David Carbone, MD, PhD: Let’s wrap up this discussion with Dr Gillaspie, pondering on what changes you foresee in the perioperative landscape going forward.

Erin A. Gillaspie, MD, MPH, FACS: I think [there are] a few things that I’m excited about. I do have to say that I hope our adjuvant regimens don’t get completely thrown away, and here’s why. There are patients who have occult N1 disease, occult N2, disease that we are discovering at the time of treatment. There’s still going to be a role for these patients that we’re identifying at the time of surgery, and it’s really important to continue exploring and honing in treatment regimens for that patient population. I think that’s really important. I think there is no doubt that there are tremendous advantages to the neoadjuvant regimens. To me, they are few-fold. One, we have a higher completion of therapy. The patients seem really committed to getting this sort of limited amount of therapy. I think there’s a huge advantage to that. To your point, Dr Carbone, we’re getting pre and post biopsies. We’re able to assess the pathologic response, able to assess the efficacy, which is extraordinary. I love that, and I’m hoping that, you know, I kind of bucket patients into my head based on pathology and a few different groups. You guys have to tell me what your thoughts are on this, but complete pathologic response, major pathologic response, that kind of little bit of response, and then the nonresponders. I think, ultimately, we’re going to have to think about those groups pretty differently and what we’re going to do for them in that adjuvant space.

I think that we do still see a decent amount of drop-off in completion of therapy afterward in the adjuvant space and so trying to figure out how to structure those regimens so that if we are doing periadjuvant, we’re not making it overwhelming to the patients or at a personal cost, financial cost, time away from family, all of those things we need to balance significantly. I can tell you, as a surgeon, I am so excited about all of these things. I know there’s a great deal of fear in some of the members of my specialty. You sort of hit the nail on the head when you said there’s a lot of people talking about, well, we’re now losing the opportunity to operate on these patients. My thoughts on that are probably those were not patients we should have been operating on anyways because they’re failing, and they’re failing in a systemic way. They were never going to do well.

David Carbone, MD, PhD: Patients aren’t failing. The treatment is failing the patient.

Erin A. Gillaspie, MD, MPH, FACS: Exactly. Exactly. We’re not using the therapies in the right way for these folks. To me, I don’t think that’s a miss. I think that we’re identifying patients who we need to go a different trajectory on.

David Carbone, MD, PhD: And we have a great option if they can’t get surgically resected.

Erin A. Gillaspie, MD, MPH, FACS: And I’ll tell you, one of the groups that I’ve been part of and papers that I’ve most interested to read are the patients who don’t go on to have surgery and what’s happening to them, because that’s an important discussion that I’m having up front with my patients. I say, okay, we’re going to meet back after you get this new adjuvant regimen. We’re going to decide then, are you going to go on to have surgery? And if not, where do we need to send you from there? And I think that’s a group that we really need to keep studying.

David Carbone, MD, PhD: It’s a real question as to whether…the current studies really took surgical patients, but should you take marginally resectable patients and try to make them surgically resectable? There’s talk about doing a trial like that, too. We have a lot of things to learn over the next few years.

Transcript is AI generated and reviewed by an AJMC editor.