Cancer Surgery After Immunotherapy: How Pre-Surgery Treatment Is Changing the Operation

What Is Neoadjuvant Immunotherapy?

Neoadjuvant simply means "before the main treatment." In this case, immunotherapy is given before surgery instead of after it.

Immunotherapy works differently from chemotherapy or radiation. Instead of directly attacking cancer cells, it trains the immune system to recognise and destroy them. When given before an operation, it can:

• Shrink the tumour, sometimes significantly
• Reduce the number of cancer cells circulating in the body
• Make the tumour easier to separate from nearby organs and blood vessels
• Lower the chances of the cancer returning after surgery

This approach is now being used in melanoma, lung cancer, bladder cancer, certain head and neck cancers, and select gastrointestinal tumours. Research is expanding into more cancer types every year.

Why Doctors Are Rethinking the Order of Treatment

Traditionally, surgery removed the visible tumour first, and chemotherapy or radiation followed to clean up any remaining cancer cells. The logic was simple: cut out the problem, then manage what's left.

But oncologists noticed something interesting. When immunotherapy was given before surgery, the immune system had a fully intact tumour to learn from — with all its markers and signals still present. This seems to trigger a stronger, more targeted immune response than when immunotherapy is given after the tumour is already removed.

In simple terms: the body gets a better "training sample" before the tumour is gone.

How Pre-Surgery Immunotherapy Changes the Operation Itself

This is where things get genuinely different for patients. The surgery that follows immunotherapy often looks nothing like the surgery that would have happened without it.

1. Smaller, More Precise Tumours

When immunotherapy shrinks a tumour before surgery, surgeons sometimes face a smaller, better-defined mass. This can mean:

• Less tissue needs to be removed
• Nearby organs and structures are easier to preserve
• Minimally invasive techniques, like laparoscopic or robotic surgery, become possible in cases that once required open surgery

2. Changed Surgical Planning

Surgeons can't simply plan an operation based on the original scan anymore. After a few cycles of immunotherapy, imaging is repeated to see how the tumour has responded. Surgical strategy is then adjusted based on:

• New tumour size and location
• Changes in blood supply to the area
• Whether the tumour has separated from nearby structures or become more fibrous

This means the operation is planned around the tumour's current state, not its original one.

3. Complete Pathological Response

In some patients, immunotherapy works so well that no active cancer cells are found in the tissue removed during surgery — a result doctors call a "complete pathological response." When this happens, long-term outcomes tend to be significantly better. It doesn't happen for everyone, but it's one of the most encouraging developments in modern oncology.

4. Tissue Changes Surgeons Must Account For

Immunotherapy can cause inflammation and scarring around the tumour site. While this is usually a sign the immune system is doing its job, it can also make tissue planes harder to dissect. Surgeons need specific training and experience to operate confidently on tissue that has been altered by immunotherapy.

Table: Surgery Before vs. After Immunotherapy

Who Is a Candidate for Pre-Surgery Immunotherapy?

Not every patient or every cancer type qualifies. The decision depends on several factors:

• Type and stage of cancer
• Tumour markers and genetic profile
• Overall health and organ function
• Whether the tumour is technically resectable to begin with

This is why a multidisciplinary approach matters so much. Medical oncologists, radiologists, pathologists, and surgeons need to work together to decide if this sequence makes sense for a specific patient. A qualified cancer specialist in Gurugram will usually order detailed imaging, biopsy analysis, and sometimes genomic testing before recommending this route.

What Patients Can Expect During the Process

Here's a general outline of what the journey typically looks like, though every case is individualised:

1. Diagnosis and staging – Full workup including scans and biopsy to confirm cancer type and extent.

2. Immunotherapy cycles – Usually administered over several weeks, with regular monitoring for side effects.

3. Response assessment – Repeat imaging to check how the tumour has responded.

4. Surgical planning – The surgical team reviews updated scans and decides on the best approach.

5. Surgery – Performed once the medical team agrees the timing and tumour status are optimal.

6. Recovery and follow-up – Includes wound healing, pathology review, and long-term surveillance.

Benefits Patients Are Seeing

• Higher chance of preserving organ function
• Reduced extent of surgery in many cases
• Lower recurrence rates in certain cancers
• Better long-term survival outcomes in select tumour types
• Opportunity to test how well the tumour responds to treatment before committing to a major operation

Things to Discuss With Your Doctor

Before starting neoadjuvant immunotherapy, it helps to ask specific questions:

• How will we know if the treatment is working?
• What happens if the tumour doesn't shrink or grows instead?
• How will surgery timing be decided?
• What side effects should I watch for during immunotherapy?
• Will this affect my recovery time after surgery?

Being informed reduces anxiety and helps patients feel like active participants in their own care rather than passive recipients of a treatment plan.

A Team-Based Approach Matters

This shift toward pre-surgical treatment isn't something one doctor manages alone. It requires close coordination between medical oncology, radiology, pathology, and surgical oncology. When these specialties communicate well, patients get a treatment plan that's built around their tumour's actual behaviour — not a one-size-fits-all protocol.

Dr. Vidur Garg works closely with multidisciplinary tumour boards to determine the right sequencing of treatment for each patient, ensuring that surgical decisions are based on the most current information available at every stage.

Final Thoughts

Cancer surgery is no longer a standalone event. It's increasingly becoming the final step in a coordinated, personalised treatment plan that starts with the immune system. Pre-surgery immunotherapy is helping many patients undergo smaller, more precise operations with better long-term outcomes.

If you've been told surgery is part of your treatment plan, it's worth asking your care team whether pre-surgical treatment could apply to your case. The right sequencing can make a meaningful difference in both the operation and your recovery.

Cancer Risk Assessment & Early Screening

Consult Dr. Vidur Garg — Surgical Oncologist in Gurugram

MCh (Surgical Oncology) | Consultant Surgical Oncologist
Narayana Superspeciality Hospital, Gurugram
Specialising in lung cancer, breast cancer, bladder cancer, GI cancer, and robotic & laparoscopic cancer surgery

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