Benjamin P. Levy, MD: We’ll talk about neoadjuvant immunotherapy in the next segment, but how about neoadjuvant chemotherapy? Is that an option for patients? I mean, 4 cycles before surgery vs 4 cycles after surgery. Does it make a difference, Dr Naidoo?
Jarushka Naidoo, MBBCh: I trained at a very pro-neoadjuvant chemotherapy institution, so I feel I’ve been well schooled on these data. But my understanding is there are believers and nonbelievers when it comes to neoadjuvant approaches or neoadjuvant chemotherapy in the context of lung cancer.
The believers would say there are good data to suggest that for patients who get neoadjuvant chemotherapy, there is a 40% increased rate of completion of their chemotherapy based on the phase 3 NATCH study. This is opposed to those who receive chemotherapy in the adjuvant setting. Obviously, it’s an in vivo test of the response rate of the chemotherapy. It may potentially downstage patients to allow them to have a less morbid surgery. Of course, there’s the potential benefit of eradicating micrometastatic disease.
Those are the points by those who are in favor of a neoadjuvant approach. As an adjuvant approach, we recognize that surgery is a definitive part of this definitive paradigm. Neoadjuvant chemotherapy is delaying the time to the definitive part of things, potentially introducing toxicity early and potentially complicating the achievement of an uncomplicated surgery.
Then, of course, there are complications of interpreting a pathologic staging—ypT staging as opposed to a simple pT staging—if we use a neoadjuvant approach. There are pros and cons. As Dr Salgia mentioned, discussing both options with the patient is reasonable because there are pros and cons. It’s a tailored approach.
Benjamin P. Levy, MD: Dr Zhang, do you guys consider neoadjuvant chemotherapy at your institution?
Jun Zhang, MD, PhD: Again, this is a multidisciplinary discussion. If the tumor is very small, we prefer to go for surgery and adjuvant chemotherapy. But let’s say the patient has a relatively larger tumor. In that instance we prefer neoadjuvant chemotherapy in order to try to shrink the tumor, then we go to surgery.
Benjamin P. Levy, MD: Dr Leal, what is the University of Wisconsin experience with neoadjuvant vs adjuvant therapy outside a clinical trial?
Ticiana Leal, MD: Outside a clinical trial, we are preferentially an adjuvant chemotherapy institution.
Benjamin P. Levy, MD: OK. Dr Salgia, what is City of Hope’s experience with this?
Ravi Salgia, MD, PhD: We have 31 sites, and we have a large academic site in Duarte, California. We also have many clinical networks. We have become very standardized. In the appropriate setting, a neoadjuvant approach makes sense so your surgical resection is much more feasible and palatable. Otherwise, we consider adjuvant therapy.
Benjamin P. Levy, MD: This was nicely highlighted by all of us. There are pros and cons associated with each of these approaches. The meta-analysis with neoadjuvant chemotherapy has a hazard ratio identical to the meta-analysis of adjuvant chemotherapy. Both seem like reasonable options for patients, and both have their pros and cons.
Transcript Edited for Clarity