An antibody-drug conjugate is an engineered system: a targeting antibody, a linker, and a cytotoxic payload. Its toxicity is not the diffuse myelosuppressive picture clinicians associate with classical chemotherapy — it is frequently organ-specific, driven by payload class, linker stability, and off-target delivery.

Ocular surface toxicity, interstitial lung disease, and hepatic effects appear in ADC programs in patterns that a chemotherapy-shaped monitoring plan can under-weight or miss. The monitoring schedule, the specialist referrals built into the protocol, and the signals the safety team is told to watch for all have to be organ-aware and payload-aware from the start.

The governance implication is the same one that runs through all of advanced-therapy safety: the people defining and adjudicating these signals need to understand the modality at a clinical level. A generalist pharmacovigilance process, however diligent, is operating without the map the molecule requires.