Questions discussed in this category
One particular circumstance involved detecting a ROS1 fusion upon the metastatic recurrence. Is this pneumonitis risk seen with osimertinib alon...
With low #s of patients on the durvalumab PACIFIC trial with EGFR mutated disease, and LAURA trial design of osimertinib until progression, should we ...
Would your approach change based off of the PDL1 level?
Is there objective evidence demonstrating a benefit of consolidative durvalumab or prophylactic cranial irradiation in patients with stage I small cel...
These mutations were not eligible in the LAURA trial. Afatinib has a more durable PFS than osimertinib in these patients. How would you choose be...
Would you consider nivolumab/ipilimumab?
USPTF and CMS guidelines differ in age criteria, and NCCN guidelines do not have an upper age limit.
Would you recommend concurrent chemoradiation or targeted therapy with lorlatinib?
Would you offer chemotherapy after radiation is completed?
Al-Ibraheem et al., PMID 33731050
Have you encountered changes in prolactin, testosterone, etc?
NCCN states that all operable NSCLC patients should be evaluated for pre-op therapy with strong consideration of nivolumab + chemotherapy for those wi...
Some consider T4N3 Stage IIIC to be a borderline case. None of these patients were included in either PACIFIC or KEYNOTE-024 for example. Would y...
Would the recurrence while already on the checkpoint inhibitor sway you from offering durvalumab?
Would you consider it for a patient who had bulky thoracic disease, with limited extrathoracic disease at diagnosis and achieved a CR after induction ...
Do you perform NGS on all specimens? If so, how much do you rely on that alone to determine clonality?
Would you consider omitting local therapy?
What clinical factors do you take into consideration?
Would you recommend chemo-immunotherapy regimens for a fit patient who relapses at 6 mos post-t...
Per NCCN exclusion of EGFR/ALK alterations at a minimum is recommended prior to consideration of neoadjuvant chemoimmunotherapy.
How does the changing landscape of first-line treatment impact your decision making for second line therapy?
A female in her 60s who has been on afatinib for 6 years. Has been NED on CT, PET, and MRI for > 5 years. Had isolated T-spine mets (radiated) and ...
Do you increase the dosage of the TKI or switch to a different generation TKI? How does your answer differ for EGFR vs. ALK, and for discrete brain me...
And would your answer be different if you had used pre-op nivolumab (CM-816)?
Given that LU002 has failed to meet its progression free survival benefit in results presented at ASCO, will you offer consolidative radiotherapy for ...
How do you decide between entrectinib or crizotinib? Since no head-to-head comparison, can real-world datasets (such as Doebele et al., Journal of Cli...
If so, when and to what extent?
I've seen a handful of fatal radiation pneumonitis associated with rapid steroid tapers by the non-treating physicians. How do you recommend prescribi...
Can you explain the expansion cohorts into larger trials and the current amendments to the the protocol?
Are there specific patient factors for which you would more preferentially use this regimen?
Do you consider dose escalating to 160 mg or do you add chemotherapy to osimertinib?
Should we switch to a new TKI?
If CCRT is pursued, would you move forward with durvalumab consolidation? Assume the patient with ECOG PS 0 and no co-morbidities. How might this chan...
Would you offer consolidative brain SRS, SRS + consolidative RT to the primary (e.g. lung), consolidative RT to the primary alone?
Does the site of treatment factor into your decision?
If so, would you recommend adjuvant chemotherapy and PCI after?
Does the type of autoimmune disease (ex IBD, rheumatoid arthritis, interstitial lung disease) matter?
Does reducing the rate of infusion, or adding Montelukast reduce chances of future reactions?
For instance, do you factor availability of RNAseq, inclusion of normal blood controls, and QNS rates into your decision?
If so, what would be your approach to radiation? Could SBRT be an option?
Does tumor size, age, or performance status play a role in your decision-making?
As SCLC in never smokers is extremely rare, do you consider NGS testing, or do you modify treatment in any way?
Is this acute or long-term, and does it matter whether this is SBRT vs fractionated?
Is there any role for immunotherapy?
The left breast cancer is an ER-negative, PR-negative, HER2-negative cT2N0 invasive ductal carcinoma, while the left lung primary is a cT2N1 squamous ...
This has become standard practice at our institution for patients with a good performance status, with whole brain radiotherapy given after the comple...
How would you integrate RT with molecular agents?
How do you decide when to “pull the trigger” in these cases where the growth trajectory is slow?
Is there any role for targeted therapy, or would you consider consolidation durvalumab for these patients?
Patient already on methotrexate and plaquenil.
Based on subgroup analysis, do you have a preference for cisplatin over carboplatin?
Is this an artifact of what agent prior clinical trials used or something to do with the mechanism of action (i.e., less mineralocorticoid effect of d...
Do you ever consider bridging with chemotherapy, and if so for how long?
Please specify how your institution is allocating resources now or will be soon.
IMPower110 data add further support to use of checkpoint monotherapy; however guidelines continue to support either I/O monotherapy vs chemo-immunothe...
Assuming the patient had no contraindications to immunotherapy and no other significant comorbidities.
Is there a minimum standard for which stations to sample? Does lymph node size affect your recommendations?
I.e. based on the findings of ADAURA in surgically managed patients.
Lately I have seen patients with a concurrent gynecologic (requiring chemoRT), head and neck (requiring surgery), and early stage NSCLC (requiring SBR...
Are there scenarios in which you would proceed with checkpoint inhibitor for PDL1+ disease before having full molecular testing results?
How do you decide between starting infliximab, MMF, or IVIG? If a patient presents in respiratory failure (nearing or requiring intubation), woul...
This would “combine” approaches from both CheckMate 816 and IMpower010.
Do you consider any neoadjuvant therapy or proceed to surgery followed by adjuvant chemotherapy and osimertinib? Does the type of mutation (ex a rare ...
What specific platforms do you use, individual biomarker/PD-L1 status vs NGS, tissue vs liquid or both?
Must you wait for PD-L1 testing if mutation t...
Or would you conduct tissue or blood testing if no actionable results are found?
Ex. TP53, BRCA, T790M, or another? As of now, T790M mutation is one of the few de novo mutations found in treatment naïve patients that have been...
Would you recommend standard definitive chemoradiation followed by adjuvant durvalumab? Would you treat pre- or post-systemic therapy volumes?
Are patients with long standing malignant central airway obstruction poor candidates for central airway stents? What is considered to be an acceptable...
Given the substantial risks associated with transporting an intubated and ventilated patient to Radiation Oncology, is there any evidence to support t...
Does PET avidity factor in your decision?
And, for additional information, what are the differences in 5 year survival and disease specific survival for stage I NSCCA between lobectomy vs SBRT...
If so, how often do you check these labs?
Does your management change if symptomatic or asymptomatic?
In light of CheckMate 816 and IMpower010 and FDA approval for neoadjuvant chemo-nivolumab and adjuvant chemo-atezolizumab, how do you decide which sys...
NGS without any actionable mutations and PD-L1 TPS 15%.
Would you offer chemotherapy, radiation, or immunotherapy and, if so, in what order?
Are there specific clinical factors, efficacy, or treatment tolerability issues that lead you to favor one agent over another?
How do you compare or ...
Based on results of the recently published study.
Traditionally these patients may have received chemotherapy prior to chemoRT.
Would you offer adjuvant atezolizumab, osimertinib, or neither? Both IMpower010 and ADAURA only had patients with EGFR exon 19 deletion or L858R mutat...
Do the results of the unplanned subset analysis of the PACIFIC trial showing no OS benefit in this population lean you away from consolidation?
How reliable is somatic testing to detect an underlying germline predisposition?
Is skin testing advised prior to trialing alternative?
Do you routinely offer post-operative adjuvant radiation in addition to chemotherapy? Are the results of the recently published negative phase II...
What factors do you use to decide between weekly low-dose carboplatin and paclitaxel combination vs cisplatin based doublet, and do you routinelt...
Would you still use ram/doce in 3rd or later lines after ram/pembro?
Did S1800a stratify by prior treatment response? Would you choose different 2L treatment for a patient who progresses rapidlly on pembro + platinum do...
How do you counsel patients on the available second line options?
Is there anything to differentiate the two agents? CNS penetration reportedly with adagrasib, FDA accelerated approval has been given with sotorasib.&...
What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical practice?
I recently saw a patient who had been treated with concurrent pembrolizumab-RT elsewhere. Is this an acceptable practice outside the setting of a clin...
How do you operationalize finding biomarker information in EHRs/testing portals, either for your own patients or if they have changed providers?
If a...
Is there evidence or experience to support use of targeted therapy for KRAS G12C mutated NSCLC as first line in place of chemotherapy?
Do you use specific PDL-1 assays for each approach?
Are there data for using checkpoint inhibitors in this setting?
Would you attempt targeted therapy or would you choose chemo-immunotherapy?
Would the timing of the relapse (eg within 6 months) impact your decision making?
How are your teams effectively evaluating and counseling patients to ensure they are prepared for potential extended adjuvant treatment approaches? Is...
How would you approach treatment of a patient with metastatic NSCLC with PD-L1>1% and HER2-mutation?
Does this change for PDL1 1-49% vs >50%? Will you be more likely to employ other checkpoint inhibitors before use of HER2 targeting therapy? Or sta...
Patient has been on pembrolizumab and had two symptomatic soft tissue mass treated with radiation.
E.g. One NSCLC with N2 disease, and additional ipsilateral small nodule that is a biopsy-proven second primary. When do you consider SBRT to a nodule ...
Can atezo be used even if patient has completed chemotherapy preoperatively?
If a patient is asymptomatic at presentation, how do you incorporate local treatment options (RT/surgery) and when?
Does the 2020 approval of Nivolumab and Ipilimumab for mNSCLC with PDL1 >1% impact your decision?
Do you consider size > 2cm, visceral pleural invasion or vascular invasion as indications for cisplatin-based chemotherapy?
For medical oncologists, would you offer a PD-1/L1 inhibitor? For other subspecialties, how would you counsel the oncologist regarding the risk of usi...
Would you consider the immune suppressed status of the patient as a high risk factor to offer adjuvant therapy?
Will degree of PD-L1 status impact your decision?
Would you ever offer to stage IB patients as per study enrollment? Do AJCC v8 staging guideli...
Would you consider second line nivo-ipi for patients with a specific histology or tumor PD-L1 expression?
Is there a certain time interval where you would feel comfortable to rechallenge with immunotherapy at recurrence (6m vs 1y vs 2y?) Does degree of PDL...
Are the experts convinced by DFS when the OS is immature?
How many in BSC arm went on to receive immunotherapy and was that adequate?
What would you do for a patient with a non-EGFR actionable mutation?IMpower010 included EGFR and ALK mutated NSCLC. Is there any concern in the use of...
In elderly patients (>70-75) with a good performance status, does the risk of neurocognitive decline outweigh the benefit of PCI?
Do you initially start with systemic therapy alone or do you proceed directly to chemo-radiation?
Would you stop all treatment after 4 cycles, or proceed with pembrolizumab alone, and would PD-L1 expression factor into your decision?
How and when do you plan to perform HER2 testing in patients with NSCLC?
What would be the treatment duration if using oral TKI?
How does trastuzumab deruxtecan compare to other HER2 targeted strategies?
How are you thinking about sequencing therapies for these patients (IO vs chemo vs T-Dxd)? Are the data from DESTINY-Lung01 strong enough to warrant e...
Can patients be re-challenged after developing ILD? Is the toxicity seen with T-Dxd a potential barrier to use?
Do you feel the dosing used in...
What is your general rationale for selecting from available options?
If yes, do you recommend it be given concurrently with chemotherapy or sequentially? What is your target volume and dose?
Would you offer topotecan, lurbinectedin, or another agent given the CNS progression as well?
How do you interpret the comparative efficacy in squamous cell subsets among the CM vs KN vs EMPOWER studies?
Do you choose Lorlatinib or brigatinib? Or do you try to add chemotherapy to alectinib?
E.g. disease burden causing airway or vascular compression.
Given that prophylactic cranial irradiation (PCI) has been shown to decrease the incidence of symptomatic brain metastases in patients with extensive ...
Would you prioritize the head and neck cancer or treat the lung cancer first with SBRT to take care of it first? How about if there is mediastinal inv...
Can the ipsilateral supraclavicular field and bilateral hilar nodes still be limited stage?
How do you balance the risk of an EGFR flare while holding osimertinib vs the risk of pneumonitis when continuing?
Are two negative pleurocentesis' adequate to conclude that the patient does not have metastatic disease? Do you routinely recommend VATS and pleural b...
Patient is <60 years old
Would there be any benefit to surgery in a healthy/good PS patient? There is so little data on pulmonary atypical carcinoid and radiation respons...
E.g. for a 7cm central NSCLC, would you offer 8 fx SBRT or ChemoRT? Patient is not a surgical candidate.
One example of this scenario would be a patient receiving consolidative durvalumab after chemoRT for stage III NSCLC who develops a new peripheral lun...
Can adjuvant durvalumab or other I/O or osimertinib (if EGFR+) be considered?
Although a small subset, do you generally move these patients directly on to chemotherapy +/- immunotherapy or does it depend on the specific mutation...
Patient has been treated with carbo/etop/atezo, WBRT, and maintenance atezo. Currently on high-dose steroids. Would you consider hospice or trial chem...
If starting with entrectinib would you still try crizotinib, or move to lorlatinib or another novel TKI? Or change entirely to chemotherapy, immunothe...
Is there any role of radiation therapy for these patient for symptomatic relief?
Would you consider afatinib? Afatinib has shown some activity in NRG1 fusion + patients but amplifications is unclear.
Is your decision swayed by RB1 status or by duration since platinum therapy?
Given recent data in Blood (Moik et al, 2021), and the potentially overlapping risks with other clinical factors associated with NSCLC.
Will you alte...
The ALTA and ALEX trials showed better PFS with brigatinib v. crizotinib and alectinib v. crizotinib. How do you choose your first...
Would you test for resistance mutations in this setting, using blood-based sample if no progression outside CNS?
What is the current data regarding acquired resistance mutations for ALK?
Should newer agents such as lorlatinib be reserved for later lines a...
Eg T2N2 who required management of cardiac comorbidities leading to months-long delay but scans are still clear.
Are you routinely performing molecular sequencing? Would you modify your treatment approach in first or later lines based on PDL1 status?
Such as dysgeusia, headache, rash, fatigue, etc
Would you consider SBRT and continue osimertinib?
Do you aim to give a total of 26 doses or do you stop at one year from first dose no matter how many were given?
If so, do you allow a period of "washout" between immunotherapy and radiation?
How do you decide between supportive care v. chemoimmunotherapy? Is there a threshold of disease burden that would push you towards recommending hospi...
I am considering every 6 week pembrolizumab dosing in patients >70 years old in whom I want to reduce clinic visits for, especially in the context ...
Conversely: In a patient with N2 EGFR+ NSCLC receiving radiation, would you still consider use of osimertinib?
Are there any data to support a specific TKI therapy for non-T790M exon 20 mutations/insertions?
Would you differentiate between patients with measurable disease vs NED? Are there specific data to guide us?
E.g. chemo/durvalumab vs chemo/atezolizumab?
What was the magnitude of benefit for patients with EGFRm NSCLC by stage?
Are you still considering adjuvant osimertinib for patients with earl...
If yes, do you re-biopsy for tissue, or perform blood-based sequencing?
Are you performing repeat molecular sequencing after progression on targeted therapy? If so, are you obtaining tissue biopsy vs liquid platform?
If patients do recur, do you perform these tests on the initial surgical specimen or on tissue from a fresh biopsy (or both?)
Is data available regarding the percentages of patients in each arm who underwent staging PET or the breakdown of CNS imaging modalities?
Are the rates of adjuvant chemotherapy used in ADAURA consistent with real-world practice?
Assuming no clinical trial, no actionable mutation, and PD-L1 < 50%, do you consider the patient to be primary refractory to platinum and move to s...
Pathology is not carcinoid or small cell.
For T2bN0 or T3N0 disease, you consider radiation alone, sequential radiation followed by chemotherapy, or concurrent chemoradiation?
After initiation of anti-TB treatment and 3 negative AFB smears, would you initiate concurrent chemoRT? Would you give sequential RT then chemo to giv...
Does the recent CROWN trial affect your first line treatment decision?
No primary thoracic mass identified. Knowing these often following an aggressive clinical course, would you consider concurrent chemo/RT, incorporate ...
Following chemoradiation, would you consider maintenance durvaluamb as for NSCLC even given the SCLC component?
Chemoradiation completed 1.5 years prior
Would you modify the radiation dose or field in this setting?
Would you pre-emptively dose reduce chemotherapy, or modify the dosing of ruxolitinib?
Would you offer SBRT to both sites, SBRT to the primary and standard fractionation to the node due to proximity to the main bronchus/proximal lobar br...
Would it matter the site of recurrence (ie lung nodule vs bone lesion)?
Does the reported positive endpoint in OS for Checkmate 743 change your practice?
SRS done to the single brain met, PD-L1 5%, BRAF G469A mutation
The patient remains without evidence of systemic disease outside of the CNS on serial imaging. Would you continue treating with SRS as lesions appear,...
What is your standard approach for patients with platinum and ICI refractory small cell lung cancer?
Topotecan, nivolumab/ipilimumab and others are listed within NCCN guidelines, and lurbinectedin was recently approved in this space. How do you decide...
Is there an advantage to early diagnosis and intervention versus observation until the nodules are amenable to percutaneous biopsy?
The recent NELSON trial evaluates screening in a slightly different population than the USPSTF/NLST criteria. Which will you follow?
How do you balance risk of chemo after surgery with risk of progression of disease while waiting for healing after surgery before starting chemo?
Are you placing more weight on patient risk factors such as age >65 or co-morbidities?
Are there subsets of patients who will not benefit with addition of first line immunotherapy?
Would you hold treatment for patients who develop PE/DVT while on BRAF-directed therapy?
Would you treat with platinum-etoposide alone again, or would you add atezolizumab?
IMpower133
Does the availability of first line checkpoint inhibitor therapy affect your treatment decision?
Would you treated with local therapies (RFA or SRS) and continue pembrolizumab or would you move to second line treatment?
What are the risks of infection with COVID-19 if using immunotherapy?
How do you prescribe a steroid taper? If it is grade 2, would you keep them on low dose prednisone while continuing? When do you feel comfortable re-c...
Are there specific mutations or co-mutations were you would consider use of this agent?
Should staging and treatment decisions be made based on imaging alone?
How would you approach a patient who is receiving chemoRT but has confirmed COVID-19 with minor symptoms, as breaking treatment for 2 weeks quarantine...
Would you continue pembrolizumab with a re-challenge with carboplatin/taxane or move to second line therapy?
Are the specific Exon 18 mutations that are more sensitive to TKI?
If so, how long is too long to wait?
Many commercial testing assays report on EGFR gene amplification in addition to the known sensitizing mutations. Are there any data that this can be u...
Would you treat with chemotherapy (carboplatin/etoposide) vs anti-pd-1 monotherapy vs combination chemoimmunotherapy vs supportive care?
Would you proceed with maintenance atezolizumab or switch to second line therapy?
Do you ever consider stopping if stable disease and good tolerance?
Patient does not want chemo but is tolerating these well otherwise.
Does timing of recurrence (early vs late) factor into your decision and would you consider consolidation durvalumab?
How, if any, do you utilize genomic testing to guide systemic therapy?
Keynote 407 recently published data on pembrolizumab +/- chemo for metastatic squamous cell lung cancer. The confidence interval for the group w...
Does the degree of PD-L1 expression weigh into your decision?
Do you offer EPO and TPO support? Do you modify your systemic therapy up front or after subsequent cycles?
Especially if you don't have trials available at the moment.
Would you try off-label erdafitinib (given recent data on bladder cancer) or 2nd line ge...
Our medical oncology team wants to give a patient Vitamin B12 and Folate 1 week before chemo- do we need to push back the RT start date to start both ...
How do you approach this given the limited # of patients this applies to? Checkmate 017 and 057 only had 5-7% of patients still on nivolumab at ...
Would your choice of concurrent chemotherapy be impacted by this histologic finding?
PET-CT and Brain MRI are negative for other evidence of disease.
Would nivo + Ipi be appropriate in this situation, especially if high TMB?
In patients who have a mixed response or progression and are poor candidates for other systemic agents, would you consider consolidating the chest? Wo...
Would you consider single agent immunotherapy given recent exposure to platinum agent or chemoimmunotherapy?
In the absence of a frontline clinical trial, would you treat with carboplatin+pemetrexed+pembrolizumab or consider IMPOWER 150 or other?
Are the other options of chemotherapy that can be used instead of platinum based doublets, including with paclitaxel?
Would you consider first line treatment with somatostatin analog or Lu 177 dotatate? Is observation an option for asymptomatic patients?
Are there any data regarding response to checkpoint inhibitors for these patients?
In a patient with lung cancer with both NSCLC and SCLC components, would you offer carbo/pem/pembro or carbo/etoposide/atezolizumab? Or any other alte...
Would you suspect progressive disease v. radiation necrosis vs optic neuritis due to immunotherapy. Eyes were within radiation field 8 months ago.&nbs...
The NCCN guidelines regard MET exon 14 skip mutation as an emerging biomarker but no formal recommendation to start crizotinib. If high P...
Is there any advantage of one regimen over the others?
Are there any biomarkers that would affect your decision for first line PD-1 therapy (including but not limited to STK11)?
1st-line pembrolizumab is supposed to be used AFTER failure of appropriate targeted agents in this setting, but would you consider the reverse sequenc...
How would you utilize PD-L1 expression to guide your decision making in this situation?
For instance, not chronic autoimmune diseases (eg RA, IBD) that may relapse/remit but events like Guillan Barre syndrome that is not likely to recur b...
Would you continue osimertinib after radiation therapy, switch to crizotinib, or consider chemotherapy +/- immunotherapy?
Given the potential high risk of developing pneumonitis with TKI post checkpoint inhibitor, do you avoid TKIs and try a different regimen (ex carbo/pa...
If so, what is your approach to sequencing and timing of targeted therapy and local therapy?
Should these patients be managed using small cell lung regimens?
ie renal dysfunction, hearing loss, neuropathy
Would PDL-1 status impact your decision?
With the recent finding of benefit of pembrolizumab and SBRT (PMID: 31294749), would you consider "adjuvant" pembrolizumab for PDL1 positive patients?...
Do you recommend or make any modifications in the PACIFIC regimen for patients > 75 years of age?
Would you reserve TKI for after standard of care chemotherapy and immunotherapy or consider earlier line of treatment?
If so do you favor repeat tumor biopsy or cfDNA?
What if only site of progression was in the brain/CNS?
Do you offer consolidation chemotherapy prior to durvalumab in locally advanced, unresectable NSCLC?
In clinical practice, consolidation chemotherapy is sometimes used, though this was not implemented in the PACIFIC trial.Antonia et al., PMID 28885881...
Would this approach be different for a patient treated with tri-modality therapy (ie neoadjuvant chemoradiation followed by resection)?
Given the prior results of Keynote 189, how do you plan to utilize the data from Keynote 042 with pembrolizumab monotherapy?
Or do you reserve in case of oligo-progression or progressive/symptomatic disease?
Would the presence of high-titer antiphospholipid antibodies (for example) in the absence of a clot history alter your decision?
CT or PET? If so, how often?
What are the major factors that impact your decision? If you opt for surgery, what factors impact your decision to offer RT preoperatively vs. postope...
Rate of pneumonitis was low in the PACIFIC trial but does it mirror the real world setting? We are seeing increased pneumonitis in our practice.
Is IO related pneumonitis in the radiation field or more diffuse?
SELECT trial
Do you feel it is important to start durvalumab within 14 days of completing cCRT? What real life challenges do you face in doing so and wh...
http://abstracts.asco.org/239/AbstView_239_262655.html
Medical inoperability is clearly defined, anatomical resectability is also pretty much clear (invasion of trachea/carina/esophagus, etc). But what abo...
Would you treat to the GEJ regardless of whether the positive node was identified in the upper portion of station 8? Do surgeons routinely dissect to ...
NCCN guidelines recommend adjuvant chemotherapy for patients with stage 2 or 3 R0 resected NSCLC including 4 cycles of platinum based chemotherapy, bu...
If so, would you combine them vs monotherapy? Patient ECOG is 1
Do you consider specific pre-medications, an alternate checkpoint inhibitor, or abandon ICI altogether?
If so, how would you modify this regimen?
Retrospective studies (PMID: 29935305, PMID: 30125216) have shown a correlation between poorer outcome and baseline steroid use in patients treat...
If you are using a standard 30/10 fractionation, is there a benefit to keeping chemo on board for radio-sensitization?
Retrospective data suggest clinically significant disease flare after tyrosine kinase inhibitor discontinuation in patients with EGFR-mutant lung canc...
Do you use crizotinib for first-line therapy?
First line pembrolizumab is only approved after progression on TKI - but would you ever offer chemo-immunotherapy prior to target therapy?
Is the timing of progression (in relation to chemoradiation) a factor, and is there any role for repeat PD-L1 testing at the time of progression?
Is there one drug that carries the least risk of pneumonitis?
The FDA has approved the new dosing schedule of Nivolumab 480 mg every 4 weeks for multiple disease sites (melanoma, RCC, urothelial carcinoma, SCC of...
For the first treatment day (during combined chemo/XRT courses), is it ok to give XRT first then send the patient for chemo or should the chemo be giv...
Is there a role for attempting to continue EGFR inhibition in addition to chemotherapy for small cell lung cancer?
Would you consider adding atezolizumab to a cisplatin/irinotecan regimen, or cisplatin instead of carboplatin?
If it is still within the 12 month period and no disease recurrence?
Would you give adjuvant chemotherapy or start osimertinib?
Some retrospective data reports that STK11 (AKA LKB1) makes NSCLC resistant to immunotherapy.
No other site of metastatic disease. It is unclear if this situation should be managed as two separate primaries or metastatic disease.
There is no primary and no distant disease seen on restaging PET. RTOG 0236 shows significant regional failure rate. Some have reported salv...
Do you routinely perform molecular testing?
Would you offer immunotherapy combination (nivo/ipi) in patients who have failed nivolumab mono-therapy?
Do you recommend or withhold influenza and pneumonia vaccines while on treatment with checkpoint inhibitors?
At what point (ie 8, 10, 12 weeks or more) would you no longer offer consolidation durvalumab?
Since the randomized phase II data from Gomez et al presented at ASTRO 2018 showed a survival benefit, is there concern about randomizing patients to ...
Does your practice differ based on limited or extensive stage disease?
If there is no other evidence of metastatic disease, would you offer thoracic radiation? Either upfront with chemo or after initial system therapy if ...
The NCCN guidelines suggest surgery can be considered for up to T3N2 NSCLC after a period of induction chemotherapy/chemo-radiation without progressio...
Is this recommended in a certain subset of patients (EGFR positive or 1 metastasis only)? Or should we await maturation of the MD Anderson/Colorado/On...
How common is hyperprogresion, and are there any strategies to mitigate it?
What if the patient has thymoma-associated myasthenia gravis?
Carbo/pemetrexed/pembrolizumab, carbo/pemtrexed without immunotherapy or second line immunotherapy (Nivo, Pem or atezolizumab)?
Prior to the PACIFIC trial, patients were treated with definitive chemo/rads. With local recurrence <1yr after chemorads and definitive treatment f...
Has the publication of IMpower133 changed standard of care?
All tumors in this case were <2cm in size.
Would starting with chemotherapy be preferred in this situation and consider concurrent radiation, then switch over to Pembrolizumab once some control...
If so how would you select patients (ie. PS, histology, PD-L1 expression level)?
There is no evidence of disease outside the lung on PET, and the patient is completely asymptomatic with negative EGFR, ALK, ROS1, and BRAF and a PD-L...
PD-L1 < 50% and no targetable mutations. Would you use carbo/pemetrexed/pembrolizumab or Nivolumab or pembrolizumab?
For example, would a + vascular margin, extranodal extension of N1 disease, translobar disease, or high risk histologies (large cell neuroendocrine, s...
Would you repeat PET or is it adequate to change to CT surveillance? Although surveillance PET/CT is not recommended by NCCN guidelines, these are oft...
Would you treat with localized therapy with chemoradiation or SBRT or consider ROS-1 directed therapies?
Would you use the same schedule as early stage NSCLC primary?
The current NCCN guidelines reserves radiation for patients who are not resectable after induction chemotherapy. Does it make sense to offer concurren...
Lung primary is inaccessible for biopsy and metastatic sites are only 2 small bone lesions. In a non-smoker, a driver mutation is suspected but would ...
Would you offer adjuvant therapy post resection?
Would your choice of treatment change if the same patient was T790M negative and osimertinib was given as a first-line therapy?
Do you prefer carboplatin-paclitaxel-bevacizumab, carboplatin-pemetrexed-pembrolizumab, or chemotherapy alone?
Does the more recent NEJ026 trial describing benefit from Bevacizumab plus Erlotinib over Erlotinib alone in patients with EGFR driver mutations ...
Certainly ovarian cancer will respond to carboplatin and paclitaxel and it sounds like a reasonable chemotherapy to give to a stage IV NSCLC, however ...
If there are 3 negative scans, do you continue annual screening?
A recent phase III trial published in JCO describes the NVALT-11/DLCRG-02 study, evaluating PCI vs observation in patients with stage III NSCLC s/p co...
Specifically, would carbo-taxol-bev-atezo (IMpower 150) be an attractive option given the activity of bev-atezo in sarcomatoid PDL1+ metastatic RCC (I...
Is there any data for the benefit for systemic chemo in such situation?
For the Impower 150 trial, is there data reported on PFS and OS for ABCP vs ACP (atezolizumab/bevacizumab/carboplatin/paclitaxel vs atezolizumab/carbo...
Or would you wait to start coincident with the start of cycle 2? If a shorter time from the start of any therapy to the end of radiation (SER) is sign...
How do you interpret the results of Checkmate 227 in light of Keynote 189 and Keynote 407?
Can SRS or whole brain radiotherapy be reserved for progression in these young, healthy patients?
Does the recent FDA approval based on PFS and response rate in KEYNOTE-021 warrant it's use?
By the definition this would be M1 disease, but would definitive treatment be appropriate? Is there clear data that a single pleural nodule has no cha...
Would you consider "aggressive" concurrent chemoradiation followed by SRS to the CNS lesion and possible consolidative immunotherpay (the PACIFIC...
Would you consider MS an absolute contraindication to this treatment?
Given the results of Keynote 189, is there any benefit of chemotherapy+pembrolizumab in specific subsets of patients in the first line setting?
In the absence of clinical trial, is there are role for dose-escalating alectinib, or would you consider brigatinib or chemotherapy?
When would you favor delivering local therapy (e.g. SBRT) prior to systemic therapy?
These patients have been largely excluded from these trials. What if the infection is well controlled?
Assuming it is clinically indicated, would a checkpoint inhibitor be efficacious in a patient who has a concurrent autoimmune illness (PMR/TA) and is ...
Would you ever considering re-starting immunotherapy before completing the taper?
According to the new guildelines on managing immunotherapy related ...
If you treat pre-chemotherapy volumes, is there a benefit to induction chemotherapy even in bulky disease. If so, how do you define disease that ...
If so, what would be the regimen?
What factors influence your decision (R1 v. R2 resection? T stage?) If sequential, do you typically prefer radiation before or after chemotherapy?
Would you consider second line immunotherapy before considering chemotherapy?
What regimen do you prefer?
Can T790M mutation develop within this early time frame, or are these perhaps patients who may benefit from switch to chemotherapy?
Or do you recommend treatment with systemic therapy alone, as this represents Stage IV disease?
Are you using ctDNA blood tests for targetable mutations at the time of diagnosis, at the time of disease progression, or not at all?
How does this approach change with mediastinal lymph node involvement? What are the indications for definitive or adjuvant radiotherapy +/- chemothera...
What is the best evidence for what dose to use? When would you give it in relation to the checkpoint inhibitors? Which metastatic sites do you choose ...
How do you select between the available treatment options (gemcitabine, docetaxel, paclitaxel, nab-paclitaxel) in combination with platinum?
Up...
When there is biopsy proven mediastinal disease, do you offer definitive chemoradiation and monitor, or do you try to prove the presence/absence ...
Has the recent FDA approval of dabrafenib/trametinib changed your practice?
Have the results of LUX-Lung 7 changed your routine practice? Are there promising up-front clinical trials that these patients may benefit from?
Do you incoprate Ki67% or mitotic rate into your treatment decision, and is there any use for somatostatin based imaging such as octreoscan or gallium...
In IB-IIIA cases?
Is there any role for a trageted agent with CNS penetration (such as second generation ALK inhibitors) after completion of postoperative brain radiati...
Should we be routinely sequencing ALK to select an ALK inhibitor with the appropriate efficacy, matched to resistance patterns?
What factors influence your decisions to offer neoadjuvant chemotherapy?
Is there any role for either the addition of bevaciziumab or for maintanance pemetrexed?
For instance with isolated progression at one metastatic site, with all other disease stable and clinically doing well.
How do the different assays compare when choosing a specific immunotherapy, and does this change for first vs second (or beyond) line of therapy?
How long do you typically wait before starting consolidation chemotherapy, and do you routinely perform re-staging scans prior to consolidation?
What immunosuppressive agents are used and in what order? Does your approach differ depending on the organ involved, e.g. colitis vs. pneumoniti...
In addition to addresing the brain met (surgery vs. SBRT), would you proceed with systemic "adjuvant" chemotherapy, or would you treat the patient as ...
Is there any data to support this approach? If not, are there trials you are aware of looking at "rescuing" these patients with a different chec...
Does the extent/duration of systemic disease control (complete response vs. stable disease, for example) influence your decision? What about whe...
Does the risk of severe inflammation of the liver lead you to choose other therapies in in this population? What about in patients with mild liv...
Does the presence of a sarcomatoid component influence this decision?
If these are presumed to be immune-mediated (e.g. immune neutropenia or immune thrombocytopenia), do you treat with steroids?
Based on JO25567 and the phase Ib trial of afatinib and cetuximab, for patients otherwise tolerating therapy would you consider adding these agents or...
The Phase III J-ALEX study and two phase II studies seem to suggest favorable intracranial response rates for alectinib.
What about patients who are still on steroids for radiation pneumonitis?
Does recent data from the OAK study showing a survival benefit for atezolizumab over docetaxel even in non-smokers affect your decision making?
Would you consider giving the therapy with concominant steroids, or with a dose reduction?
Do you add bevacizumab regardless of whether you are using paclitaxel or pemetrexed with the platinum agent?
Also, are you testing for PD-L1 routinely prior to initiation of first-line systemic therapy?
For fit patients, what regimen do you prefer outside of a clinical trial?
I ask this question recognizing there is no great data here, and that "pseudo-progression" is rare, but I am looking for any guidance with regard to h...
Based on recently published data from CheckMate 032, do you now offer nivolumab to small cell patients who have progressed after first-line chemothera...
What about specifically in never-smokers?
4cm has historically been used as the cutpoint for determining benefit from adjuvant chemotherapy in this population (Strauss et al, JCO 2008; Bu...
Although PD-1 inhibitors are now standard of care for second-line therapy of advanced NSCLC, there remains the question of which therapy is best to us...
Would you offer adjuvant TKI following ADAURA data? Or proceed with durvalumab based on PACIFIC data?
As it is suggested for larger tumors treated with surgery, based on post hoc CALGB analysis?
The NCCN guidelines discourage the use of PET/CT surveillance but the recent analysis of RTOG 0235 found post-CRT PET uptake to be associated with wor...
Based on the European data published in the Lancet (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2814%2961085-0/abstract), are you s...
For example, should nivolumab be considered standard second-line therapy for adenocarcinoma patients? Can it be considered for first-line thera...
I am aware that chemotherapy can obviate the need for RT in patients with SVC syndrome, but I'm not sure if this can be extrapolated to spinal cord co...
If so, what would you include in the target and what dose?
Should mutations other then EGFR and ALK be routinely tested for? Should next generation sequencing be routinely done?
Would you stop the Tarceva at this point?
I've read about patients who were treated with concurrent bevacizumab-RT who developed lethal tracheoesophageal fistulas. How long would you have to w...
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