Trials like the dostarlimab study in rectal cancer and NICHE in colon cancer show neoadjuvant immunotherapy can induce profound responses in MSI-high tumors. This is creating a new paradigm where major surgery might be avoided entirely for some patients, marking a significant shift in treatment strategy.

The success of immunotherapy in neoadjuvant and adjuvant settings has rendered the traditional, sequential referral model (dermatologist to surgeon to oncologist) obsolete. Optimal care now demands an integrated, team-based discussion among all specialists *before* the first treatment decision is made to determine the best sequence and timing.

While neoadjuvant pembrolizumab (KEYNOTE-689) is now standard of care for resectable head and neck cancer, it carries a critical risk. During the pre-surgical treatment window, some patients may experience disease progression or toxicity that makes them ineligible for their planned curative surgery.

The systemic process for referring SCLC patients from community clinics to academic centers for trials is too slow. The most effective solution is not a systems overhaul but for community physicians to build direct communication channels (text, email) with academic specialists to "make a spot" and bypass formal referral backlogs.

Despite strong data favoring pre-surgical systemic therapy, a surgeon argues that many patients will continue to undergo surgery first. This is due to real-world factors like surgeons being the point of diagnosis, urgent symptoms requiring rapid intervention, and patient preferences to have the tumor removed immediately.

Standard cancer surgery often removes lymph nodes—the factories producing immune cells. Administering immunotherapy *before* this destructive process is critical. It arms the immune system while it is still intact and capable of mounting a powerful, targeted response against the tumor.

With highly effective neoadjuvant therapies now available, the surgeon's role in muscle-invasive bladder cancer is evolving. They are moving from being the primary decider and treater to being a key manager of a 'perioperative bundle,' where their first goal is often to get patients to medical oncology for systemic treatment.

The physical separation of oncology specialists creates significant logistical hurdles to coordinated, multi-modal treatment. This discoordination can lead to suboptimal care, such as patients receiving neoadjuvant therapy without ever consulting a surgeon, highlighting a systemic flaw in care delivery.

Clinical trial data suggests immunotherapy's timing is crucial in early-stage TNBC. Given with chemotherapy before surgery (neoadjuvant), it improves outcomes. However, when given alone after surgery (adjuvant), the IMPASSION 030 trial showed no benefit and was halted for futility, indicating pre-surgical tumor priming is essential.