My talk is about is radiotherapy a back-up in the perioperative landscape. I think it’s a very provocative question – as radiation oncologists we have our more well-established indications, we are well-known in stage 3 lung cancer but then we also play a role in the early stage. We also, of course, do the chemoradiotherapy sequencing in small cell lung cancer and, of course, we have the ablative treatments in the metastatic setting.

So now with this changing landscape, with all these new adjuvant approaches coming in, we see a lot of breath of fresh, new air coming into this space. We are actually finding that we are seeing patients that maybe we didn’t see so much before. So it is a very valid question – what do we do with these patients that maybe they go through these new treatments and then what happens with them if things don’t go according to plan? What if they progress, what if they can’t undergo surgery? We very well know that not all patients that we see in the real world, in our everyday clinics, they really represent patients in the trials. So this is something that will come more and more and we will see more and more patients like this.

Then the other interesting question is could radiotherapy potentially replace, maybe, surgery in this setting? I think, as with many ideas in oncology, this probably should be given its own time to be tested. We have to incubate this idea; as with all new ideas there’s a certain hype and hype builds up and then we have some disappointments and then somehow we assess, we settle on a status quo. I can very well see that might also happen with radiation oncology, with radiotherapy, in this perioperative setting.

In the current treatment landscape, when should radiotherapy be considered after neoadjuvant chemo-immunotherapy?

The more classic indications are the ones that I mentioned before but we also have to mention that radiotherapy is also considered if, for example, we have some unfavourable risk factors. So, for example, positive margins or maybe the patient did not have a good response. So some of these indications could then be applied into this patient setting.

How do response patterns to chemo-immunotherapy influence the decision to use radiotherapy?

Here we also have to take a look at how lung cancer patients fail. So, for example, is it a local failure, regional, distant? So we saw this, the best example for this was that in the postoperative landscape although we could halve the risk of the  mediastinal relapses, there still wasn’t enough to counterbalance the distant failure rates. And we also gave some cardiopulmonary toxicity. So these things will still have to be taken into account.

How might future trials or biomarkers refine the role of radiotherapy in this treatment sequence?

The idea has to be put on the table that, as a treatment with radical intent, could radiotherapy replace surgery, yes or no? Maybe this could be investigated. As well, what if after these postoperative results we see that the patient might still require radiotherapy postoperatively?