Circulating tumor DNA (ctDNA) in early-stage NSCLC: a new frontier in precision oncology

Abstract

Recent advances in the management of early-stage non-small cell lung cancer (NSCLC), including perioperative immunotherapy and targeted treatments, have significantly improved outcomes. Nevertheless, a considerable proportion of patients relapse after curative-intent surgery, emphasizing the need for biomarkers that can more accurately define recurrence risk and guide individualized treatment. Circulating tumor DNA (ctDNA) has emerged as a promising, non-invasive biomarker for detecting minimal residual disease (MRD), assessing molecular response, and identifying relapse before clinical or radiologic evidence. Across retrospective and prospective studies, ctDNA detection at baseline or after treatment is consistently associated with inferior recurrence-free and overall survival, with postoperative positivity marking patients at the highest risk of relapse, often several months ahead of imaging findings. Evidence from recent pivotal trials further reinforces the prognostic significance of ctDNA dynamics in the perioperative setting. However, translation into clinical practice remains limited. ctDNA detection in early-stage disease is inherently challenging due to its low abundance and technical variability across assays. Moreover, no platform is yet validated or approved for MRD detection in this setting, and the predictive impact of ctDNA-guided treatment adaptation remains to be demonstrated. Ongoing efforts are focused on refining assay sensitivity, standardizing workflows, and conducting prospective interventional trials to establish ctDNA as a clinically actionable biomarker. This review provides an overview of current evidence, emerging technologies, and future directions toward clinical integration of ctDNA in resectable NSCLC.

Keywords

Non-small cell lung cancer / early-stage / circulating tumor DNA / minimal residual disease / liquid biopsy / perioperative management / prognostic biomarker / circulating tumor cells

References

[1] Forde PM,Lu S.Neoadjuvant nivolumab plus chemotherapy in resectable lung cancer.N Engl J Med.2022;386:1973-85

[2] Wakelee H,Kato T.Perioperative pembrolizumab for early-stage non-small-cell lung cancer.N Engl J Med.2023;389:491-503

[3] Heymach JV,Mitsudomi T.Perioperative durvalumab for resectable non-small-cell lung cancer.N Engl J Med.2023;389:1672-84

[4] Cascone T,Spicer JD.Perioperative nivolumab in resectable lung cancer.N Engl J Med.2024;390:1756-69

[5] Felip E,Zhou C.Adjuvant atezolizumab after adjuvant chemotherapy in resected stage IB-IIIA non-small-cell lung cancer (IMpower010): a randomised, multicentre, open-label, phase 3 trial.Lancet.2021;398:1344-57

[6] Wu YL,He J.Osimertinib in resected EGFR-mutated non-small-cell lung cancer.N Engl J Med.2020;383:1711-23

[7] Wu YL,Ahn JS.Alectinib in resected ALK-positive non-small-cell lung cancer.N Engl J Med.2024;390:1265-76

[8] Zer A,Barlesi F.Early and locally advanced non-small-cell lung cancer: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up.Ann Oncol.2025;36:1245-62

[9] National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology (NCCN Guidelines®). Non-Small Cell Lung Cancer. Version 5 2026. Available from: https://www.nccn.org/professionals/physician_gls/pdf/nscl.pdf [Last accessed on 23 Apr 2026]

[10] Goldstraw P,Crowley J.The IASLC lung cancer staging project: proposals for revision of the TNM stage groupings in the forthcoming (Eighth) edition of the TNM classification for lung cancer.J Thorac Oncol.2016;11:39-51

[11] Abbosh C,Harrison T.Tracking early lung cancer metastatic dissemination in TRACERx using ctDNA.Nature.2023;616:553-62 PMCID:PMC7614605

[12] Normanno N,Rachiglio AM.Circulating tumour DNA in early stage and locally advanced NSCLC: ready for clinical implementation?.Nat Rev Clin Oncol.2025;22:215-31

[13] Corcoran RB.Application of cell-free DNA analysis to cancer treatment.N Engl J Med.2018;379:1754-65

[14] Hendriks LE,Menis J.Oncogene-addicted metastatic non-small-cell lung cancer: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up.Ann Oncol.2023;34:339-57

[15] Rolfo C,Scagliotti GV.Liquid biopsy for advanced NSCLC: a consensus statement from the international association for the study of lung cancer.J Thorac Oncol.2021;16:1647-62

[16] Marinello A,Pagliaro A.Circulating tumor DNA to guide diagnosis and treatment of localized and locally advanced non-small cell lung cancer.Cancer Treat Rev.2024;129:102791

[17] Stejskal P,Srovnal J,van 't Veer LJ.Circulating tumor nucleic acids: biology, release mechanisms, and clinical relevance.Mol Cancer.2023;22:15 PMCID:PMC9862574

[18] Diaz LA Jr.Liquid biopsies: genotyping circulating tumor DNA.J Clin Oncol.2014;32:579-86 PMCID:PMC4820760

[19] Newman AM,To J.An ultrasensitive method for quantitating circulating tumor DNA with broad patient coverage.Nat Med.2014;20:548-54 PMCID:PMC4016134

[20] Bartolomucci A,Ferrier T.Circulating tumor DNA to monitor treatment response in solid tumors and advance precision oncology.NPJ Precis Oncol.2025;9:84 PMCID:PMC11930993

[21] Herbreteau G,Knol AC.Quantitative monitoring of circulating tumor DNA predicts response of cutaneous metastatic melanoma to anti-PD1 immunotherapy.Oncotarget.2018;9:25265-76 PMCID:PMC5982743

[22] Takayama Y,Muto Y.Monitoring circulating tumor DNA revealed dynamic changes in KRAS status in patients with metastatic colorectal cancer.Oncotarget.2018;9:24398-413 PMCID:PMC5966256

[23] Diehl F,Choti MA.Circulating mutant DNA to assess tumor dynamics.Nat Med.2008;14:985-90 PMCID:PMC2820391

[24] García-Foncillas J,Aranda E.Incorporating BEAMing technology as a liquid biopsy into clinical practice for the management of colorectal cancer patients: an expert taskforce review.Ann Oncol.2017;28:2943-9 PMCID:PMC5834030

[25] Corless BC,Cooper S.Development of novel mutation-specific droplet digital PCR assays detecting TERT promoter mutations in tumor and plasma samples.J Mol Diagn.2019;21:274-85 PMCID:PMC6419583

[26] Dong L,Fu B.Evaluation of droplet digital PCR and next generation sequencing for characterizing DNA reference material for KRAS mutation detection.Sci Rep.2018;8:9650 PMCID:PMC6269532

[27] Vessies DCL,van Rooijen KL.Performance of four platforms for KRAS mutation detection in plasma cell-free DNA: ddPCR, Idylla, COBAS z480 and BEAMing.Sci Rep.2020;10:8122 PMCID:PMC7229219

[28] Forshew T,Parkinson C.Noninvasive identification and monitoring of cancer mutations by targeted deep sequencing of plasma DNA.Sci Transl Med.2012;4:136ra68

[29] Kinde I,Papadopoulos N,Vogelstein B.Detection and quantification of rare mutations with massively parallel sequencing.Proc Natl Acad Sci USA.2011;108:9530-5 PMCID:PMC3111315

[30] Newman AM,Klass DM.Integrated digital error suppression for improved detection of circulating tumor DNA.Nat Biotechnol.2016;34:547-55 PMCID:PMC4907374

[31] Kurtz DM,Co Ting Keh L.Enhanced detection of minimal residual disease by targeted sequencing of phased variants in circulating tumor DNA.Nat Biotechnol.2021;39:1537-47 PMCID:PMC8678141

[32] Zviran A,Shah M.Genome-wide cell-free DNA mutational integration enables ultra-sensitive cancer monitoring.Nat Med.2020;26:1114-24 PMCID:PMC8108131

[33] Martín-Arana J,Henriksen TV.Whole-exome tumor-agnostic ctDNA analysis enhances minimal residual disease detection and reveals relapse mechanisms in localized colon cancer.Nat Cancer.2025;6:1000-16 PMCID:PMC12202492

[34] Abbosh C,Wilson GA.Phylogenetic ctDNA analysis depicts early-stage lung cancer evolution.Nature.2017;545:446-51

[35] Forde PM,Provencio M.Overall survival with neoadjuvant nivolumab plus chemotherapy in lung cancer.N Engl J Med.2025;393:741-52

[36] Reck M,Zhu Z.Association of post-surgical MRD status with neoadjuvant ctDNA dynamics, genomic mutations, and clinical outcomes in patients with resectable NSCLC (R-NSCLC) from the phase 3 AEGEAN trial.J Clin Oncol.2025;43:8009

[37] Herbst RS,Grohé C.Molecular residual disease analysis of adjuvant osimertinib in resected EGFR-mutated stage IB-IIIA non-small-cell lung cancer.Nat Med.2025;31:1958-68 PMCID:PMC12176615

[38] Wakelee H,Felip E.1211P IMpower010: ctDNA status and 5y DFS follow up in patients (pts) with resected NSCLC who received adjuvant chemotherapy (chemo) followed by atezolizumab (atezo) or best supportive care (BSC).Ann Oncol.2024;35:S779-80

[39] Black JRM,Abbott CW.Ultrasensitive ctDNA detection for preoperative disease stratification in early-stage lung adenocarcinoma.Nat Med.2025;31:70-6

[40] Coombes RC,Salari R.Personalized detection of circulating tumor DNA antedates breast cancer metastatic recurrence.Clin Cancer Res.2019;25:4255-63

[41] Heider K,Ruiz-valdepenas A.Abstract 735: sensitive detection of ctDNA in early stage non-small cell lung cancer patients with a personalized sequencing assay.Cancer Res.2020;80:735

[42] Provencio M,Nadal E.Overall survival and biomarker analysis of neoadjuvant nivolumab plus chemotherapy in operable stage IIIA non-small-cell lung cancer (NADIM phase II trial).J Clin Oncol.2022;40:2924-33

[43] Provencio M,González-Larriba JL.Perioperative nivolumab and chemotherapy in stage III non-small-cell lung cancer.N Engl J Med.2023;389:504-13

[44] Andrikou K,Verlicchi A.Circulating tumour cells: detection and application in advanced non-small cell lung cancer.Int J Mol Sci.2023;24:16085 PMCID:PMC10671094

[45] Ward MP,A Norris L.Platelets, immune cells and the coagulation cascade; friend or foe of the circulating tumour cell?.Mol Cancer.2021;20:59 PMCID:PMC8011144

[46] Moose DL,Kim TH.Cancer cells resist mechanical destruction in circulation via RhoA/actomyosin-dependent mechano-adaptation.Cell Rep.2020;30:3864-74.e6 PMCID:PMC7219793

[47] Koltai T.Anoikis: To die or not to die?.Int J Mol Sci.2026;27:579

[48] Tsering T,Wu T,Burnier JV.Extracellular vesicle-associated DNA: ten years since its discovery in human blood.Cell Death Dis.2024;15:668 PMCID:PMC11393322

[49] Alix-Panabières C.From discovery to diagnosis: a perspective for circulating tumor cells in personalized oncology.Cancer Discov.2025;15:1985-2001

[50] Nasr MM.How circulating tumor cluster biology contributes to the metastatic cascade: from invasion to dissemination and dormancy.Cancer Metastasis Rev.2023;42:1133-46 PMCID:PMC10713810

[51] Chaudhuri AA,Lovejoy AF.Early detection of molecular residual disease in localized lung cancer by circulating tumor DNA profiling.Cancer Discov.2017;7:1394-403

[52] Peng M,Yin W.Circulating tumor DNA as a prognostic biomarker in localized non-small cell lung cancer.Front Oncol.2020;10:561598 PMCID:PMC7523087

[53] Li N,Li J.Perioperative circulating tumor DNA as a potential prognostic marker for operable stage I to IIIA non-small cell lung cancer.Cancer.2022;128:708-18

[54] Xia L,Kang R.Perioperative ctDNA-based molecular residual disease detection for non-small cell lung cancer: a prospective multicenter cohort study (LUNGCA-1).Clin Cancer Res.2022;28:3308-17

[55] Qiu B,Zhang F.Dynamic recurrence risk and adjuvant chemotherapy benefit prediction by ctDNA in resected NSCLC.Nat Commun.2021;12:6770 PMCID:PMC8605017

[56] Kuang PP,Liu Z.Circulating Tumor DNA Analyses as a potential marker of recurrence and effectiveness of adjuvant chemotherapy for resected non-small-cell lung cancer.Front Oncol.2020;10:595650 PMCID:PMC7919598

[57] Waldeck S,Wiesemann S.Early assessment of circulating tumor DNA after curative-intent resection predicts tumor recurrence in early-stage and locally advanced non-small-cell lung cancer.Mol Oncol.2022;16:527-37 PMCID:PMC8763652

[58] Gale D,Ruiz-Valdepenas A.Residual ctDNA after treatment predicts early relapse in patients with early-stage non-small cell lung cancer.Ann Oncol.2022;33:500-10 PMCID:PMC9067454

[59] Wang S,Zhang J.Circulating tumor DNA integrating tissue clonality detects minimal residual disease in resectable non-small-cell lung cancer.J Hematol Oncol.2022;15:137

[60] Chen K,Shen H.Individualized tumor-informed circulating tumor DNA analysis for postoperative monitoring of non-small cell lung cancer.Cancer Cell.2023;41:1749-62.e6

[61] Jung HA,Kim YJ.Longitudinal monitoring of circulating tumor DNA from plasma in patients with curative resected stages I to IIIA EGFR-mutant non-small cell lung cancer.J Thorac Oncol.2023;18:1199-208

[62] Tran HT,Sujit S.Circulating tumor DNA and radiological tumor volume identify patients at risk for relapse with resected, early-stage non-small-cell lung cancer.Ann Oncol.2024;35:183-9 PMCID:PMC11233158

[63] Tan AC,Saw SPL.Detection of circulating tumor DNA with ultradeep sequencing of plasma cell-free DNA for monitoring minimal residual disease and early detection of recurrence in early-stage lung cancer.Cancer.2024;130:1758-65

[64] Ohara S,Sudhaman S.Clinical significance of perioperative minimal residual disease detected by circulating tumor DNA in patients with lung cancer with a long follow-up data: an exploratory study.JTO Clin Res Rep.2025;6:100762 PMCID:PMC11847260

[65] Martin TK,Sudhaman S.Early real-world experience monitoring circulating tumor DNA in resected early-stage non-small cell lung cancer.J Thorac Cardiovasc Surg.2024;168:1349-59.e2

[66] Oh Y,Lee J.Personalized, tumor-informed, circulating tumor DNA assay for detecting minimal residual disease in non-small cell lung cancer patients receiving curative treatments.Thorac Cancer.2024;15:1095-102 PMCID:PMC11062881

[67] Schuurbiers MMF,Hartemink KJ.Recurrence prediction using circulating tumor DNA in patients with early-stage non-small cell lung cancer after treatment with curative intent: a retrospective validation study.PLoS Med.2025;22:e1004574 PMCID:PMC12021277

[68] Zhang JT,Gao X.Follow-up analysis enhances understanding of molecular residual disease in localized non-small cell lung cancer.Clin Cancer Res.2025;31:1305-14

[69] Giobbie-Hurder A,Regan MM.Challenges of guarantee-time bias.J Clin Oncol.2013;31:2963-9

[70] Zhang JT,Gao W.Longitudinal undetectable molecular residual disease defines potentially cured population in localized non-small cell lung cancer.Cancer Discov.2022;12:1690-701

[71] der Leest P, Schuuring E. Critical factors in the analytical work flow of circulating tumor DNA-based molecular profiling.Clin Chem.2024;70:220-33

[72] Cascone T,Spicer J.Perioperative nivolumab (NIVO) vs placebo (PBO) in patients (pts) with resectable NSCLC: updated survival and biomarker analyses from CheckMate 77T.J Clin Oncol.2025;43:LBA8010

[73] Felip E,Reck M.1O IMpower010: ctDNA status in patients (pts) with resected NSCLC who received adjuvant chemotherapy (chemo) followed by atezolizumab (atezo) or best supportive care (BSC).Immuno Oncol Technol.2022;16:100106

[74] Provencio M,Insa A.Neoadjuvant chemotherapy and nivolumab in resectable non-small-cell lung cancer (NADIM): an open-label, multicentre, single-arm, phase 2 trial.Lancet Oncol.2020;21:1413-22

[75] Provencio M,Insa A.Perioperative chemotherapy and nivolumab in non-small-cell lung cancer (NADIM): 5-year clinical outcomes from a multicentre, single-arm, phase 2 trial.Lancet Oncol.2024;25:1453-64

[76] Reck M,Zhu Z.LBA49 associations of ctDNA clearance (CL) during neoadjuvant Tx with pathological response and event-free survival (EFS) in pts with resectable NSCLC (R-NSCLC): expanded analyses from AEGEAN.Ann Oncol.2024;35:S1239

[77] Goss G,Westeel V.LBA68 CCTG BR.31: Adjuvant durvalumab (D) in resected non-small-cell lung cancer (NSCLC): Final overall survival (OS) and minimal residual disease (MRD) analyses.Ann Oncol.2025;36:S1609

[78] Liu C,Yue D.PT1.07.03 adjuvant osimertinib in IB-IIIB NSCLC with uncommon EGFR mutations (admin): mutation profile and ctDNA dynamics.J Thorac Oncol.2025;20:S601

[79] He J,Weder W.Neoadjuvant osimertinib for resectable EGFR-mutated non-small cell lung cancer.J Clin Oncol.2025;43:2875-87

[80] Blakely C,Lee S.OA02.02 molecular residual disease (MRD) analysis from NeoADAURA: neoadjuvant osimertinib ± chemotherapy in resectable EGFRm NSCLC.J Thorac Oncol.2025;20:S12-3

[81] Blakely CM,Gubens MA.Neoadjuvant osimertinib for the treatment of stage I-IIIA epidermal growth factor receptor-mutated non-small cell lung cancer: a phase II multicenter study.J Clin Oncol.2024;42:3105-14

[82] Brown T,Mulvey C.P1.07.40 detection of ctDNA prior to neoadjuvant osimertinib treatment correlates with decreased EFS in EGFR-mutated NSCLC.J Thorac Oncol.2025;20:S153-4

[83] Lee JB,Shim HS.Neoadjuvant and adjuvant osimertinib in stage IA to IIIA, EGFR-mutant NSCLC (NORA).J Thorac Oncol.2025;20:641-50

[84] Pignon JP,Scagliotti GV.Lung adjuvant cisplatin evaluation: a pooled analysis by the LACE collaborative group.J Clin Oncol.2008;26:3552-9

[85] Felip E,Zhou C.Overall survival with adjuvant atezolizumab after chemotherapy in resected stage II-IIIA non-small-cell lung cancer (IMpower010): a randomised, multicentre, open-label, phase III trial.Ann Oncol.2023;34:907-19

[86] Moding EJ,Alizadeh AA.Detecting liquid remnants of solid tumors: circulating tumor DNA minimal residual disease.Cancer Discov.2021;11:2968-86 PMCID:PMC8976700

[87] Liu MC,Klein EA,Seiden MV.Sensitive and specific multi-cancer detection and localization using methylation signatures in cell-free DNA.Ann Oncol.2020;31:745-59 PMCID:PMC8274402

[88] Cristiano S,Phallen J.Genome-wide cell-free DNA fragmentation in patients with cancer.Nature.2019;570:385-9

[89] Tsui WHA,Lo YMD.Cell-free DNA fragmentomics in cancer.Cancer Cell.2025;43:1792-814

[90] Larson MH,Kim HJ.A comprehensive characterization of the cell-free transcriptome reveals tissue- and subtype-specific biomarkers for cancer detection.Nat Commun.2021;12:2357 PMCID:PMC8060291

[91] Nesselbush MC,Jeon YJ.An ultrasensitive method for detection of cell-free RNA.Nature.2025;641:759-68

[92] Cohen JD,Wang Y.Detection and localization of surgically resectable cancers with a multi-analyte blood test.Science.2018;359:926-30

[93] Henriksen TV,Christensen E.The effect of surgical trauma on circulating free DNA levels in cancer patients-implications for studies of circulating tumor DNA.Mol Oncol.2020;14:1670-9 PMCID:PMC7400779

[94] Wang X,Kong L.Advances in circulating tumor cells for early detection, prognosis and metastasis reduction in lung cancer.Front Oncol.2024;14:1411731 PMCID:PMC11224453