung or head and neck (HN) cancer were enrolled. ePROMs questionnaires, comprising EQ-5D-5L and 14 lung or 19 HN cancer-specific questions adapted from CTCAE v5.0, were sent to patients at eight timepoints: pre-radiotherapy, mid-radiotherapy, end of radiotherapy, weekly for four weeks post-treatment, and first face-to-face follow-up appointment. Upon completion, automated advice was provided based on responses. Grade 2 or above symptoms were escalated to clinicians. Patient feedback was obtained through structured interviews. Over two months, 19 eligible patients (10 lung, 9 HN) were recruited: 13 received concurrent chemoradiotherapy, and six received radiotherapy alone. ePROMs completion rate was 69.1%, ranging from 47.4% to 89.5% at each timepoint. Three patients reported grade 3 or above symptoms on 5 instances during and after radiotherapy. Fourteen patients participated in the interviews: all 14 reported ePROMs were easy to complete, took an acceptable amount of time, and made them feel better supported. Integrating ePROMs into personalised follow-up is feasible and acceptable to patients. ePROMs provide insights into patients’ symptoms during and after radiotherapy, highlighting the need for a tailored approach.

Introduction: Current treatments for patients with stage III non-small-cell lung cancer (NSCLC) are not sufficiently personalized, resulting in suboptimal outcomes and high mortality rates. The Developing Circulating and Imaging Biomarkers Towards Personalized Radiotherapy in Lung Cancer (VIGILANCE) study employs innovative health technologies to collect a range of clinical data and features. This includes longitudinal analyses of cell-free and circulating tumor DNA from blood samples and radiomic features extracted from standard-of-care imaging. Additionally, patient-reported outcome measures will be collected to capture patients’ symptoms and quality of life. This will provide invaluable insight into the patient experience during and after radiotherapy. We aim to evaluate whether the data, including patient-reported outcomes, can serve as biomarkers to refine treatment strategies, improve post-treatment follow-up and provide patients with realistic outcome predictions. Key endpoints include the following: (1) assessing whether baseline ctDNA status and its early on-treatment dynamics can identify patients with radioresistant disease who could benefit from treatment intensification; (2) determining whether post-radiotherapy ctDNA clearance can predict benefit from consolidation durvalumab, potentially sparing ctDNA-negative patients from unnecessary immunotherapy; and (3) developing integrated models combining novel ctDNA and radiomic biomarkers to distinguish between radiation fibrosis and tumor recurrence and to predict survival. We adopt a pragmatic approach by recruiting patients receiving standard-of-care treatments in a real-world setting. In addition, most of the clinical data is already routinely collected in our center, except for the blood tests for cell-free and circulating tumor DNA analysis. Methods and analysis: This is a single-center, prospective, exploratory, longitudinal, follow-up study, recruiting patients with stage III NSCLC undergoing standard-of-care curative-intent radiotherapy (with or without systemic therapy). Data collection spans from baseline to during radiotherapy and is extended up to 1 year following radiotherapy. The longitudinal analysis aims to describe and characterize dynamic changes in the collected features and assess their utility as prognostic and response biomarkers. Trial registration number: NCT06086574.

The management of stage III non-small cell lung cancer (NSCLC) has become increasingly complex, driven by advances in neoadjuvant and perioperative chemo-immunotherapy as well as targeted therapies. These evolving treatment paradigms have introduced new challenges for multidisciplinary teams (MDTs), regarding patient selection, treatment sequencing, surgical planning and definitions of operability and resectability. We present a case of a 69-year-old male with cT3N2aM0 (single-station N2) adenocarcinoma NSCLC with a programmed death-ligand 1 (PD-L1) tumour proportion score of 100%. Following discussion in MDT, he received 3 cycles of neoadjuvant carboplatin, paclitaxel, and nivolumab. The initial surgical plan was for a pneumonectomy due to tumour proximity to the right main bronchus, a procedure associated with perioperative risk and long-term functional compromise. Restaging computed tomography (CT) scan demonstrated a partial response, with a 60% reduction in axial tumour dimensions. This downstaging facilitated a change in surgical plan from pneumonectomy to the less extensive right upper lobectomy, resulting in a pathological complete response (ypT0ypN0). The case was discussed during an academic webinar in August 2025. Expert faculty from respiratory medicine, thoracic surgery and medical and radiation/clinical oncology highlighted key discussion points and challenges. This included: 1) evolving definitions of operability and resectability, 2) perioperative systemic therapy selection, 3) the risk of not proceeding to surgery, and 4) the role of postoperative radiotherapy (PORT) and salvage therapy in case of progression. The case underscores current controversies in the management of stage III NSCLC and the critical role of the MDT. While neoadjuvant and perioperative chemo-immunotherapy offers an opportunity for less extensive surgical resection and improved oncological outcomes, this strategy is not without risks and validated biomarkers to guide decision making are lacking. Concurrent chemoradiotherapy (cCRT) followed by durvalumab remains the standard for fit patients with unresectable or inoperable stage III disease. Future progress depends on clinical trials, biomarker development, and real-world data collection and national audits.