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Jun 5, 2025, 12:06
Jonathan Spicer Shared Perspective on Neoadjuvant vs Perioperative Immunotherapy Strategies
Jonathan Spicer, Medical Director of the McGill Thoracic Oncology Program, shared a post on X:
“It seems we are in a bit of a data quagmire. I often get asked how to choose between neoadjuvant versus perioperative immunotherapy and right now there aren’t many great answers, but for what it’s worth, here’s my general perspective…
My reasons for favouring one or the other have little to do data because we are pretty essentially unable to differentiate robustly how outcomes are influenced by the adjuvant portion without a dedicated trial. Thus, the arguments are practical in nature…
The core concept is that we don’t know what will happen to our patients on day 0 when we start the plan:
#1 your patient may not complete a full course of neoadj chemoIO and therefore it is useful to have access to post op treatment.
#2 your patient may not get to surgery and there may be value to having access to consolidation IO after CRT.
#3 your patient may have an incomplete response or may have positive surgical margins and there may be value to having adjuvant IO in those contexts.
Thus, the arguments in favour of a periop regimen are founded in the increased flexibility that these approaches offer from an access and practical perspective.
HOWEVER, it seems increasingly clear that blanket use of periop could incur undue risk and financial toxicity both of which are problematic on an individual level and most certainly at a population level. Therefore, perioperative regimens require judicious use and careful discussions with patients as we work in a data free zone about how these prolonged treatments influence their life in a broad sense.
In conclusion, I favour giving doctors the flexibility to adjust to the unpredictable and complex nature of the treatment strategy as a whole.”
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