Whether a patient should receive systemic therapy before or after definitive surgical or radiation therapy is unclear because the survival benefit is only 5% to 10%, but, in certain cases, the physical and economic costs of therapy may far outweigh the benefit. The task at hand is to apply these data to the older NSCLC patient. For certain individuals with significant comorbid illnesses or limited life expectancy, disease-free survival and improved quality of life must be weighed against the possible treatment-related burden needed to realize the demonstrated survival benefit of (neo) adjuvant chemotherapy. For fit patients with resectable NSCLC and a life expectancy of greater than 2 years, such therapies should be considered even though elderly patients may suffer increased but tolerable toxicity from chemotherapy, radiation, and surgery. At present, neoadjuvant therapy might be prescribed for older patients who are deemed borderline for curative surgery, who would benefit from tumor downstaging, or who would be best served with definitive radiation if the neoadjuvant response was suboptimal. As these and other insights are clarified and supported by trial-based evidence, the physician may be better able to tailor therapies to improve treatment outcomes and limit toxicity among all patients and, in particular, older patients.